MedStar Health Blog

Breast cancer treatment has come such a long way in recent years that life expectancy continues to improve, and we are often able to approach treatment like we would a chronic disease. But some women with an aggressive form of breast cancer known as “HER2-positive” can face another health risk – a weakened or damaged heart.

Current guidelines actually recommend not giving HER2-targeted medication to women with an abnormal heart function. And women whose heart function declines during treatment are sometimes taken off these lifesaving drugs altogether.

As a cardiologist who specializes in helping protect cancer patients’ hearts, this situation concerned me a great deal. We know how effective these cancer treatments can be. That is why I am so pleased with the results of a recent multi-center study called SAFE-HEaRt, published in the Breast Cancer Research and Treatment journal in March 2019. It is the first study of its kind to include women with heart dysfunction, and it showed that it is safe for them to continue HER2-targeted therapies. The caveat is that they should be receiving protective heart medication managed by a cardiologist at the same time.

What is HER2-Positive Breast Cancer?

Every year, more than 330,000 women in the United States will develop breast cancer, and about one in four will be HER2-positive. This type of breast cancer has a higher-than-normal level of a protein called HER2 (human epidermal growth factor receptor), which makes it a more aggressive form of the disease.

Fortunately, highly targeted therapies have significantly improved the outcomes for patients with this type of cancer. Unfortunately, these therapies can put added stress on the heart and result in heart failure. We see heart function decline in about 10 to 15 percent of women with HER2-positive breast cancer. While many patients never show any noticeable symptoms, about two to three percent do.

SAFE-HEaRt Trial: The Who, What, Where and Why

We developed the SAFE-HEaRt trial in association with Sandra Swain, MD, associate dean for Research Development at Georgetown University Medical Center, and Filipa Lynce, MD, medical oncologist at MedStar Georgetown University Hospital.  The trial was a collaboration that included MedStar Heart & Vascular Institute as well as the cancer institutes at both MedStar Washington Hospital Center and MedStar Georgetown. The study’s purpose was to determine whether it was safe to continue giving HER2-targeted medications to patients with reduced heart function.

The study was investigator-initiated, meaning that we developed the protocol, and Genentech supported its execution. Genentech is the maker of the HER2-targeted therapies that were delivered to the patient.

This is the first prospective study of its kind. We approached patients who needed HER2-targeted therapy and also had an abnormal heart study to ask if they would be interested in participating. If they were interested and eligible, they received treatment as part of the study.  We ultimately evaluated 30 patients.

Of these patients, some were treated for their cancer with trastuzumab (Herceptin), others with a combination of trastuzumab and pertuzumab (Perjeta) or TDM-1 (ado-trastuzumab emtansine). Cardiac treatment included beta blockers, ACE inhibitors, or ARBs (angiotensin II receptor blockers).

What Did We Learn? Cancer Therapy Can Continue Safely

• Our study indicates that it is safe to continue HER2-targeted therapies in patients who have mildly reduced heart function or whose hearts show some declines during treatment. Twenty-seven patients (90 percent) completed their planned HER2-targeted therapies without having a cardiac event or seeing a significant decline in their heart function.
• Patients must receive appropriate heart medications during treatment.
• This approach requires close collaboration between the oncologist and cardiologist.

This study is a valuable first step in helping us identify the best ways to protect the heart while making sure patients receive the most effective breast cancer treatments available. The next steps include gathering information about these and similar patients in the long term, and developing larger trials among patients in community hospitals, not just tertiary care centers like the ones in this study.

Regular exercise and a good night’s sleep are two well-known ways to help prevent heart disease. However, eating tree nuts may also lead to lower heart disease risk, particularly for people with diabetes, according to a 2019 study.

The study found that people with diabetes who ate at least five small servings of tree nuts a week were 17 percent less likely to develop heart disease. Researchers followed patients from a younger age in their life and followed up with them over time to determine whether they developed heart disease.

