Inactive (722)

Segment Number 2
Audio File meridian/1550md1b.mp3
Doctors Ash, Carol
Featured Speaker Carol Ash, DO
Guest Bio Carol Ash, D.O., is a board certified general internist and fellowship-trained pulmonary, critical care, and sleep medicine specialist with more than 15 years’ experience in clinical medicine. Currently, Dr. Ash is the director of Sleep Medicine at Meridian Health in New Jersey.
She is a featured speaker on many nationally syndicated television and radio shows as well as a featured expert in related articles for many national magazines. She has been interviewed on The TODAY Show, Good Morning America, MSNBC, CNN, The Dr. Oz Show, ABC's Katie with Katie Couric, Fox and Friends weekend show, Fox’s nationally-syndicated The Morning Show with Mike and Juliet, CBS Early Show, ABC’s Nightline with Cynthia McFadden. She has been a featured expert in many national magazines and print media including, The New York Times, The Philadelphia Inquirer, Women’s Day, Shape, Parenting, Parents, Prevention, Glamour, Reader’s Digest, Huffington Post, Self, Success, and more. She is also on the Advisory Board for Ladies Home Journal.

Learn more about Carol Ash, D.O
Transcription Bill Klaproth (Host): A good night’s sleep is important for maintaining your overall health and well-being. There are many disorders and disorders can affect men and women differently. With us is Carol Ash, D.O. She is the Director of Sleep Medicine at Meridian Health in New Jersey. Dr. Ash, thank you so much for being on with us. So, let’s start with, what are the most common sleep disorders that you see?

Dr. Carol Ash (Guest): Most people, when they think about sleep disorders, they typically think of sleep apnea or obstructive sleep apnea. That is a condition where individuals can stop breathing in their sleep. Or, they think of insomnia. There are also some movement disorders. One common one is called “restless leg syndrome.” Some people will describe it as the “Jimmy legs” or that’s how people will typically think of it. Then, insufficient sleep because of our lifestyle or medications or other health problems is also something that people will commonly struggle with. But, there are more than 80 different sleep disorders and science is showing us so much about the mechanics of sleep. It’s just a fascinating time to be practicing sleep medicine.

Bill: Absolutely. Are these sleep disorders mainly caused by hereditary things or are they caused by lifestyle or depression or stress, or maybe all of the above?

Dr. Ash: All of the above. You can have a sleep disorder like obstructive sleep disorder that could be due to the fact that you have larger tonsils or the shape of your face. Or, you can have a sleep disorder because of lifestyle. If you’re somebody who is trying to burn the candle at both ends or you are very stressed, it can cause your sleep to be disrupted or you may not get enough sleep. Restless legs – that’s a condition where we can see people having difficulty with unusual or uncomfortable symptoms in their legs that is relieved by activity that can be present because of an iron deficiency. People with insomnia, they commonly travel with other disorders like depression. We used to think of insomnia as a symptom. We now know that insomnia itself is its own disorder and tends to travel with other disorders like depression and anxiety. When you treat the insomnia, it’s actually easier to treat the depression or the anxiety that might be occurring with the insomnia. All of the above is the answer.

Bill: So, when is the time to go see the doctor, then? Someone may think, “Oh, geeze. I’m just being stressed out; I’m working too hard; I’m not eating right. This will go away.” When should someone come see you?

Dr. Ash: What I typically tell my patients or folks in the community when I talk to them is the first thing is just recognizing that there may be an issue that your doctor or a sleep specialist could help you with. The first thing that people need to be mindful of is, if you’re finding that you are not able to get the right amount of sleep that you need or if you’re somebody that has what we would classically think of as insomnia: if you’re having difficulty falling asleep at night; you’re not able to maintain sleep at night; you’re waking up too early or you just feel exhausted and tired during the day, that’s certainly somebody who might want to consider reaching out to their provider. Sometimes it could be something really simple. I’ll ask patients when they come to see me, “Why do you think you have a problem?” Patients know. They just haven’t really thought about how they can solve the problem. If you have a test you’re trying to study for or a lot of demands, it may be that you just need to understand how important sleep is and have somebody give you some insight about things that you could be doing to help make your sleep better so you can get the rest that you need and you wake up in the morning feeling wide awake. I’ll give people some simple tips such as, I want you to make sure you get the right amount--and most of us need about eight hours, the range being seven to nine. There isn’t really anybody who can really function well with less than seven hours of sleep. You want to make sure that you’re getting the right amount of sleep and you want to stick to a routine regular schedule every day. Most important is getting up the same time every day because there is a master clock in your brain and when you open your eyes in the morning and expose yourself to light, one of the strongest setters of the master clock is that light. If you get up the same time every day, if you need eight hours of sleep, and to keep it simple, if you got up at 8 a.m. and exposed yourself to light in the morning at 8 a.m., that light will help set rhythms for wake and sleep so that you’d be able to get to bed at 12 midnight. You would easily drift off and then you would wake up again at 8 a.m., even without an alarm clock. So, every day you would wake up feeling well rested and able to stay awake and alert all day long. If you’re sticking to those basic principles – getting the right amount, getting up the same time every day, and keeping the environment dark, quiet and cool to help facilitate sleep – if, after a month, you’re still struggling, then you really do need to talk to your doctor.

Bill: Very good tips. Thank you for sharing those. I appreciate that because I was going to ask you about healthy sleep habits. When it comes to determining a diagnosis, what tests are given for you to find out if somebody does have a sleep disorder?

Dr. Ash: If you find your way to the doctor because you are still struggling, the first thing they’ll do is go through a list of symptoms that would help them to understand what tests would be best for you. If you’re somebody who is snoring and you’re finding that your sleep is restless and you’re tired during the day and if you have cardiovascular disease, then that would suggest that you probably are at risk for obstructive sleep apnea. If you have a disorder like that, you would need a study called a polysomnography which is an overnight sleep study. You would go into a sleep lab where they would hook you up to monitors. They would watch your breathing, watch your heart rhythms, watch your oxygen count and your sleep and determine if there is a problem with your breathing in your sleep. If you do, there are some simple interventions. There is an appliance called a C-pap, there are surgical interventions, there are dental appliances. For some people, simple weight loss or just alleviating nasal congestion can solve the problem. If you come in and you describe to the doctor symptoms that suggest you can’t fall asleep easily at night, you have racing thoughts, your sleep is restless, typically, for those people, there are some simple sleep habits they could work on. They could use cognitive behavioral therapy to help people with insomnia. There are also certainly some medications we could use. Usually, people with classic insomnia symptoms, they wouldn’t need a test. People with restless legs, which is a common Jimmy leg sensation, and with that, pretty much from a history you can get the information that you need and there wouldn’t be a technical test that you would need. You could get a lab test – like a ferritin count which would look for a low iron level. The word “ferritin” is the word we use for iron. If the iron level is low, you just need the iron replacement. In that sleep study, typically we can bring people in if the symptoms do not strongly suggest an answer and you need a study to look into your sleep no different that an MRI would look into your body if you had pain or you had a problem that the doctor needed to get more information on. The sleep study is a way of the doctor looking into your sleep to discover what the problem might be, if you have symptoms suggesting a sleep disorder.

Bill: We’ve heard about sleep apnea and you’ve talked about that; and the C-Pap machine and you’ve talked about, good healthy sleep habits. What about these over the counter medicines or pills you can take? It seems like I see a new commercial every night where “if you’ve having trouble sleeping, try the Z thing and it will make you sleep”. That seems like not a good thing for people to be taking medication at night and trying to get good sleep on their own by taking some kind of a Tylenol sleep aid all night.

Dr. Ash: I always try to encourage patients to stay away from medications when they can and if you stick to those simple tips: making sure you get up the same time every day, keeping the right amount of hours at night, making sure the environment is conducive to sleep – the quiet, dark and cool bedroom. When you find you can’t sleep, sometimes what people can simply do is just do some simple breathing exercises. If you just really slow your breathing down and take a few slow breaths in and exhaling and getting the breathing to slow down. For some people, that can be enough to help them to drift off into sleep. Or, just starting with your toes and working all the way up to your head and just relaxing your muscles may be all you need to do to help you drift off to sleep without any over the counter medications. Typically, what the over the counter medications are is they are antihistamines that can be very sedating. So, you are taking advantage of a side effect of a medication that is really used for something else. Part of the reason why it’s been so difficult to control insomnia with medications in the past is, we didn’t really understand the mechanisms of sleep and wake. What we now know is there’s two separate circuits – one for sleep and one for wake. What the problem has been is, we now know that people that are having trouble falling asleep at night, it’s as if they have a foot on an accelerator because it is really a problem with hyperarousal in the wake system not shutting off. It’s as if they have a foot on the accelerator and what most of these over the counter medications and even prescriptions sleeping meds were designed to do was to put the foot on the brake. But, if you think about that for a second, it doesn’t make sense that if the foot is on the accelerator that simultaneously putting the foot on the brake is really going to accomplish what you need. We’re now really realizing that what we do to solve insomnia has to take the foot off the accelerator. So, those breathing techniques, trying to relax the muscles and decrease the tension in your muscles. There are some newer prescription medications that are designed to take a foot off the accelerator, but not the over the counter meds. So, your first bet is just really trying to relax your mind. Again, simple breathing exercise and muscle relaxation can work really well for that.

Bill: Dr. Ash, thank you so much for your time today. You’ve given us a lot of useful information. For more information, please visit MeridianHealth.com. That’s MeridianHealth.com. This is Meridian Physician Podcast with Meridian Health. I’m Bill Klaproth. Thanks for listening.
Hosts Bill Klaproth

When You’re Afraid To Sleep: Nightmares and Nightmare Disorders

Additional Info

Segment Number 5
Audio File allina_health/1546ah1e.mp3
Doctors Blackburn, Richard A.
Featured Speaker Richard A. Blackburn, PhD
Guest Bio Dr. Blackburn is a board-certified behavioral sleep medicine specialist, providing safe, effective treatment for insomnia, nightmares and circadian rhythm disorders. He treats insomnia and related sleep disorders using proven, effective behavioral and non-pharmacologic (non-prescription medication) approaches. He helps patients develop tools and skills to get a better night’s sleep.

