Studying a common childhood virus; preserving personal memories; treating arthritis of the hand: Upstate Medical University's HealthLink on Air for Sunday, Feb, 6, 2022
Pediatrician Joe Domachowske, MD, tells of a clinical trial aimed at preventing a common childhood virus. Editor Deirdre Neilen, PhD, talks about preserving memories of the pandemic. Hand surgeon Brian Harley, MD, shares treatment options for arthritis of the hand and thumb.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air": a physician scientist is looking for a way to prevent respiratory syncytial virus in babies and toddlers...
Joe Domachowske, MD: "...The virus was discovered more than 50 years ago, and we have not been able to develop a vaccine for this particular infection. So the most promising movement in that direction has just been in the last few years..."
Host Amber Smith: ...a literary magazine editor gives advice for recording memories of the pandemic years....
Deirdre Neilen, PhD: . "...One of the things that we are always emphasizing to our med students is there's value in stepping away from a situation and thinking, reflecting..."
Host Amber Smith: ....and an orthopedic surgeon talks about treatment options for arthritis of the hands....
Brian Harley, MD: "...We know that in the hands specifically, women get arthritis moreso than men, . especially at the base of their thumb and their fingers..."
Host Amber Smith: ...all that, and a visit from The Healing Muse coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll talk about how and why you may want to preserve memories of the pandemic. Then, what are your treatment options if you develop arthritis in the hands? But first, a physician scientist is working on a way to prevent RSV, a virus that almost all children become infected with when they're young.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Almost all children will become infected with respiratory syncytial virus, called RSV, by the age of 2. Infections range from mild to more severe, and RSV is a common cause of hospitalization in children under the age of 5. But there's so much more that doctors still want to learn about RSV. And today I'm talking with the principal investigator of a study underway at Upstate. Dr. Joe Domachowske is a professor of pediatrics and microbiology and immunology, and he's a true expert in RSV. Welcome back to HealthLink on Air, Dr. Domachowske.
Joe Domachowske, MD: Thanks, Amber. It's good to be here.
Host Amber Smith: First, some clinical questions about RSV. How do you describe this virus?
Joe Domachowske, MD: RSV is a cold- and flulike virus. It comes every winter. It's quite predictable, although we don't know when the season will start and when it will go away. It's here every year. There's only been one exception. These are the babies, mostly under 2 years of age, that start with a nasty cold to have a lot of junk coming out of their nose -- we call it coryza, or just a diffuse rhinorrhea. And then they start to wheeze. Not all of them do, but the ones that develop lower respiratory infection begin to wheeze, and that's not typical for a lower respiratory tract infection in an infant otherwise. So pneumonia doesn't typically cause wheezing, but RSV causes this entity that we refer to as bronchiolitis. And that's a wheezing illness of infants and young kids.
Host Amber Smith: So, are pediatricians able to predict which child is going to have just the cold symptoms and the mild case versus the one that will develop the wheezing?
Joe Domachowske, MD: That's the tricky part, because we know that most kids will have this infection, at least once by the time they're 2 years old. And once the infection starts with the upper respiratory complaints, the coughing and the runny nose, we don't know who's going to progress. We know the high risk groups to progress. Typically the most common child in the hospital during the winter time has no underlying risk factors. Other than being only a few months old.
Host Amber Smith: You said they'll catch it, typically, at least once. Does that mean that if a child has RSV once, that doesn't protect them from getting the virus again?
Joe Domachowske, MD: The first infection that we get, all of us, is usually the worst of the bunch. And then we get a little bit of immunity from that. So subsequent infections tend to be much milder, and we even get reinfected with this during our adult years. So, it is a fairly common cause of just a regular common cold in adults. And if we're around newborn babies, we have to be careful because if we have RSV, we can subject them and expose them to the infection when they get sick for the first time with RSV. That's when they get into trouble.
Host Amber Smith: Why does RSV seem to prefer infants and toddlers? I know you said adults can get it, but doesn't it prefer the younger children?
Joe Domachowske, MD: It does infect and cause more dramatic clinical symptoms in the very young and in the very old, but the very young are being infected for the first time. So they have no immunity to this whatsoever. Subsequent infections occur in the context of some preexisting exposure and immunity. So the immune system is able to sort of dampen things down a bit. So typically the most severe of all of the infections will be in that first year or two of life.