Peanuts are the most popular “nuts” in grocery stores, but they are actually legumes that grow underground. Common tree nuts include:

• Almonds
• Cashews
• Hazelnuts
• Pine nuts
• Pistachios
• Walnuts

The benefit eating tree nuts—which are a key component of the heart-healthy Mediterranean diet—has for the heart adds to our understanding of what constitutes a heart-healthy diet, especially for individuals who have diabetes. Let’s discuss why tree nuts are good for us, ways to incorporate them into our diets, and other diet tips people with diabetes should consider.

LISTEN: Dr. Bering discusses the benefits of eating tree nuts in the Medical Intel podcast.

Why are Tree Nuts Good for Heart Health?

Tree nuts provide us with a lot of bang for our buck when we consume them, as they’re packed with high-quality nutrients including:

• Fiber
• Minerals, such as calcium, potassium, and magnesium
• Phytochemicals
• Unsaturated fats
• Vitamins, such as vitamin E and folic acid

Vitamin E in particular has been shown to reduce inflammation in the body, which is important for people with diabetes who can experience inflammation in the eyes, kidneys, and vasculature. Moreover, the anti-inflammatory effects, as well as unsaturated fat and potassium found in tree nuts, can help lower people’s high blood pressure.

Tips for Adding Tree Nuts to Your Diet

The first step of incorporating more tree nuts into your diet is identifying which ones you think taste best, as you’ll be more likely to eat them regularly. Once you get into a habit or purchasing tree nuts, not only can you eat them by themselves, but you also can add them to a variety of meals. For example, you can add them to yogurt or salad, adding extra texture, crunch, and flavor. For more ideas, simply search online for healthy meal ideas that include tree nuts.

Tree nuts also are easy to transport. This makes them an ideal on-the-go snack and a much healthier option when compared to junk food or fast food.

As you eat tree nuts, make sure to monitor your portion sizes. One serving of nuts generally is about a third of a cup. Many of the portions we receive at restaurants or that we see in TV advertisements are much too large for what we should actually be eating. I recommend following portion size recommendations from the American Heart Association to learn what portions of different types of food should look like.

Furthermore, keep an eye on the salt content in the tree nuts you purchase. Some nuts come presalted or preflavored, and this can be an issue for people with diabetes who have problems with their kidneys or have had heart disease. Try purchasing nuts that are labeled as unsalted. If you don’t like the taste, opt for sodium-free salts.

What Other Diet Tips Should People with Diabetes Consider?

Aside from eating tree nuts, another great thing people can do in terms of their diet is to eat mostly fruit, vegetables, whole grains, and occasionally lean meat, and avoid eating ultra-processed foods, or foods that don’t look like anything that occurs in nature. These types of foods—ranging from drinks filled with artificial sweeteners to frozen foods with unrecognizable ingredient lists—often have negative health effects.

Drinking two or more artificially sweetened drinks a day, for example, is associated with increased risk of heart disease, stroke, and early death in women over 50. The weight gain these types of foods can lead to also can contribute to obesity-related illnesses, such as diabetes and high cholesterol.

Related Reading: Put Down the Diet Soda: How Artificial Sweeteners Increase Heart Disease and Stroke Risk

As tree nuts are associated with increased heart health, try incorporating them into your diet today. Experiment with which tree nuts taste best if you haven’t already, and think of ways you can add them to your favorite foods.

We’re no strangers to hot summer days in the District of Columbia. But when the thermometer inches toward and above 100 degrees Fahrenheit, we could all use a reminder about the dangers of heat illnesses.

Heat can be lethal. We see a few patients in the emergency room every summer who are experiencing the full spectrum of heat illness symptoms. Some just feel muscle cramps or are nauseated while others have may have collapsed while running and are suffering from exertional heat stroke, which can be deadly.

Our bodies cool themselves by sweating. But when the heat and humidity combine to make it feel like 100 degrees or more, sweating may not be enough and our body temperatures can rise to dangerous levels. Our bodies just are not meant to spend long periods of time in extreme heat and humidity, particularly if we are exerting a lot of energy.