Learn more about Dr. Blackburn
Transcription Melanie Cole (Host): Most of us experience bad dreams or nightmares at one time or another and then we soon forget about them but for some, frequent or severe nightmares can become a cause for concern. Today my guest is Dr. Richard Blackburn. He’s a board certified behavioral sleep medicine psychologist at the Allina Health Cambridge Clinic. Welcome to the show, Dr. Blackburn. Let’s just start with talking about the difference between a bad dream, a nightmare and something that would qualify as a true nightmare disorder.

Dr. Richard Blackburn (Guest): Certainly. Thanks for having me, Melanie. A bad dream is just a bad dream that’s unpleasant or undesired but it really differs in intensity from a nightmare. Nightmares are extremely upsetting dreams that usually involve threats of some kind, whether it’s the survival, security or physical safety and they occur in the second half of the night when we spend more time in REM sleep, which is often called “dream sleep.” When people wake up from a nightmare, the person usually will become oriented and alert, but they’ll vividly remember the dream and, usually, the person will experience a length of time when the content can remain upsetting. A nightmare disorder really has to do with how frequently the person has it. The criteria for a nightmare disorder says that that person has to have nightmares at least once per week and for longer than a month. Frequent nightmares can often really cause a lot of distress to the person; it can impair functioning and daily life; it can impact mood, quality of life, work and even social functioning abilities.

Melanie: And, how do all of these differ from night terrors? My son had one once and it was quite frightening to behold.

Dr. Blackburn: It is and that’s exactly it. They’re frightening to behold. Sleep terrors or night terrors often occur in young children but they can persist into adulthood. They occur in the same stage of sleep as when a person would sleepwalk which is different from the stage of sleep where nightmares typically occur. During a night terror, the person will often cry out or scream and they’ll appear very frightened, panicky or agitated. They may even be confused, mumble or resist attempts to comfort them. Unlike nightmares, however, night terrors usually aren’t remembered by the person who’s having them and, therefore, they’re not upsetting to the individual but, like you experienced, they can be really upsetting to the person witnessing them. Night terrors don’t occur when the person is dreaming and they tend to occur during the first half of the night when slow wave sleep or deep sleep is predominant. So, a lot of times, night terrors will happen within the first 2 hours of sleep.

Melanie: What a fascinating topic this is. Are some people just prone to nightmares and are there factors? When our kids are little we say, “You can’t watch a scary movie. You’ll have nightmares.” But, even as adults and in this day and age, it’s easy to have bad dreams and nightmares about things. Are some people just more prone to these?

Dr. Blackburn: Some people are. You know, nightmares are actually fairly common in adults, in general. About 2-8% of adults will report having problems with nightmares and, depending on which study you look at, 2-6% report having nightmares at least once per week or meeting the criteria for the nightmare disorder. Nightmares occur in rapid eye movement sleep which is the stage of sleep when most dreams occur. This is a stage of sleep that’s preserved. So, if you don’t get enough sleep or you become sleep deprived, we tend to go into REM sleep earlier in the night and we spend more time in REM sleep and, therefore, more time dreaming. So, if the person is prone to nightmares, not getting enough sleep increases the risk of having them. The other thing is, anything that disrupts sleep, like another sleep disorder such as untreated sleep apnea, increases the frequency of remembering dreams or nightmares. So, we typically only remember a dream or a nightmare if we awaken after it. Most people will have 4-5 dreams in a night but they won’t remember them unless they wake up immediately following or during the dream. People who have a lot of stress in their daily lives are also more prone to nightmares. A person under significant stress is more likely to have negative dreams. It’s been suggested but not completely proven that when we dream, we consolidate memories, process events of the day and kind of help regulate the day’s emotions. So, if a person has a lot of negative emotions during the day, that’s likely to be reflected in the content of their dreams at night. There are also certain mental health conditions that tend to increase the risk of having nightmares—things such as depression, PTSD or anxiety disorders can increase the risk of nightmares and, in fact, about 80% of people who have PTSD report PTSD related nightmares. In fact, nightmares are actually part of the diagnostic criteria for nightmares. Also, people who are using certain substances like drugs and alcohol, whether they’re illegal drugs or prescription medication, some of those can also increase the risk of having nightmares. So, there are several antidepressants, barbiturates which aren’t used very much anymore, beta blockers that we use to control blood pressure the neuroleptic medications that are often used to control seizures or psychosis, and even several of the Parkinsonian medications are well-known to increase nightmares. The other thing is that sometimes when we withdraw or we stop taking a medication or a drug, that also increases the risk of having nightmares. So, people who are coming off older antidepressants, alcohol or amphetamines have a greater chance of having nightmares. Then, I just want to say if you think your medications are causing nightmares, it’s really important that you talk to a physician before you stop taking them because just quitting some medications can actually be risky.

Melanie: Dr. Blackburn, is it true the myth that people say that “bad things can’t really happen in your dreams; in your nightmares”? That they almost happen but then stop before they actually do happen?

Dr. Blackburn: You mean like the old idea that you can’t die in your dream?

Melanie: Yes. Exactly.

Dr. Blackburn: If you die in your dream, you’re actually going to die? No. That’s not true. Bad things can happen in dreams. A lot of times, at that point, a person becomes so emotionally loaded that they’ll often wake up before the bad thing happens. But, you can experience bad things in dreams and that can be incredibly frightening for people.

Melanie: Very frightening. Can you change your dreams if you’re somebody who’s subject to some of these nightmares? We’re going to talk a little bit about treatment but can you change what happens during that type of sleep?

Dr. Blackburn: Yes. So, there’s a skill that’s gotten some research that’s referred to as “lucid dreaming”. Lucid dreaming is where the person is aware that they are dreaming and they can change the content of their dreams. Some people believe that this is a skill that can be taught but research hasn’t really held that out. There’s another treatment that’s referred to as image rehearsal therapy or IRT and image rehearsal therapy actually was something that was really studied by the VA and the Department of Defense to treat PTSD related nightmares. But, in it, one of the things we think nightmares are is that it’s a way of consolidating new learning and things that you think about during the day. So, if you spend a lot of time thinking about the nightmare you had last night, you’re rehearsing it and in that way, it can become a learned behavior and it’s more likely to happen again the next time you sleep. So, image rehearsal therapy is a way of rehearsing the dream but changing it in some way that makes it less scary. So, an example of this is, I had a patient who had a car accident and at night, when she would fall asleep, she would see the headlights coming toward her. When we did image rehearsal therapy, she changed it so she had the Roger Rabbit car where the car could go up and over the headlights.

Melanie: Wow.

Dr. Blackburn: And it didn’t actually change that way in her dream but because she changed the dream in a way that was not upsetting, the frequency of the dreams just kind of went away and she just stopped having them.

Melanie: Wow. That is so fascinating. When should listeners—at what point when they’re having these nightmares—should they seek help?

Dr. Blackburn: Well, most adults are probably going to have a nightmare. In fact, most people listening to this have probably had one. Like I said, they’re very common. As long as they don’t become habitual, or they don’t influence your ability to function during the day or create a lot of distress or problems with sleep, the person probably doesn’t need any help but if the person has frequent nightmares and these awful dreams carry over and really impact their ability to function the next day or if they disrupt sleep so significantly that they can’t get sufficient sleep or if they become habitual and just really affect the person all the time, there are effective treatments that available and the person doesn’t have to suffer from these.

Melanie: Dr. Blackburn, in the last minute, what an interesting topic this is. We could talk about it quite a long time. Please give your best advice for the listeners, to those suffering from bad dreams, nightmares or might possibly have nightmare disorder?

Dr. Blackburn: So, if they’re going to get treatments from them, there’s different types of treatment. There are two that are considered Level A treatments or they’re ones that have been consistently well-supported by research. Those are a medication called Prazosin or Minipress which is a medication which is usually used to control blood pressure but it affects dreams. What they’ve found is, for people who have nightmares that are related to PTSD, Prazosin can be a wonderful medication and help to reduce the frequency and the intensity of nightmares. There’s also some evidence that if you just experience a traumatic event, Prazosin may actually prevent you from developing PTSD. Prazosin, however, doesn’t seem to help with non-PTSD related nightmares or, at least, it tends to be much less effective for those. The image rehearsal therapy that we talked about is also a Level-A treatment and that seems to work both for PTSD related nightmares or nightmares that tend to be somatic. So, the person has a consistent theme every night in their dreams. If they’re just random bad dreams or random nightmares, IRT may not work but it’s something that you can try.

Melanie: Wow. What great information. Thank you so much. You’re listening to The WELLcast with Allina health. For more information, you can go to AllinaHealth.org. That’s AllinaHealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

The Latest Advancements For The Treatments of Heart Arrhythmia

Additional Info

Segment Number 1
Audio File meridian/1550md1a.mp3
Doctors Koo, Charles
Featured Speaker Charles Koo, MD
Guest Bio Dr.Charles Koo's specialties are Cardiology -Clinical Cardiac Electrophysiology.

Learn more about Charles Koo, MD
Transcription Bill Klaproth (Host): Do you sometimes feel your heart pounding or feel it racing? It could be atrial fibrillation. My guest today is Dr. Charles H. Koo, cardiac electrophysiologist with Meridian Cardiovascular Network. Dr. Koo, thank you so much for being on with us today. So, let’s jump right in. What is atrial fibrillation or A-fib?

Dr. Charles H. Koo (Guest): Atrial fibrillation is a chaotic upper chamber heart disorder where the upper chambers beat so quickly the mechanical function of the heart doesn’t perform. What happens is that you lose that efficiency of the heart and it can sometimes make the heart beat very quickly. The heart rate is typically very irregular and patients can suffer from congestive heart failure.