Host Amber Smith: So, how do parents know? They may recognize cold symptoms, but how do they know that it's turned the corner and it's more of a severe, the bronchiolitis type of thing? Is it, is the wheezing sort of the giveaway?
Joe Domachowske, MD: Yes. And in the subset of the young infants that go from the upper respiratory infection to develop the lower respiratory tract illness with the wheezing, the first sign is usually that they'll start to breathe faster. And sometimes with effort. So you can see the babies tugging a little bit while they're breathing. And that's a pretty important clinical sign that we watch for as pediatricians, but the parents can also notice. Well, that doesn't look right. The breathing pattern just seems a little bit odd. In the first four to six weeks of life, RSV can be associated with apnea or periodic breathing, where the breathing sort of starts and stops.
And we often admit young infants, newborns, to the hospital with RSV because they sort of are forgetting to breathe, and we have to just watch them carefully until they're past that acute phase of the infection. So they're not having those periodic breathing spells anymore.
Host Amber Smith: If a child at home is treated appropriately or cared for appropriately when they first developed symptoms, will that prevent it from progressing?
Joe Domachowske, MD: We don't have any good prevention for that. And we can't predict which of these babies will progress from a cold to a lower respiratory infection itself. So really, it's watching them very carefully and knowing what to watch for: if the breathing rate starts to increase, or they look uncomfortable, if their nose is completely clogged. You know, young infants are obligate nose breathers, so they can't breathe and eat at the same time if their nose is completely congested. So we have to watch all of those things. And often, the reason for hospitalization may not be related to a need for oxygen for the respiratory infection. It may be because they become dehydrated because they just can't eat. They're breathing too fast.
Host Amber Smith: This is Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with Dr. Joe Domachowske. He's a professor of pediatrics and of microbiology and immunology at Upstate. And one of the projects he's involved with is a study on respiratory syncytial virus or RSV. So tell us about your RSV clinical trials that you have underway. Is it true that you're following 3,000 children from several different countries in different parts of the world?
Joe Domachowske, MD: The combined trials that we have been working on do include over 3,000 babies, yes, in over eight countries, both in the Northern and Southern hemispheres. So it is a lot of activity and, trying to figure out a safe and effective way to prevent this infection has been impossible for the last 50 years. The virus was discovered more than 50 years ago, and we have not been able to develop a vaccine for this particular infection. So the most promising movement in that direction has just been in the last few years. The type of studies that we're working on now are monoclonal antibody studies, where the babies are given these monoclonal antibody injections. And then they're followed over the course of the cold and flu season to see which ones become infected. Because of the way the studies are designed, some of the babies actually get the antibody itself and others get a placebo, or a salt water injection. So we've been able to show how well this antibody works in a number of different circumstances in the highest risk babies. And we've just started to enroll term newborns, in these trials as well, because it looks like this stuff is really working. Finally, we have a strategy that's going to change the landscape of RSV infection for pediatricians and for families, hopefully across the world, but certainly across the US.
Host Amber Smith: The way you described, it sounds like a vaccine, but it's not a vaccine, is it?
Joe Domachowske, MD: Well, it's an immunization and, broadly speaking, immunizations are divided into two major categories. We have active immunization, typically referred to as vaccines, where we give doses in combination over time and eventually are able to boost doses or boost immunity so that there's, long-term protection. The other type of immunization is called passive immunity. That's where we just give the antibody itself because we can't figure out how to administer a vaccine by itself that can cause that same degree of protection. So this monoclonal antibody actually provides much higher level of protection than even a natural RSV infection.
Host Amber Smith: Wow. So would it protect the baby during toddlerhood and childhood, or would it protect them for life? Or maybe you don't know yet?
Joe Domachowske, MD: Well, the passive definition of immunization means that eventually the antibody is going to wear off. It's a protein, and it doesn't induce any active memory type immunity. So because we're doing it in a passive way, eventually it will wear off. And there's a tried-and-true concept with this because the very highest-risk babies have received a similar type of antibody, for more than a decade and a half. And we know that it works very well, but the downside is they need monthly injections. The change for this new strategy was to make the antibody more potent at neutralizing virus, but also to have a much longer half-life. So some very fine biochemical tricks were used to take this antibody instead of a half-life of 19 days, it has a half-life of more than 100 days. So a single dose at the beginning of RSV season can offer protection for five months or longer. And that's most important during the first year of life, because that's when most of the more severe illness happens.