While we weather this latest heat wave, let’s talk about symptoms of heat-related illness to watch out for and tips to stay safe when the temperature soars.

Types and Symptoms of Heat-Related Illness

There are two main types of heat illness: heat exhaustion and heat stroke.

Heat Exhaustion

Heat exhaustion occurs when the body overheats due to exposure to high temperatures. It can appear suddenly or over time, particularly if you’re engaging in physical activity.

Heat exhaustion symptoms include:

• Dizziness or lightheadedness
• Fatigue
• Headache
• Heavy sweating
• Muscle cramps
• Nausea or vomiting
• Pale or cold skin
• Weak, rapid pulse

If you experience any of these symptoms, get out of the heat and into a cool place to rest. Drink water and take off any tight or extra clothing. You also can lower your body temperature with an ice pack or cool bath.

If your body doesn’t cool down, heat exhaustion can turn into heat stroke, a more dangerous condition.

Heat Stroke

Once the body temperature reaches 104 degrees Fahrenheit and there are signs of neurologic dysfunction such as confusion, agitation ,slurred speech or coma, you’re considered to have heat stroke. This serious condition requires emergency treatment. Left untreated, it can cause shock, organ failure and death.

If you or a loved one have heat stroke symptoms, call 911 immediately. While waiting for emergency personnel, move to a cool location and remove excess clothing. Try to cool off further with a tub of cool water, a fan or ice packs.

While anyone can suffer from a heat-related illness, there are a few factors that can put people at increased risk:

• Age: The ability to regulate body temperature isn’t fully developed in young children, and the elderly’s may have reduced temperature control because of health conditions or medications.
• Obesity: Extra weight can cause the body to retain more heat as well as affect the ability to regulate temperature.
• Health conditions and medications: Some chronic illnesses such as heart or lung disease may increase your risk of heat-related illness. Certain medications also may affect the ability to stay hydrated and regulate body temperature, including some beta blockers, diuretics, antihistamines and antipsychotics.

How to Prevent Heat Exhaustion and Heat Stroke

Heat exhaustion and heat stroke are preventable. The best ways are to avoid being outside in the heat and avoid overexerting yourself when you are. However, we know this isn’t always possible, so listen to your body. If you’re outside and starting to feel hot or dizzy or you’re experiencing muscle cramps, take a break to go inside and cool off. Avoid going back outside until you’re feeling normal again.

You can seek relief from the heat in public facilities such as recreation centers, public libraries or senior centers. When the temperature or heat index reaches 95 degrees, the District of Columbia also activates cooling centers. Find a cooling center near you.

A few more tips to stay safe in the heat include:

• Stay hydrated: Drink fluids such as water or low- or no-sugar sports drinks every 15 to 20 minutes, even if you don’t feel thirsty. Avoid caffeine and alcohol.
• Wear loose, lightweight, light-colored clothing: People who live in very hot areas of the Earth wear long, loose-fitting clothing. They know what they’re doing!
• Take breaks: Try not to push yourself too much with exercise or work too hard. Go inside to cool down as often as possible.
• Check on your neighbors: We’re all in this together. If you aren’t sure if your neighbors have air conditioning, stop by and see how they’re doing. This is particularly important if they are elderly or live alone.

Finally, heat-related illnesses aren’t the only dangers we face during the hot summer months. We also want to avoid skin cancer from sun exposure. So don’t forget sunscreen and a hat when you’re heading outdoors.

The temperature eventually will drop to a more normal summer range, but until then, stay safe out there.

Almost every day on my work commute, I see someone riding an electric (or motorized) scooter, a surging form of transportation in the U.S. While these scooters are convenient and fun, they unfortunately are sending more people to the hospital than bicycles and walking—and most injuries are more serious in nature, if not severe.