Bill: What is the general cause of A-fib?

Dr. Koo: That is a good question. There are a lot of reasons. Most of it is related to age. You can have co-existing medical conditions that can be strongly associated with it. Things like sleep apnea, high blood pressure, diabetes, open heart surgery, congestive heart failure. Those are things associated with it. Thyroid condition, so on and so forth. The list is pretty broad. Most of it is related to some type of aging process of the heart.

Bill: Are there symptoms with this? I know you said it is a rapid, chaotic heartbeat. Do people feel this? Are there other symptoms?

Dr. Koo: Fair question. Patients can develop symptoms from this, for sure. Some patients develop the sensation that their heart is pounding out of control. They feel short of breath, dizziness, sometimes they can experience chest pain. It depends on the patient. Some patients are apathetic or what we consider to be highly a-symptomatic where they don’t really realize it at all. Some patients are totally unaware of their atrial fibrillation. I would say the majority of patients are aware, especially if it is relatively new. If it has been ongoing for a while, some patients make adjustments and they get accustomed to it. They don’t really report any symptoms for it.

Bill: How do you diagnose it? How do you find it out in someone who has it if they are not having any symptoms?

Dr. Koo: Generally, it’s a diagnosis made on an EKG. Once we have a confirmatory EKG, it will demonstrate it for us. Sometimes you can actually listen to the heart but that is a little bit difficult to do with most folks who don’t have cardiac training. But, for the most part it is an electrocardiographic diagnosis.

Bill: This sounds pretty scary. Anytime you hear about somebody with a heart condition, especially something like this where the heart is, it sounds like, beating out of control. How serious is this? Can people die from this?

Dr. Koo: There is a certain risk associated with it. It is mainly related to your other medical conditions. There is a risk stratification formula that we use to figure out whether folks are going to get sick from it, particularly when we talk about strokes. It depends on the individual, generally speaking. The big worry is the risk of stroke and/or heart failure. Those are the two big co-morbidities associated with atrial fibrillation.

Bill: Are there other complications from A-fib besides stroke or heart failure?

Dr. Koo: You can be very short of breath. It depends on the patient’s capacity and their ability to adjust for their change in physiology. Some patients feel extremely short of breath. Some folks can pass out, depending on how fast they are going. Those are the main side effects associated with it.

Bill: Dr. Koo, once someone is diagnosed with A-fib how do you treat it?

Dr. Koo: That’s a great question. Again, the two concerns are risk of stroke, heart failure and/or symptom controls. We have a point system that we use to decide whether the patient is worthy to have a blood thinner on their medical regimen. That consists of things like heart failure, high blood pressure, your age. There are two cutoffs for that--age 65 and 75. Diabetes, prior stroke, your gender. If you’re a female patient, your risk is higher. If you have prior vascular disease, your risk is higher. So on and so forth. In terms of symptom control, we generally ask the patients how they feel. If their burden is very high, that would mandate a more aggressive therapy, a more aggressive program to try to get them back within normal heart rhythm.

Bill: You mention medication such as blood thinners. Are there others? I’ve heard of electric shock or is there a situation where a pacemaker is used?

Dr. Koo: Correct. When we try to restore the heart rhythm out of atrial fibrillation back to normal, we can do that with a variety of ways. We can cardiovert or just gently shock the heart back to normal heart rhythm. There is a list of cardiac medications that we use specifically for this. It’s a very long list. All of them have good things and bad things associated with it. Certainly, most of us would try a couple of drugs first before we divert to a surgical strategy. There is an operation called an “ablation” that we do in some patients, if they qualify. Generally speaking, you can jolt the heart back to a normal heart rhythm. You can try to keep it out of atrial fibrillation or convert it with medications and if you need to you can physically go inside the heart and try to cauterize the electrical tissues responsible for atrial fibrillation.

Bill: For someone with A-fib, can it be cured? Are these one-time events or, once you have it, you have it and it’s got to be managed for a life time?

Dr. Koo: A small percentage of patients can have a curative ablation. That’s for sure. I’d say the majority of patients, you manage it or contain it. I think that is a more truthful statement. Regarding the ablation for atrial fibrillation, the surgeries work fairly well. They are not perfect operations but they are better than the heart rhythm medication that we do have at hand. That’s why some of us will try to convince patients that an ablation is probably worth their time, especially if they’ve tried a couple of medications and it hasn’t been terribly helpful.

Bill: With A-fib, what I’m getting here is that it comes and goes at times and you can manage it. Are there certain events that make it worse? Like somebody is having a normal day and all of the sudden, “Oh, it’s coming on. My A-fib is here. I feel my heart racing.” Is that true? Are there certain events that bring A-fib on?

Dr. Koo: In terms of triggers for atrial fibrillation, there is a list of things that can trigger atrial fibrillation. Things like intrinsic lung problems, congestive heart failure, high blood pressure, ischemic heart disease, heart attacks – technically. Thyroid condition can trigger atrial fibrillation. There are other heart rhythms that trigger atrial fibrillation that are not atrial fibrillation. There’s something called SVT or supraventricular tachycardia that can certainly trigger atrial fibrillation. There is a long list of things that can be the precipice for atrial fibrillation in some patients.

Bill: What about things like energy drinks?

Dr. Koo: That’s an interesting question. Energy drinks, depending on what you drink and how much you drink, contain a variety of substances including high levels of caffeine. There’s all sorts of energy boosters, vitamins, there is a mishmash of things that you have to be a little bit careful. It’s hard to get sick from caffeine unless you overdo it. There are certainly many, many examples of folks who have passed away or have gotten very sick because they were caffeine intoxicated. In energy drinks, if you kept it to a common sense level of consumption, you’re not going to get acutely ill but if you overdo it, there is a good chance you could get sick from the active ingredients inside these beverages.

Bill: I better put that third cup of coffee down then.

Dr. Koo: I think that’s probably not the case. I think if you’re addicted to this stuff and you drink it large volumes then, yeah, you can get pretty sick from it.

Bill: Let me ask you this. Are there things that people can do on their own for A-fib, such as eat a particular diet or exercise or quit smoking--things like that--that help prevent it?

Dr. Koo: That’s a very good question. There was a recent scientific trial from Australia that looked at precisely this question. Long story short—essentially, they took folks who were little heavy or very heavy and they committed them to a weight loss program. It turns out that just pure weight loss or weight control – and it’s not much; really, about 10-20% of your initial body weight. If you can lose that weight and keep it off, the incidence of A-fib drops quite a bit. More importantly, if you are able to lose that weight before your ablation, your ablation or your surgery tends to work better, which I find very interesting. So, in other words, if folks can keep themselves healthy through diet, exercise and common sense things, you can actually get your body to get rid of the A-fib, at least in part which I think is a very, very intriguing way of treating this without pills, without an operation, without some of that stuff we do in the hospital, then. Some forms of A-fib could be a marker of just an unhealthy lifestyle and an unhealthy patient.

Bill: Very interesting. Very interesting. That’s very good to hear. There is, I don’t want to say a bright side, but here is an upside to this that for taking care of yourself, eating a healthy diet, doing all the normal healthy things to stay healthy could potentially help someone with A-fib. That’s very interesting information. Dr. Koo, thank you so much for being on with us today. Why should people choose Jersey Shore University Medical Center for their care?

Dr. Koo: We’re fortunate to have a lot of great technology here in the laboratory. We have a high volume in the laboratory of experienced practitioners who do this operation every single day. The volume here has grown exponentially over the last three to four years due to the hard work of lots of people involved. A lot of us were classically trained in electrophysiology, so we know who to bring to the laboratory and who not to bring to the laboratory. Most of us have a very good philosophy in terms of committing folks to a healthy lifestyle first before thinking about a surgery. So, all in all, we have the experience, we have the practitioners, and the technology and we are more than happy to help folks with this condition.

Bill: Dr. Koo, thank you so much, again. We appreciate it. For more information, please visit MeridianHealth.com. That’s MeridianHealth.com. This is the Meridian Physician Podcast with Meridian Health. I’m Bill Klaproth. Thanks for listening.
Hosts Bill Klaproth

Orthopedic and Spine Care Made Easy

Additional Info

Segment Number 2
Audio File manchester/1549mcm2b.mp3
Doctors Gupta, Giriraj
Featured Speaker Giriraj Gupta, MD
Guest Bio Dr. Giriraj Gupta was born and raised in Alwar, Northern India. He enjoys soccer and cricket, but most of all he enjoys cooking as his biggest stress reliever. Dr. Gupta believes that being a physician is just as much a privilege as a great responsibility to provide care to patients in the best way possible.

Learn more about Dr. Giriraj Gupta
Transcription Bill Klaproth (Host): Being told that you have a spinal or orthopedic disorder is often a worrying and stressful experience. However, understanding the causes can help reduce your fears and provide a roadmap to manage the pain. With us is Dr. Giriraj Gupta, a Harvard graduate and an orthopedic and spine surgeon at Manchester Memorial. Dr. Gupta will discuss orthopedic and spine care made easy including pain management and neuromodulation. Dr. Gupta, thanks so much for being on with us. First off, what condition of the spine do people suffer from the most?

Dr. Giriraj Gupta: Well, most commonly, lower back pain and neck pain are the two conditions that patients walk into the clinic for and most of the time, it’s general degenerative changes. We also call it arthritis of the back which is the most common cause of why people have pain in their neck and the lower back. There are other conditions which are called herniated discs which means there’s a cushion between the bones of the spine that makes a hole to the back and starts pressing on a nerve. That’s called a “disc herniation” and that can cause a lot of pain in your leg because the nerve gets stressed and the nerve is what’s supplying the sensation in the leg. So, that’s no uncommon. Then, the other condition that is fairly common is a slip in the spine which we call “spondylolisthesis.” That’s a condition where two bones constituting the spine start slipping in relation to each other rather than being stable. Those conditions are fairly common that I see on a regular basis in my clinic.

Bill: Those things can happen through one, an injury; a fall; trying to lift something or just normal wear and tear over time, right?