Host Amber Smith: So for those who are participating, what is involved?
Joe Domachowske, MD: They come in for the screening visit to make sure they meet all of the criteria that are proposed in the protocol itself. And if so, we basically take a blood sample to look at their antibody levels at baseline. And they get the product, the investigational monoclonal antibody, at the same visit. They will be randomized of course, to get placebo, but none of us will know who gets placebo and who gets the antibody itself. It's a three to one ratio. So for every three children that get the antibody, only one will get placebo. So chances are pretty good that they'll get the real thing.
Host Amber Smith: And then, if over the winter months the baby becomes sick, does the parent call you, or do you get involved with them in any way after that?
Joe Domachowske, MD: Yep, we follow them for a full year, and we do passive surveillance, where we ask them to call anytime the baby develops any kind of respiratory signs or symptoms. And we also do active surveillance, where we reach out and touch base with the families at very specific times, over the course of the year. We also bring them in two other times for blood work, to check their antibody levels, to watch how the neutralizing antibody that they got at the beginning decays over time. So the pharmacokinetics, if you will, of how well their antibody will last in their system.
Host Amber Smith: Now, since you've looked at this disease in babies and other countries, I wonder, are there similarities or differences between how RSV presents in different countries or how it'streated?
Joe Domachowske, MD: The clinical presentation is very similar. And since we don't really have any treatment, other than trying to keep the nose as clear as possible and bringing them into the hospital to support their hydration or give them extra oxygen, or even more invasive type of respiratory support, it really depends on the hospital system and the resources that are available in that country. Of course we have optimal healthcare in the U S for young infants, and we can maximize the support that we can offer them. But in underdeveloped countries, often babies will just suffer at home, and if they can't work their way through the infection, many of them will die. So the main difference between what happens in the developed world and the underdeveloped world is that access to healthcare, that high-end of healthcare, a subset of those kids will die. So infant mortality is still quite high from RSV infection, if we're talking about areas of the world that aren't like the United States.
Host Amber Smith: Has the COVID pandemic had an impact on RSV in any way?
Joe Domachowske, MD: It sure did. When we first shut things down in March of 2020, we were in the middle of one of these studies, and we were at the end of our usual typical RSV season. We were getting two or three families calling us because the kids had respiratory symptoms from whatever cold and flu virus happened to be going around. And so we were doing surveillance and taking nasal swabs on all of those kids, every time they called us. Well, about a week after we shut everything down, those phone calls stopped completely. We didn't hear anything at all. Nothing. We were kind of surprised because we expect RSV to kind of linger through April and even maybe into the first part of May, typically, in Upstate New York.
We said, OK, well, you know, all the masking and social distancing must be influencing this to some degree. We'll just wait for RSP to come back that Halloween or Thanksgiving time in the fall. And it did not. It just disappeared. And we didn't have an RSV season that subsequent year at all until the following summer. It wasn't until July we started seeing cases, and we never see RSV disease in infants in the summer in Central New York. We just don't see it. So to have outbreaks, it wasn't an epidemic, but to see outbreaks in clusters of infection in July and August was extremely unusual. And I really think it has a lot to do with a relaxation of the distancing and the masking that people were doing, which was really protecting the babies from RSV and many other respiratory viral infections, including influenza.
Host Amber Smith: That's very curious. So it was just like a normal outbreak, except that it happened in July?
Joe Domachowske, MD: It started in this past July, and it has continued. So normally the RSV season that we suffer and deal with every year, we do not look forward to this as pediatricians. We know it's coming, and we just dread it. But we knew it was coming, eventually, and when it appeared early, we thought, well, maybe it'll fizzle out in five or six months. Nope. It has not. We continued to see them even now into January and, at this point, it's expected that we will continue to see cases of babies hospitalized with RSV infection even into March and April, because it's behaving now more like it used to in a typical season. It just started very early.
Host Amber Smith: Well, I'm sure you would not want parents to panic, but what do they need to know if their pediatrician diagnoses their child with RSV?