There are a number of reasons for these accidents. But the most common scenarios that result in people seeing us with electric scooter injuries include people:

• Falling while turning a corner
• Getting struck by a car
• Hitting a bump in the street or sidewalk
• Jumping off after losing control of their electric scooter

The individuals most at risk of experiencing an injury while riding electric scooters are those with a history of osteoporosis, a condition in which bones become weak and brittle, as their bones would break more easily if an accident were to occur.

If you do ride an electric scooter, make sure you wear a helmet, start slowly, and become comfortable controlling them in low-traffic areas. If you’re not careful, you can get into an accident and experience a significant injury.

LISTEN: Dr. Golden discusses electric scooters and what kind of injuries they can lead to in the Medical Intel podcast.

Common Electric Scooter Injuries We See

There isn’t one single common injury we see from electric scooter accidents. We see upper-extremity and lower-extremity injuries, and pretty much everything in between. This likely is because there are so many different ways you can land after falling from your electric scooter, as well as various areas of the body where a car can hit you.

The injuries we typically see following an electric scooter accident correspond with the most common orthopaedic trauma injuries we see, which include:

• Lower-extremity fractures: These include the hip, knee, and ankle joints, as well as the bones of the thigh, leg, and foot. The most common is breaking the tibia, one of two bones below your knee and above your ankle.
• Upper-extremity fractures: These include the fingers, hand, wrist, arm, and elbow.

Treatment after Electric Scooter Accidents

Since most of the injuries we see related to electric scooters involve broken bones, we often have to perform surgery to treat these injuries. Surgery typically involves realigning the broken bone and stabilizing it with nails, plates, or screws to hold it still and in the best position for the bone to heal. Bones usually take about three months to heal, although some bones heal a little faster or slower. In some cases, people have wounds that cannot be simply stitched closed. In these cases, we work closely with plastic surgeons to close the wounds.

Following surgery, there will be a period of immobilization that can range from a few days to several months, depending on the severity of the fracture and which bone was broken. We always encourage patients to walk and move around as soon as we determine it’s safe to minimize or avoid joint stiffness and prevent muscle loss. We see patients for checkups during their entire healing process to ensure the bone remains aligned properly and that their healing is progressing as expected.

Physical therapy can be a part of recovery for many patients following bone fractures, depending on what bone was broken and what treatment they received. For people whose fractures require prolonged immobilization, physical therapy may be necessary to minimize joint stiffness and rebuild muscle. Physical therapy isn’t always necessary for individuals who experience a fracture in the middle of one of their longer bones, such as the femur or tibia, as we can insert a rod into the bone to fix it, resulting in people being able to bear weight quickly as the bone heals around the rod.

A Success Story

We saw one patient who had just fallen off his electric scooter. He had a fairly complex fracture of his tibial plateau, the bone forming the bottom part of your knee joint. To treat him, our orthopedic trauma team performed several surgeries to properly align and stabilize his broken bone. He also required the plastic surgery team to get involved to help cover his wounds that he sustained as a result of his crash. After a few months, his fracture had healed, he participated in physical therapy, was walking on his own, and working his way to returning to more strenuous physical activity.

A Final Word on Scooter Safety

In most cases, if you’re careful and relatively healthy, you’re probably OK riding an electric scooter. But it’s important that you start slowly and become comfortable controlling your electric scooter before hitting the streets with traffic. These scooters are far different than the ones we were riding years ago—they pick up a good amount of speed. As a result, if you fall off of one, there’s a good chance you will sustain an injury. And as always, wear a helmet.

As with most forms of transportation, there is risk involved when riding electric scooters. If you own an electric scooter or have considered renting one, make sure you’re totally comfortable riding it before taking it out in areas with traffic.

When I joined MedStar Washington Hospital Center in 2012, one of our top priorities was to develop a comprehensive spine center. We wanted to create a place that would foster a real sense of teamwork with everyone involved in spinal care. That’s because team-based treatment is the foundation of successful spinal care.