Dr. Gupta: Most of the time, these conditions are not resulting from trauma. Of course, once in a while, you have a patient that will say, “I was lifting something and then I heard a pop in my back” but a lot of times, it is the back degenerative condition or that’s the back you have and it just didn’t take the stress of normal work which resulted in those conditions. Now, there are those conditions which can arise from trauma but they usually end up going to the E.R. because of conditions like fractures but more common causes of back and neck pain are degenerative.

Bill: And, on the orthopedic side, what are the more common things you see? Obviously, people suffer from and you hear a lot about carpal tunnel syndrome and elbow pain and knee problems. What’s the most common thing that you see in your practice?

Dr. Gupta: I would say there’s a range of disorders that I see in the office on a day to day basis but if I had to pick the top 5 problems that patients come up with in my office, I would say arthritis of the knee would be number one. Number two would be something like a carpal tunnel or a trigger finger in the hand and then, the third would be the lower back pain, the neck pain and then fourth and fifth would probably be conditions like a rotator cuff disorder in the shoulder and then other conditions which are like ankle pain, foot pain. Those are the top 5 conditions which probably constitutes about 30-40% of my patient population.

Bill: Okay. Help us, then. Give us some tips on how to prevent some of these problems.

Dr. Gupta: Okay. So, the most common problem I would just mention is just arthritis of the knee. Now, it can be prevented. I would say, you can’t prevent but what you can do to ensure that it doesn’t come early and it doesn’t affect you early and then, if it does, it doesn’t progress that fast, and some of the common things we can all do is keep your body weight near to the normal, ideal body weight. Studies have shown that once you have a wear and tear condition in the knee, then if your body weight is more than usual, or more than normal, then the wear and tear process is much faster. Of course, educating kids and, you know, more training in sports activities minimizing trauma of the knee is also one condition that can help prevent the wear and tear that arises from subtle injuries that happen. Once we prevent those initial injuries, the later population in their 40’s and 50’s will notice a difference in the frequency of when they start having the knee pain. There are other conditions like patients, when they start having the knee pain, I would say, avoiding certain activities like jogging or running on a concrete surface and going for less painful options like swimming or elliptical exercises—those are the conditions when you have knee pain, because of arthritis, you can somehow slow down the progression of the wear and tear. Unfortunately, some of the conditions are not totally preventable because it’s inherent with the human posture, the way we walk, there will be wear and tear on the knee. It’s just different on how patients get affected on different ages.

Bill: So, a great tip there. Maintain a normal body weight; minimize trauma during sports; avoid jogging or running on concrete surfaces and maybe switch it to something less impactful like swimming. So, Dr. Gupta, if someone is suffering from a spinal or orthopedic issue, how do you then best manage the pain?

Dr. Gupta: Well, initially, most of the time, the patients will have seen their family care physicians and even actually before that, they would have tried over the counter pain pills which are things like Motrin and Aleve and Tylenol. Then, there are prescription pain medications that you can take but if things don’t respond to these or they relieve in the short term, then there are other interventions that can be done, some of them by family care physicians like joint injections and spinal injections. A lot of times, at that point, the physicians will refer to a specialist like an orthopedic specialist or a spine specialist. When patients come to us, there’s a range of things that we can offer them starting from activity modification education, physical therapy, injections, minimally invasive interventions and then, of course, the surgical intervention. So, depending on the patient’s need and the severity of the problem, the treatment varies but most of the patients respond to conservative measures and not all of them need surgery.

Bill: Right. So first off, you’ve got your over the counter pain pills, your potentially prescription medications, spinal injections and then surgery are the different courses of treatment. So, talk to me about neuromodulation. What is that?

Dr. Gupta: Well, as the name suggests, modulation the way that nerves are doing their function. Now, neuromodulation has been there for quite some time. But, as spinal intervention has increased, so has the number of cases that have failed intervention so there’s a renewed interested in neuromodulation. This is a procedure that’s indicated for patients whose leg pain or back pain is mostly neurogenic in nature which means the nerves are getting irritated, compressed or making a person feel a lot of pain in their back or leg. So, what essentially this procedure does is it tries to gauge or monitor the way the nerves are carrying their impulses across the spinal cord to your brain to make you feel that they are being painful. So, imagine if I can put a small electric device over the nerve and stimulate it so that the normal conduction of pain impulse is lost, then your brain would probably feel that there’s nothing painful there. So, this is what the neuromodulation is based on.

Bill: It’s very interesting. So, it is a non-invasive technique? That’s what it sounds like.

Dr. Gupta: Well, it’s a minimally invasive technique. It’s nowhere near as invasive as a spinal surgery or a lysotomy or cutting your nerve. It is invasive but most of the time, it can be done with minimally invasive procedures and even if it requires an open procedure, the managing of the surgery is much less than any of the other procedures that a lot of patients need for their back or leg pain.

Bill: Is this a one-time procedure or does the patient need to come back several times when they’re getting neuromodulation?

Dr. Gupta: If it’s properly chosen for a particular patient, usually it requires a trial procedure which just ensures that the patient is the right patient for the procedure and once the trial is successful, if the patient gets good relief after trial, that is the one time procedure. Then, we require implantation of an electrode in your spine and then, of course, a battery that can fire that electrode. Once put in, they don’t need to be removed for a long, long time. These days, I think the batteries last for several years so nothing needs to be changed. The batteries can be charged from outside just as your cell phone is charged. Of course, you don’t need a cable to charge it. So, yes, once the hardware is in, it can last several years without really changing anything.

Bill: That’s really interesting. So, is this kind of a last resort, then, if all the other treatments don’t work?

Dr. Gupta: Well, I would say it’s a good option for patients who have failed the back surgeries or who have other conditions like complex regional pain syndromes; people with neuropathy pain with diabetes which is very, very common where I work. So, in those conditions where nerves seem to be why you’re hurting, this is a very reasonable and a good option.

Bill: Fantastic. Great information, Dr. Gupta. Thanks so much for being on with us today. For more info, you can visit ManchesterMemorial.org. That’s ManchesterMemorial.org. This is The Manchester Difference. I’m Bill Klaproth. Thanks for listening.
Hosts Bill Klaproth

Delivering the Best Heart Care Close to Home

Additional Info

Segment Number 1
Audio File manchester/1549mcm2a.mp3
Doctors Otalvaro, Lynda
Featured Speaker Lynda Otalvaro, MD
Guest Bio Dr. Lynda Otalvaro is a Cardiologist with Manchester Cardiology Clinic. She was born and raised in Columbia, and is the first physician of her family. She was an active player on her home town water polo team, which achieved entry to the national games during her tenure. Dr. Otalvaro believes that prevention is the key to living a long and healthy life.
Transcription Melanie Cole (Host): Have you ever wondered what role eating habits play in your heart health? My guest today is Dr. Lynda Otalvaro. She’s a cardiologist with Manchester Cardiology Clinic. Welcome to the show, Dr. Otalvaro. Tell us, what are we doing to ourselves that is contributing to heart disease?

Dr. Lynda Otalvaro: Thank you very much for the invitation. So, nowadays is the diet is increased with processed food. So, we are eating too much cookies, too much potato chips, pasta, crackers, French fries and a lot of food with a high content of sugar and bad fat. If we include not doing much exercise and smoking, we are increasing the risk of having cardiovascular disease.

Melanie: As a nation, we eat so much sodium and sugar. How do these contribute to heart disease? What are they doing to our blood pressure and our overall heart health?

Dr. Otalvaro: Yes. So, a diet with a high content of sodium, which is salt, increases volume in our body which is going to increase the blood pressure. At the end, patients will become hypertension, which is a disease that increases the risk of having heart attacks, strokes, atrial fibrillation and diseases like heart failure. So, just increasing the salt in our diet, we are increasing the risk of having a very dangerous and deadly disease.

Melanie: When you take our blood to give us a check-up every year and you’re looking at our blood levels of cholesterol and CRP and homocysteine, what are you looking for, Dr. Otalvaro, that would tell us that maybe our diets are contributing to heart problems?

Dr. Otalvaro: Okay. That’s a great question. So, when I check cholesterol, there are different cholesterols. We have bad cholesterol. We have triglycerides and we have a good cholesterol. With the bad cholesterol, I will if you are eating too much fried food, too much sugars that will increase your triglycerides. For example, if you are a person who smokes and has a sedentary lifestyle—just sitting on the couch watching TV—you will probably have good cholesterol that will be low and the good cholesterol is low if you don’t eat fish or vegetables. Other things that increase this cholesterol is avocado, for example, or nuts. So, in the diet, just with the test, I can figure out what’s the diet. Also, with the CRP, if I check this level, if it’s too high, it’s a predictor of cardiovascular diseases and pro-heart attacks in a period of time, in 10 years. So, if the patient comes and we do some testing and the patient is having some symptoms, we can catch the patient earlier.

Melanie: So, let’s talk about fats. You were mentioning cholesterol. So, what are some good, healthy fats? You mentioned avocado and fish. What else should we be eating that are good, healthy fats that may even help us prevent heart disease?

Dr. Otalvaro: Yes. So, one of the good things is, I mean, we are in a health environment. If we go outside, we have a lot of green. We have the possibility of having vegetables from our own garden. So, any kind of vegetables, fruits, nuts, grains. If we increase the content of fish which has Omega 3, we don’t need to take Omega 3, which is a huge pill, and that will contribute to health. Other things that we can add is, for example, yogurt instead of whole grain milk or decrease other kinds of food that has a lot of sugar and fat. Other things that we can eat, for example, can be eggplant, zucchini, spinach, mushrooms, olives, apples, grapes and all kinds of things that are in nature.

Melanie: So, a good plant-based diet is really what you’re recommending. What about exercise? Where does that fit in?

Dr. Otalvaro: Yes, exercise is key. It’s very important. Having a sedentary lifestyle we know increases cardiovascular disease. So, we are recommending, according to the ACC guidelines, to do a physical activity every day. We used to tell patients to do it 3 times a week. Now, it’s every day at least 30 minutes of brisk walk. Having an active job, for example, sometimes patients say they are very active in their jobs but that doesn’t mean that they are physically active. That means that they have a job with a lot of stress and they’re active. What we need is the patient to go outside, enjoy the park, go with adequate shoes and clothing and then decrease stress and go do their walking which should increase intensity with time according to the patient’s regular physical activity and capacity.

Melanie: If we’re trying to eat healthier and we’re cooking with fats and solid fats and now that trans fats are disappearing from our diet, what do you tell your patients about the proper way and the best way to cook their foods?

Dr. Otalvaro: Yes, I’m noticing that my patients are cooking with grease and I usually tell them to hold on this practice and probably to use other kinds of oil. The first thing is, please don’t fry food but if you do it, do it with probably canola oil. But, whatever you do, if you fry the food, any goo oil will lose the good components and the components we want to protect our hearts. So, I usually tell them, for example, try grilled food and if, for example, with salads, I usually tell them to not put so much dressing because dressing has salt and sometimes sugar and all the benefits of the salad, we are decreasing with the dressing. So, I usually tell them to do the olive oil with the salad and do not use salt but use pepper or lime or lemon instead of other components to get the healthiest diet.

Melanie: That’s great advice. What about cutting down on sugar? We see so many people drinking soda and sugary beverages. What do you tell your patients about those?

Dr. Otalvaro: That’s an excellent question. I usually ask what kind of hydration they have and they usually tell me they drink pop. So, that’s new to me. They drink like 10 pops a day and that certainly is not a good way to hydrate our bodies. So, I usually tell them to cut down or quit sodas and to hydrate themselves with water. That’s better or any beverage that the component of sugar is very low, close to zero.

Melanie: In just the last minute, Dr. Otalvaro, give your best advice for the role that our eating habits play in preventing heart disease.

Dr. Otalvaro: Yes. My best advice is what we eat is what’s going to determine our cardiovascular health. So, everything depends on us. So, if we are conscious about all these issues of food, if we try our best to eat healthy and stop processed food and fried food and fast food and spend more time with our families and eating healthier, we’re going to have a healthier life and probably live longer.

Melanie: Thank you so much. It’s such great information. You’re listening to The Manchester Difference with Manchester Memorial. For more information, you can go to ManchesterMemorial.org. That’s ManchesterMemorial.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Pelvic Floor Disorders: Don’t Let Them Slow YOU Down

Additional Info

Segment Number 4
Audio File city_hope/1541ch2d.mp3
Doctors Wittig, Kristina
Featured Speaker Kristina Wittig, MD
Guest Bio Kristina Wittig, M.D., is a urologic surgeon and an assistant clinical professor of surgery. Dr. Wittig attended medical school at SUNY Downstate Medical Center College of Medicine. She was a recipient of multiple awards and honors including Magna Cum Laude / Alpha Omega Alpha Medical Honor Society. Dr. Wittig completed her urology residency at University of Connecticut Health Center. Dr. Wittig went on to complete her Urologic Oncology Fellowship at City of Hope, Duarte.

Learn more about Kristina Wittig, MD
Transcription Melanie Cole (Host): Although an estimated one-third of American women are affected by pelvic floor disorders which include urinary and fecal incontinence, as well as uterine and vaginal prolapse, cultural constraints and embarrassment keep many sufferers from discussing their conditions or seeking treatment. My guest today is Dr. Kristina Wittig. She is a urological surgeon at City of Hope. Welcome to the show, Dr. Wittig. What is the pelvic floor?

Dr. Kristina Wittig (Guest): Pelvic floor are the muscles that hold your bladder and your uterus and vagina in place, basically. After you have children or when you get older, the pelvic floor muscles relax and you can have a prolapse of the bladder; you can have prolapse of the uterus and the vaginal wall. Those can cause various symptoms such as incontinence or other lower urinary tract symptoms. Also, pressure and pain in that area.

Melanie: What are some of these disorders? We see those commercials, Dr. Wittig, for women, adult diapers, and medications for incontinence. What are some of the pelvic floor disorders that we’re speaking about?

Dr. Wittig: There are different types of incontinence. You can have stress incontinence. You have urgency incontinence. Some women just have some irritating voiding symptoms, such as they have urinary frequency and urgency. Those things can definitely interfere with your quality of life because your life pretty much revolves around the bathroom. Also, you can have pelvic organ prolapse such as urinary prolapse, vaginal wall prolapse, or bladder prolapse.

Melanie: Is there a certain cause you can point to for these disorders? You mention having a baby.

Dr. Wittig: Yes. Most of them are child-bearing, just because that is one of the important factors which can cause relaxation of the pelvic floor muscles.

Melanie: So, what do we do about it? If women are incontinent, and, of course, this is something very embarrassing but if women come to you to discuss this or they’ve had one of the urologic cancers and as a result now suffer from pelvic floor disorder, what do you do for them?

Dr. Wittig: Depending on what type of incontinence or what symptoms they are experiencing, there are medications that we can try that helps relax the bladder and reduce the amount of incontinence or reduce the urgency and frequency sensation. There are also some conservative options that we try if somebody has urge-related incontinence we can try Botox injections to the bladder to try to relax the bladder muscle. There is also sacral nerve stimulation for women with urgency frequency and urgency incontinence, but also some women who are enduring urinary retention that could work and sacral nerve stimulators implantation of a little device like a pacemaker into your sacral spine, a little electrode goes into your spine, and you have this pacemaker-like device implanted into your upper buttocks and that stimulates the nerves that control the bladder and are very effective in reducing urgency frequency and urgency incontinence symptoms. Then, there are surgical options such as repair of the pelvic floor prolapse. There are various surgical options, depending on what you present with.

Melanie: Is there any issue with working on Kegel exercises if you are somebody with some kind of urologic cancer – doing those exercises before you do surgery or after? Is there therapy that you recommend women do to help strengthen their pelvic floor muscles?

Dr. Wittig: Kegel exercises are something that all women should do, actually--especially women who are having children or had children, even women who haven’t had children. Those are just good general things to do to keep your pelvic floor muscles strong. Also, not only women but males who have a prostatectomy for prostate cancer also end up with stress incontinence and we also encourage them to do Kegel exercises before their surgery and after their surgery because they have a similar type of problem.

Melanie: If they go on medications that you were mentioning, or do biofeedback or Botox, is this something that they would have to do again? Would they have to be on the medications for a long time or is it something that maybe would come and go?

Dr. Wittig: Also, I forgot to mention pelvic floor physical therapy. That has shown to be very effective also because physical therapist teach them more effective techniques than just Kegel exercises to try to strengthen the pelvic floor. As far as the medication, if the medication is helping you – the medication that was taken to relax the bladder – if it’s helping then it’s a lifelong daily medication that you take. Botox is something that would usually have to be injected about every six months because it is not something that is permanent.

Melanie: What about the pelvic sling? Women hear about this. We hear about commercials and see things in the media. Tell us a just little about the pelvic sling and what’s involved in having one put in.

Dr. Wittig: A pelvic sling is usually performed for women who suffer from stress incontinence which is incontinence that you have when you are coughing, sneezing, laughing, jumping, and any kind of stressful physical activity, basically. It is a sling that is put in that holds your urethra up and helps prevent the leakage. I know there has been a lot of talk in the media about vaginal mesh and various lawsuits related to that; however, that does not apply to the pelvic sling so much. But, for women who are very reluctant to undergo this type of surgery because they are worried about the mesh and all the bad publicity that it has gotten we do offer an autologous sling, which basically is an option to harvest your own piece of fascia from the lower abdominal wall and then you use that as a sling material to do the same thing.

Melanie: Wow. That’s really fascinating. In just the last minute here, Dr. Wittig, what do you tell women that come and they are embarrassed about talking to you about painful intercourse, urination or even fecal incontinence, just something they don’t want to think about or discuss but it is affecting the quality of their life? What is your best advice and why should they come to City of Hope for their care?

Dr. Wittig: I usually tell them this is nothing to be embarrassed about at all. I see a lot of women suffering from the same problems. If there is something we can do to help and even improve their symptoms even just a little bit, I think it can make a tremendous difference in their quality of life.

Melanie: Why should they come to City of Hope for their care?

Dr. Wittig: Because City of Hope has the best trained physicians. The majority of us who do this type of surgery or any kind of cancer surgery are fellowship trained. We can offer the latest, the best techniques to perform these procedures.

Melanie: Thank you so much, Dr. Wittig. Its great information and so important for women. You’re listening to City of Hope Radio and for more information you can go to CityofHope.org. That’s CityofHope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

Hypersensitivity Pneumonitis: What Are the Most Common Causes and Treatments?

Additional Info

Segment Number 5
Audio File virginia_health/1547vh5e.mp3
Doctors Gomez-Manjarres, Diana
Featured Speaker Diana Gomez-Manjarres, MD
Guest Bio Dr. Diana Gomez-Manjarres is a board-certified physician in internal medicine whose specialties include hypersensitivity pneumonosis and interstitial lung disease.

Learn more about Dr. Diana Gomez-Manjarres

Learn more about UVA Pulmonary & Respiratory Care
Transcription Bill Klaproth (Host): This is Bill Klaproth in for Melanie Cole. Breathing in certain substances often causes hypersensitivity pneumonitis. What are the two types of hypersensitivity pneumonitis and what are the causes and treatments? Here with us today is Dr. Diana Gomez. She is a UVA specialist in pulmonology, a board certified physician in internal medicine whose specialties include hypersensitivity pneumonitis and interstitial lung disease. Dr. Gomez, thank you so much for being on with us today. Let’s start right here. What is hypersensitivity pneumonitis or HP?