I’ve been a spine surgeon for many years, and I’ve treated countless patients for a number of conditions. But I don’t have all the answers. The MedStar Spine Center pulls together spinal experts from many fields to share our knowledge and resources. This collaboration allows us to provide better, more comprehensive care to our patients than any of us could alone.

‘One-Stop’ Spine Care

Just as mega-marts and big-box retailers are convenient for consumers because everything they need is under one roof, the MedStar Spine Center gathers a spectrum of spine care providers in one convenient location. Working with doctors from all across the spectrum of spine care lets us share our thoughts about complicated cases and opinions on what sorts of treatments would be best for particular patients.

In addition to neurosurgeons, some of the other providers available at the MedStar Spine Center include:

• Pain management specialists
• Physiatrists, or doctors of physical medicine and rehabilitation
• Physical and rehabilitation therapists

We are unique among MedStar hospitals in that our orthopedists and neurosurgeons take turns being on call for spinal emergencies. Our orthopedic colleagues are trained in treating back and spine conditions, and we work together to bring our unique perspectives to the table for the good of our patients.

When we are determining whether a patient needs surgery, we consider all possible angles of treatment. As a spine surgeon, I routinely meet with patients to determine if they are good candidates for spine surgery. However, if they are not a good surgical candidate, I don’t just send them away or try to get them a referral to some other provider in a couple of months. Instead, I walk them down the hall to one of my teammates I think would be able to help, and I introduce them. Patients often are more comfortable hearing that they don’t need spine surgery directly from a spine surgeon, and they appreciate not having to wait months for a referral appointment with a brand-new doctor they have never met.

If a patient is a good candidate for spine surgery, we keep close watch on their brain and spinal cord function during their operation. This is called intraoperative monitoring, and it lets us confirm that patients are doing well during surgery and that we are precisely where we need to be with our surgical instruments. This is possible because of our use of the Airo Mobile Intraoperative CT system, exclusive to us in the Washington, D.C., area, which allows us to take high-definition computed tomography (CT) scans of the spine during surgery.

Our Spine Center providers are like athletes on an elite sports team. We support and encourage each other to perform to a higher standard. Working with the best of the best motivates us to elevate the care we provide our patients that much further.

Solutions for Common and Complex Spinal Conditions

Across all our specialties, we see many patients for a wide range of common spine problems, such as:

• Back or leg pain
• Degenerative disc disease, an age-related wearing-down of the “shock absorbers” between the spinal bones (vertebrae)
• Herniated disc, a rupture of one of the spine’s discs
• Spinal stenosis, a narrowing of the space around the spinal cord created by the vertebrae

Patients often can find relief through nonsurgical options, including physical therapy or pain management, which involves the use of medications and other treatments to relieve pain. But for complicated conditions or cases in which nonsurgical treatments haven’t worked, surgery might be necessary, such as disc fusion or disc replacement (arthroplasty) surgery.

We also care for patients who have severe conditions, such as tumors on the spine or spinal cord, as well as spine trauma. MedStar Washington Hospital Center is home to MedSTAR Trauma, a Level I trauma center, and the region’s referral center for traumatic injuries. No one else in the region can match our expertise in caring for the most challenging spine injuries and conditions.

Related reading: Quick! Name some important diseases: Is traumatic injury on the list?

Spine Care Successes

Every day, we take care of people who suffer traumatic injuries to the spine, such as gunshot wounds or high-speed car accidents. We also treat people who come in after years of suffering from spine conditions that just keep getting worse on their own. Patients come back to the office and tell us how their lives have changed after treatment. They are spending more time with their kids or their spouses, enjoying the activities they love. They feel like they have their lives back.

Having great outcomes like these draws in the top-notch doctors that we want to join us, because they want to work in an outstanding environment. Having the top doctors then continues to drive our patients’ successes. It’s a true win-win for everyone involved, and our Spine Center is the key that makes it possible.