Dr. Diana Gomez (Guest): Good afternoon. Hypersensitivity pneumonitis is a lung condition that is caused by inhalation of some type of allergen that is in the environment, usually mold or a bird antigen and when I say that, I mean an exposure to chicken or feathers could cause it. What you see in the lungs is some inflammation, sometimes its scar tissue. The reason why this happens is because it is an immune response to these allergens that are in the environment. It can happen from exposures that you have at home or actually in your work environment.

Bill: When you say “inhaled substances” such as mold or chicken feathers, things like that, I’m thinking of a guy on a construction site inhaling sawdust or concrete dust or some type of insulation dust. Can somebody get hypersensitivity pneumonitis from that, too?

Dr. Gomez: What usually happens is the dust that you get exposed to in a construction environment causes a different type of condition. It’s not hypersensitivity pneumonitis. It’s called “pneumoconiosis,” which is completely different. Hypersensitivity pneumonitis happens when people are exposed to organic allergens.

Bill: Okay, now I understand. Very good. I just wanted to clarify that for people listening right now. Are there different levels of HP?

Dr. Gomez: Yes. The presentation is different. The big groups are acute presentation and chronic presentation and the symptoms vary accordingly. When a patient has acute hypersensitivity pneumonitis, the most common symptoms happen four to six hours after the exposure. Usually, people have fever, flu-like symptoms. They feel tired, headaches, chest tightness, cough, shortness of breath. Those last for a few hours until the exposure is resolved. It is acute and improves in a few hours. The other type is called “chronic HP” or “chronic hypersensitivity pneumonitis” and that happens to patients that are being exposed without them knowing that they have the exposure. They don’t have this acute presentation. They just start feeling short of breath and start coughing over time. When we see them in clinic, they already have scar tissue in the lung. They never had an acute presentation or they maybe just thought it was a viral infection and they just disregarded it. When they come to clinic, it is a little advanced, if you want to say it that way. There is already scar tissue in the lungs.

Bill: Someone with acute the symptoms come on hard and fast. Do they go away, then?

Dr. Gomez: Yes, they go away. They usually go away after they stop exposure to the allergen.

Bill: Someone with chronic, this is where they are constantly coughing, maybe having tightness of chest, breathing issues where they are constantly having it?

Dr. Gomez: Right. They present with a more chronic picture. Like, it happens over a month, most of the time.

Bill: What are the classic symptoms then? Is it mainly the coughing and shortness of breath?

Dr. Gomez: For the chronic one, yes. Cough, shortness of breath. Some people have some unintentional weight loss.

Bill: How can someone be diagnosed with HP?

Dr. Gomez: Unfortunately, we don’t have a system that is evidence based yet because it is a condition that we need to have much information before we come to the diagnosis. Basically, we need to get a very good history from the patient. We always ask them about exposures and, as I said, mold exposures. We usually see this in people who have humidifiers, dehumidifiers at home, any water damage in their basement, or they live on a farm and they have moldy hay. In the history, the patients have to tell us about the exposure. The next step will be some blood work. If the patient is unaware of exposure, the blood work may tell us if they are being exposed to something that could cause this condition. The next step is a CT scan or some type of chest imaging and there are some changes. One of them is scar tissue, some inflammation in the lungs. There are certain patterns that we see that make the diagnosis higher on our list. After the CT scan and all of the blood work, then we may consider something called “bronchoscopy:. That is when we go inside the lungs with a camera and get some fluid washings and then some type of cells that we get from those washings will make the diagnosis, again, more possible. Sometimes just with exposure with the CT scan and the bronchoscopy, we can make the diagnosis but if it still unclear to us why the patient has this issue we may need to get biopsies. The way that we do them is doing the same procedure as the bronchoscopy. When we do the washings, we will do some cell bronchial biopsies. They actually have a high yield to make the diagnosis. But, if those are unrevealing the next step will be a surgical lung biopsy. Of course, it is patient based. We want to make sure that the patient’s lung function is good enough for them to undergo that type of invasive procedure. We need different information before we come up with the diagnosis. There is not a straightforward diagnosis.

Bill: If someone is diagnosed with HP then, it is really incumbent upon them to find out what in their environment is causing this. Correct?

Dr. Gomez: That is correct. Actually, sometimes when we send the blood test in and it comes back positive for mold exposure or chicken exposure, sometimes they have to have the house professionally inspected because sometimes they are unaware of the exposure.

Bill: Right. Then, you know. If left untreated can this disease lead to something more serious?

Dr. Gomez: The acute presentation the patients usually do okay, meaning they stop the exposure and then they improve. But people who present with chronic HP, they can progress to respiratory failure, meaning they will need oxygen. They may retain carbon dioxide. It’s a little more serious once the lungs are scarred down and, unfortunately, we don’t really have medications to get rid of the scar. If it’s inflammation, we can use medication to improve the inflammation but once there is scarring in the lungs, then, unfortunately, there is not much that we can do at that point.

Bill: So, it’s crucial to find out early what in the environment is causing the HP and get rid of it so you don’t wind up in a situation where you do have scarring of the lung. What treatment options are available to somebody with HP?

Dr. Gomez: As you said, actually, the main goal is to identify the allergens and avoid further exposure. If there are birds, remove them. If the patient has been exposed at work, then they need to change jobs. Actually, some people actually had to change houses just because they were exposed and they couldn’t remediate the mold. It’s that serious. If they fail to resolve the allergen exposure, that will, of course, increase the chance of progression and development of this irreversible lung damage.

Bill: They’ve got to find it and get out of there. Right. Why should someone come to UVA Pulmonary and Respiratory for treatment?

Dr. Gomez: One thing I wanted to add, in terms of management, the therapy.

Bill: Okay. Go ahead.

Dr. Gomez: There is some medication called Prednisone that sometimes we use and it will help the inflammation to come down. What we see on the CT scan is mostly inflammation. It doesn’t take care of the scar tissue but it improves inflammation and that may help the patient to feel a little better. All of the medications because it is an inflammatory condition. You want to fight the immune system, it weakens the immune system. The ongoing inflammation may be taken care of by all of the medications. What I mean by that is there is something called Isoptin or Mycophenolate that we usually try. Those take care of the inflammation so that we don’t have to use the prednisone in the long term. We don’t think it is a good medication chronically because it has so many side effects and those include diabetes, high blood pressure and other problems.

Bill: It’s good to know that there are ways that you can relieve some of the symptoms with somebody with HP.

Dr. Gomez: Right.

Bill: So, why should someone come to UVA Pulmonary and Respiratory for their treatment?

Dr. Gomez: I think the main reason why people should come to UVA is because we have very experienced physicians that we have seen many cases and then we know how to approach this condition and how to get the patient’s work up. We have all the resources that the patient needs to come up with a diagnosis and then therapy for them. It is a very experienced team and we’ll do what’s best for the patient.

Bill: That sounds great. Dr. Diana Gomez, thank you so much for being on with us today. We really appreciate it. For more information please visit UVAHealth.com. That’s UVAHealth.Com. I’m Bill Klaproth in for Melanie Cole. This is UVA Health Systems Radio. Thanks for listening.
Hosts Melanie Cole, MS

How Can Sarcoidosis Be Treated?

Additional Info

Segment Number 4
Audio File virginia_health/1547vh5d.mp3
Doctors Vranic, Andrew
Featured Speaker Andrew Vranic, MD
Guest Bio Dr. Andrew Vranic is a board-certified physician in pulmonary medicine and critical care medicine whose specialties include sarcoidosis.

Learn more about Dr. Andrew Vranic

Learn more about UVA Pulmonary & Respiratory Care
Transcription Bill Claproth (Host): Hi. This is Bill Claproth in for Melanie Cole. Sarcoidosis is caused by inflammation in the lungs and can cause an array of symptoms. What are the causes and symptoms along with treatment options? Joining us is Dr. Andrew Vranic, a UVA specialist in pulmonology, board certified physician in pulmonary medicine and critical care medicine whose specialties include sarcoidosis. Dr. Vranic, thank you so much for being on with us today. Let’s start right at the beginning. What is sarcoidosis?

Dr. Andrew Vranic (Guest): Thank you for having me today, Bill. Sarcoid is actually an idiopathic disease which means that we actually don’t know what causes it. We assume that in certain susceptible individuals something in their environment triggers it for them to develop this type of inflammation in their body called “granuloma inflammation”. This inflammation usually affects the lungs but it can actually affect any part of the body. Again, it most commonly affects the lungs which is why it is treated by lung doctors like myself. Outside of the lungs, it can affect almost anything. More commonly after the lungs, things like the skin, the eyes, other lymph nodes in the body and even sometimes, in rare cases, the heart and the brain. So, it can go pretty much anywhere.

Bill: Does it always start in the lungs?

Dr. Vranic: The symptoms that bring it to light don’t always necessarily have to do with pulmonary symptoms but almost everybody with sarcoid will have some lung involvement.

Bill: What are the common symptoms associated with sarcoidosis?

Dr. Vranic: Interestingly many patients won’t have any symptoms at all with sarcoidosis. They may come to light incidentally, such as when they get an x-ray for some other reason. Maybe their primary care doctor orders an x-ray for bronchitis or pneumonia but the x-ray ends up showing some findings suggestive of sarcoid and then they are sent to us. If they are going to have symptoms, usually the symptoms are lung related because, again, the lungs are the most commonly involved organ. They may have symptoms like shortness of breath, chronic cough, occasionally chest pains. Many of them will have non-specific symptoms such as fatigue. Like I said earlier, because sarcoid can involve any other part of the body besides the lungs, you need to look out for the heart, the skin, things like that as well. It can actually present in a myriad of ways but most often with pulmonary symptoms.

Bill: If someone comes to visit you, how is it traditionally diagnosed then?

Dr. Vranic: Usually by the time they get to see me we have a pretty good suspicion already based on the x-ray and they probably had a CT scan of their lungs as well. Once you suspect it, you almost always want to do a biopsy to see if they actually have that type of inflammation that I mentioned earlier – that granuloma inflammation. You want to biopsy the easiest thing to get at. So, if they have a rash that is usually a good place to start because the skin biopsy is pretty easy; it’s fairly non-invasive. In general, though, most of these patients, because most of them have some pulmonary involvement, most of them will get a lung biopsy which is done via a procedure called a bronchoscopy. Most of the time people with sarcoid will actually have enlarged lymph nodes or glands around their airway. We actually do a very cool procedure these days called an EBUS which stands for “endobronchial ultrasound”. That actually allows us to get inside their airways. Through, this very small ultrasound on the end of our scope we can actually look through the airway, outside of the airway, visualize the lymph nodes sitting outside the airway, and actually visualize our needle going through their airway into that lymph node. The cool thing, too, is we usually have a pathologist in the room with us when we do this, so they can tell us almost instantly whether or not we’ve gotten the diagnosis.

Bill: Is sarcoidosis confused with other diseases? It seems like this is kind of like an unknown disease. It sounds like you are getting to the point now where you can easily diagnose this, where you know right away instead of “you may have this; you may have that”. Is that correct?

Dr. Vranic: That’s, more or less, correct, yes. Most of the time, sarcoid presents fairly straightforwardly--again, usually with pulmonary symptoms or abnormal x-rays, or abnormal CT scans of the lungs. But, as you mentioned earlier, it certainly can be confused with a lot of other things, in part because it can affect so many organs of the body outside of the lungs. I’ve certainly had patients who had no problems breathing but they presented with difficulty walking, difficulty with their gait and balance and ended up having sarcoid in the brain. Patients present with palpitations and, again, their lungs were fine, but they had sarcoid involving the heart that is causing them to skip beats and have palpitations and things like that. Because it can present in so many ways, it can often be confused with many different diseases and often is quite a complicated diagnosis to make. Most of the time, that’s not true, but certainly it can be true.

Bill: What treatment options are available to patients suffering from sarcoidosis?

Dr. Vranic: The nice thing about sarcoid is that in the vast majority of patients, they are going to do just fine. About 50-75% of them are going to experience a resolution of the disease within a few years, usually without treatments. For the majority of the patients we see in clinic, it is more watchful waiting to make sure they don’t develop any manifestations of sarcoid that does need treatment. In the small subset of patients that do require treatment, they can often be quite sick. In about 5-10% of those patients, they might have very severe fibrosis in their lungs from their sarcoid or they may have heart involvement or brain involvement that requires treatment. In those patients, the disease can be quite debilitating and life limiting. For those patients, we usually put them on medicines to suppress the immune system or weaken their immune system, if you will, and thus calm down that inflammation that I alluded to earlier that’s causing all the problems. Traditionally, patients have been treated with steroids although the problem with steroids like prednisone is that when they are given long term, they can often have really terrible side effects, sometimes worse than the disease itself: things like osteoporosis, issues with their sugar, blood pressure, weight gain, fluid retention, cataracts, etc. There are other drugs sometimes referred to as “steroid-sparing agents” that can be given long term that will weaken the immune system enough to suppress the sarcoid without causing all of those terrible side effects.

Bill: You said in a high percentage of patients, it just goes away.

Dr. Vranic: It does, yes. So, again, most patients present with mild sarcoid and most of those patients – about 50-75% of them--will experience resolution of the disease without treatment at all. Their symptoms are mild, if present at all. Again, most of the time, our job is to do no harm and to monitor them should they develop things like heart involvement or worsening lung disease that would require treatment.

Bill: Is it fair to say, then, most people will live a normal life after being diagnosed?

Dr. Vranic: I think that’s a very fair statement. I think that the vast majority of patients with sarcoid can and will live a normal life with their disease. It’s just that small subset of patients that develop that very severe pulmonary fibrosis or disease outside of the lungs that can often be quite sick.

Bill: Are there certain environmental conditions that exacerbate it? I happen to have a nephew that has this and cold weather makes it worse for him. Is it true that where you live can make a difference in this?

Dr. Vranic: In general, no, environmental factors don’t play much of a role in sarcoid. Some people with sarcoid will actually have involvement of their airways as opposed to the lung tissue, the lung parenchyma itself. In those patients, they can often have what acts like asthma almost. In those patients, changes in the weather and things like that do make their symptoms worse. They have more of a cough and perhaps more shortness of breath as well.

Bill: Who is more susceptible to get this? Is it anyone or a certain type of person that would have a higher incidence to get this?

Dr. Vranic: Absolutely. That’s a great question. In general, this is a disease of younger people. Most of the time it comes to light usually between the ages of 20-40. It affects younger people, not older people. It is more common in African-Americans than in whites or Caucasians and a little bit more common in women as opposed to men.

Bill: Okay. Interesting. Dr. Vranic, thank you so much for being on with us today. Last question. Why should someone come to UVA Pulmonary and Respiratory for treatment?

Dr. Vranic: We actually have a clinic at UVA specifically tailored to patients with diseases like sarcoid called “The Interstitial Lung Disease Clinic”. Sarcoid, like so many of these lung diseases, is pretty rare and it is often complicated and it is a disease that many pulmonary physicians don’t see on a regular basis. I think there is a lot of evidence out there, the best example being something like cystic fibrosis, that when you have a really complex illness, you want to see a group of physicians that focus on just that one disease and take care of only these patients on a daily basis. By doing so day in and day out, they get to be truly experts of managing that disease. I think that they have better outcomes. There are currently three of us in the ILD clinic at UVA--Dr. Borna Mehrad, Dr. Diane Gomez and myself--that focus just on these diseases – these interstitial lung diseases like sarcoid. We really enjoy taking care of patients with those diseases. We really enjoy treating them. I think that’s my reason.

Bill: Absolutely. We’ve been talking with Dr. Andrew Vranic a UVA specialist in pulmonology. Thank you so much again for your time today. Very interesting. For more information please visit UVAHealth.com. That’s UVAHealth.Com. I’m Bill Claproth in for Melanie Cole and this is UVA Health Systems Radio. Thanks for listening.
Hosts Melanie Cole, MS

Should I Be Screened for Lung Cancer?

Additional Info

Segment Number 3
Audio File virginia_health/1547vh5c.mp3
Doctors Malpass, Howard
Featured Speaker Howard Malpass, MD
Guest Bio Dr. Howard Malpass is a board-certified physician in pulmonary medicine and critical care medicine whose specialties include lung screenings.

Learn more about Dr. Howard Malpass

Learn more about UVA Pulmonary & Respiratory Care
Transcription Melanie Cole (Host): Should you consider lung cancer screening? And, what’s involved? My guest today is Dr. Charles Malpass. He is a board certified physician in pulmonary medicine and critical care medicine whose specialties include lung screenings. Welcome to the show, Dr. Malpass. Have there been any recent changes to the screening criteria and what exactly is cancer screening?

Dr. Charles Malpass (Guest): Absolutely. A large part of this is based upon a publication from 2011 in the New England Journal of Medicine. It actually showed that we can save lives by doing a low dose lung cancer screening CT scan of the chest. There are three societies that have weighed in on what is the target population for lung cancer screening. But, the big piece to know is that at age 55-75, someone who has smoked for greater than 30-pack years. To do the calculation, if you smoked one pack of cigarettes for one year, that’s a one-pack year, so 30-pack years in total. Or, if you were, let’s say two packs a day. That’s only 15 years of smoking. And, the person who is a current smoker or has stopped smoking in the past 15 years has really been our target population for lung cancer screening.

Melanie: What’s involved in the screening? Is this a complicated thing?

Dr. Malpass: No. It’s very simple. It’s a low dose CT scan of the chest. This is a radiation exposure comparable to a mammogram or, basically, a few chest x-rays. There are no IVs. There are no medicines given to you for that and it only takes a few minutes in the CT scanner to obtain the study.

Melanie: If people have been 30-year pack smokers, or 15, or even a half a pack a day, are they somebody who should get screened? Who do they talk to, first of all? And is this something that insurance will recognize?

Dr. Malpass: Absolutely great questions. Really, what was done with the study and what we are doing now to try to mirror the findings and the work process of the study is trying to capture that highest risk population which would include people that had recently quit smoking within the past 15 years and who have had a large exposure with that 30-pack year history. We do not know the answer to the question of if you’ve smoked for a 15-pack year history, is this a beneficial screening study for you? That answer is just not known and has not been studied yet. We chose the highest risk population to say, “Could we exert a benefit for these patients with that?” We just don’t know that second question yet.

Melanie: If somebody does get screened, what are you looking for in that screening?

Dr. Malpass: What we’ve done here at UVA is had the radiologists pattern their practice of reviewing the CT scan in identifying small nodules. What we want to do is be able to find lung cancer early so that we can enact change upon it, mostly through surgical methods of curative intent. The problem with lung cancer is the lung does not sense pain itself. So, by the time someone develops symptoms associated with their lung cancer often it’s too late. We can’t make huge differences in their care as far as complete removal of that lung cancer. If we find it early, we really can embark on improving their mortality and also markedly improve it there. What we want to do is be able to find small nodules in the earliest stage of lung cancer in the lung itself.

Melanie: Dr. Malpass, we use the word “screening”, so it’s not a diagnostic test. Is this something that goes on a permanent record because people hesitate to go in to have something that they think is going to follow them.

Dr. Malpass: It is a study that the results of will be in your medical record. Though and I completely agree that it is not a definitive test in that you can identify a nodule of the lung, but it really takes following that nodule over time and/or a diagnostic procedure of sampling that nodule to be able to say what it is from. If we look at our population as a whole here in central Virginia and across the eastern seaboard, there are a very large number of people who have never smoked and that are going to have lung nodules on their CT scan which should not affect their healthcare or their access to their healthcare and can be a very benign finding. With the screening CT scan, we often do find something and that’s why we want to target the highest risk population of those former smokers to be able to increase the probability of that being a possible cancer in our diagnostic procedures.

Melanie: What about the non-smokers? Can they get screened as well?

Dr. Malpass: At this time, I do not think it’s beneficial for those people to get a screening CT scan. Lung cancer does occur in the non-smoker, though to a much smaller extent in comparison to the smoker. It’s a balance of exposing those people to radiation that they don’t need to be exposed to. If we do find something, exposing those people to potentially the risk of a diagnostic procedure whether it be a biopsy or further radiation screening. We do not think that is immediately beneficial for those people in that screening process.

Melanie: Does insurance cover this particular screening?

Dr. Malpass: Good question. If done correctly and mirroring the trial that it was done where you have the discussion of the benefits of screening, the risks of screening, the radiation exposure, and also targeting the right population, if that’s done correctly in concert with a smoking cessation intervention, it should be covered most often by insurance providers in this process with the appropriate documentation.

Melanie: Are there any recent advances and exciting things that you want to quickly discuss in the field of lung cancer treatment? Things you want the listeners to know about what’s going on out there in the field of research?

Dr. Malpass: Absolutely. What we’re trying to do on the pulmonary side, which often is on the front end and diagnostic end, identifying patients that do have lung cancer and appropriately getting them into oncological care and surgical care as appropriate, is that we have methods of minimally invasive methods of sampling the lung and identify what that process is. Here at University of Virginia, we offer bronchoscopic procedures that would facilitate a sampling of lymph nodes central into the chest which is a same day procedure and can be done under minimal sedation--the same sedation that would be done for a colonoscopy. We offer procedures where we can target legions from the inside bronchoscopically navigating through a CT scan. Also, on the radiology side, they offer comprehensive services as far as diagnosing from the outside and in biopsy via a CT scan, as well, too, abnormal legions. Additionally, and importantly, if it is a malignancy, targeting that person’s malignancy through genetic testing. We offer TruSight genetic screening panel which is done on all non-small cell lung cancers that are of adenocarcinoma and can really allow us to do some targeted new therapies which are exciting in practice.

Melanie: That’s absolutely fascinating. In just the last minute, Dr. Malpass, why should someone come to UVA Pulmonary and Respiratory for their treatment?

Dr. Malpass: Absolutely. I think we do an excellent job of coordinating our services. On a weekly basis, we meet as a group and allow close face-to-face communication of providers that are all helping take care of patients. So, if, unfortunately, someone does develop lung cancer, face-to-face I’m talking to surgeons that can potentially provide curative care. I’m talking to the oncologist. I’m talking to radiologists that are specialized in thoracic imaging. Additionally, I’m talking to radiation oncologists. Under one roof, you have specialists in all fields of medicine to compliment that care to try to get them early, aggressive care in treating their process.

Melanie: Thank you so much. You’re listening to UVA Health Systems Radio. For more information, you can go to UVAHealth.com. That’s UVAHealth.Com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Treatment Options for Interstitial Lung Disease

Additional Info

Segment Number 2
Audio File virginia_health/1547vh5b.mp3
Doctors Mehrad, Borna
Featured Speaker Borna Mehrad, MD
Guest Bio Dr. Borna Mehrad is a board-certified physician in pulmonary medicine and critical care medicine whose specialties include interstitial lung disease.

Learn more about Dr. Borna Mehrad

Learn more about UVA Pulmonary & Respiratory Care
Transcription Melanie Cole (Host): Interstitial lung disease causes scarring of the lungs and can be a lifelong chronic health concern. My guest today is Dr. Borna Mehrad. He is a board certified physician in pulmonary medicine and critical care medicine whose specialties include interstitial lung disease. Welcome to the show, Dr. Mehrad. What is interstitial lung disease?

Dr. Borna Mehrad (Guest): Hello. Interstitial lung disease is really not one disease. The best way to describe it is as a category of illnesses. There are perhaps 200 illnesses that fall under this umbrella term interstitial lung disease. All of these, what they have in common is varies degrees of fibrosis, scarring and inflammation in the lungs. Because there are a large number of illnesses that fall into this category, it is very important to identify which specific one a patient has because the treatment and outcome and so on of the illnesses are quite different.

Melanie: What are some of the risk factors and symptoms and potential causes of these diseases?

Dr. Mehrad: The most common, or the one that has the most press, is an illness called “idiopathic pulmonary fibrosis”. IPF is an illness of unknown cause that results in scarring of the lungs. Smokers are overrepresented in patients with idiopathic pulmonary fibrosis. There is often a remote history of smoking. In addition, there are also increasing numbers of genetic conditions that are being discovered with patients with idiopathic pulmonary fibrosis. However, many patients that are labeled as idiopathic pulmonary fibrosis--in other words, they are labeled as this person has pulmonary fibrosis and we don’t know the cause--once you look into the illness in a lot of detail and assess it, you find an identifiable cause for the interstitial lung disease. I’ll give you some examples of that. There is a condition called “hypersensitivity pneumonitis”. That’s a mouthful. This is a condition where the body’s immune system that is meant to be fighting off infection makes an error and attacks inhaled substances that it should be ignoring. As a byproduct of this attack, it results in inflammation and scarring of the lung. This is very common in our practice. We see people who have had exposures – even low level exposures to things like mold in their environment or agricultural environments or pet birds – and, as a result of this, they develop lung inflammation and scarring that is often mistaken for idiopathic pulmonary fibrosis. This is a really important distinction, though, because both the outcome and the treatment for hypersensitivity pneumonitis and IPF are very different. Another example of an interstitial lung disease that can be mistaken for IPF are autoimmune diseases. The most famous of these are illnesses like lupus and rheumatoid arthritis. These are illnesses where the immune system actually attacks parts of the body by mistake. These illnesses can affect many organs in the body but almost all of them affect the lungs. In our practice, we often see patients whose lung symptoms predominate over their other problems. They may or may not have skin problems or joint problems but when they are really short of breath and progressively short of breath, that’s the thing that brings them to the doctor. When we look at it in detail, we find that, in fact, instead of having IPF, they have one of these autoimmune diseases. Again, the illnesses, treatment and prognosis are very different and really quite better than IPF.

Melanie: What symptoms would someone notice? People cough or they think it’s bronchitis. These symptoms can be nonspecific. What would send them to see you?

Dr. Mehrad: The lung only has one of a few ways in letting you know that something is wrong. The most common complaint is progressive shortness of breath. The person has shortness of breath. They notice that in carrying the groceries in from the car or going up a flight of stairs, they get more short of breath then they used to be. This is something that slowly progresses over time. Now, compared to six months ago compared to a year ago, they’re more short of breath. As you said, cough is also a symptom, although this shortness of breath is the most common thing that we see. Most patients who have shortness of breath in this way, initially go to their general doctor and often they get a chest x-ray and so on. Often patients with interstitial lung disease are initially thought to have something else. It’s not rare for our patients to have initially been treated for other more common lung diseases, such as asthma or COPD. After some period of time, when their symptoms don’t resolve, often months pass and then, eventually, they get referred on when the diagnosis is made.

Melanie: What are some treatment options that are available - medication, oxygen, therapy? Do we do pulmonary rehab using spirometer? What do they do for interstitial lung disease?

Dr. Mehrad: The first thing when we see a patient with interstitial lung disease is, we want to really work hard to identify the cause. Part of identifying the cause we do, as you said, spirometry depending on the severity of the illness, CT scan, and a bunch of blood tests. Depending on what we find, that guides further workup as to the cause, as to the underlying etiology. Your question is about treatment. A couple of things in pulmonary medicine have been clearly shown to prolong life in people with significant lung disease regardless of the actual cause of the lung disease. The first is, anybody who smokes has to stop smoking. Stopping smoking definitely prolongs life. The second is that we want to make sure that people are up to date on their vaccinations because people who have severe lung disease are more predisposed to more severe respiratory infections and if they get them they will do badly. We want to make sure that we reduce the likelihood to ensure that they have had their flu and pneumonia shots. The third issue, which is a very important issue is oxygen. In people, basically the way we measure oxygen is using a machine called a “pulse oximeter”. This measures oxygen as a percent saturation of hemoglobin. A normal saturation is about 95%. Expert data shows the longer a person spends below the threshold of 88%, the shorter the time they are going to live. So, we want to make sure that we give patients that have below 88%, however much oxygen they need to make them stay above 88% the whole time. These are generic treatments not specific to interstitial lung disease but they are extremely important treatments because they prolong life. Depending on the specific cause of the illness – what is the cause of their interstitial lung disease – we want to attack the underlying process. That depends, as I say, very much on what they have. For many of these illnesses, the high percentage of pneumonitis that I mentioned, for example, identifying the environmental exposure that caused the illness is very important. So, you want to avoid that. For these immunological illnesses such as autoimmune diseases and hypersensitivity pneumonitis, immune weakening medicines often have a role. And, most importantly, in the past year, two new drugs were approved by the FDA for the treatment of idiopathic pulmonary fibrosis. These drugs really transformed the landscape of how these patients are treated. University of Virginia was the center for testing one of these drugs – Pirfenidone. In the appropriate person--in the person who has idiopathic pulmonary fibrosis and not one of these other etiologies--treating the underlying disease with one of these drugs is an excellent choice because it slows the progression of the illness.

Melanie: In just the last minute, Dr. Mehrad, why should someone come to UVA Pulmonary and Respiratory for their treatment and your best advice for someone who is suffering from lung disease?

Dr. Mehrad: What we offer is real world experience. These illnesses are not a common part of the practice of a general primary doctor, even an excellent primary doctor. We have three physicians that all we do is see people with interstitial lung disease. Our volume of patients is very large and, necessarily, our experience in dealing with them is very large. The second reason is we have a multidisciplinary team of lung doctors, radiologists, pathologists, and a number of ancillary services that we put our heads together and provide the best information about what the person has to try to help them. Lastly, research. We are a center for research in these diseases trying to find new treatments to try to help patients. Patients have the opportunity to get enrolled in clinic trials contributing new knowledge about their illness.

Melanie: Thank you. It’s such great and very important information. You’re listening to UVA Health Systems Radio. For more information you can go to UVAHealth.com. That’s UVAHealth.Com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

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