Joe Domachowske, MD: Just watch carefully for signs and symptoms of inability to feed effectively, depending on the baby's age, if they're nursing, or if they're taking a bottle. You want to make sure that they're not struggling to feed because they're trying to breathe instead, right? So if that starts to happen, we would bring those babies into the hospital, and we support them the best we can. We keep their nose and their upper respiratory tract as clear as we can using suctioning techniques and, a saltwater syringe with a bulb syringe to clean out their nose.
But there really isn't anything else that we can offer them as an outpatient because nothing works. Things have been tried, and they just do not change the natural course of this infection. When we bring them in the hospital, that's also true, but we have IVs. We can put IVs into babies, and hydrate them up. We can have a nurse at the bedside keeping their nose as clean and as clear as possible and supplemental oxygen or more invasive types of respiratory support, as needed. So when those events start to be considered, that's when we bring the babies in, and the younger, they are, the more inclined we are to hospitalize them.
Host Amber Smith: Well, good luck with the clinical trials, and I really appreciate you making time for this interview.
Joe Domachowske, MD: My pleasure. Thanks for getting the word out.
Host Amber Smith: My guest has been Dr. Joe Domachowske, a professor of pediatrics and of microbiology and immunology at Upstate and the principal investigator of a clinical trial on RSV. I'm Amber Smith for Upstate's "HealthLink on Air."
What memories of the pandemic are worth preserving -- next on Upstate's "HealthLink on Air."
From Upstate Medical University and Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." We're living through a pandemic, and some of us might want to leave our heirs with a description of what this time has been like. For help with that, I'm turning to Dr. Deirdre Neilen. She's an associate professor of bioethics and humanities at Upstate and the editor of Upstate literary and visual arts journal, The Healing Muse. Thank you for making time for this interview, Dr. Neilen.
Deirdre Neilen, PhD: Oh, Amber, thank you so much for thinking about it, and then for thinking of me with it, because all of your questions got me thinking in lots of different ways about the pandemic, and it was really nice to do.
Host Amber Smith: Well, there's been a lot of death and suffering the past two years, and there's been isolation from quarantine, tons of uncertainty. Is there value in making note of that in some way?
Deirdre Neilen, PhD: Obviously, I'm going to say yes, because I'm a person who teaches literature, and there's always a value in reflection. I mean, one of the things that we are always emphasizing to our med students is there's value in stepping away from a situation and thinking, reflecting. We encourage them on rounds to have a notebook and jot down something that occurs to them when they're listening to a patient's story. And I think that this time of uncertainty and suffering is just tailor made, obviously for people who want to reflect on their experiences through writing. That's not to say that there aren't a lot of other ways, obviously, but writing is such a simple way. We don't need a lot of fancy equipment. You don't have to sit down and take lessons.
I've noticed from my friends that many people are taking lessons, are using this time of isolation to sign up for classes or teach themselves how to play the guitar and knit -- you know, all very worthwhile projects, but you don't have to do any of that with writing. You just have to sit down and think.
And your original question was, is it worth it for the future time to think back on this, and I'm thinking, yes. I mean, would you agree that we live this, and I think that our nerves are just on edge lately. I mean, it's been two years of thinking we're almost done. We can start to relax. And then there's another variant or there's another fly in the ointment, et cetera. So, I would love to look back five years from now and think about what I thought at this time, because you'll forget that, you know. And I think that there would be value for you and value for the people who love you that want to talk about this time later on. So yes, I think there is value in that.
Host Amber Smith: Yeah. And even if some of those things are painful, you're right. Like, even just five years from now, we may not remember what we were feeling during the time that it was so painful.
Deirdre Neilen, PhD: Exactly, exactly. In this new issue of The Healing Muse, we got some beautiful poems, of course, about the pandemic, but there was one written by a physician. And she talked about the writing life with being a physician. And I think, if I could read a little bit of her poem to you, I think it bears on what we're talking about. She called her poem "Prayer Beads." Her name is Deborah Bayer.
"I long to leave the doctor's life behind,
"but patients are still pulling at my sleeve.
"I head for healing of another kind.
"Four days a week I keep a writer's mind
"and pray the words and stanzas flow with ease.
"I long to leave the doctor's life behind.
"The other three are days I run behind
"the schedule and try my best to please.
"I need a healing that is soft and kind.
"My pen moves smoothly over pages lined
"in purple ink. I argue my conceits.
"I long to leave the doctor's life behind."
And then she continues, but I think you get that sense of, there's a healing in writing. And I do think that people, especially who are feeling anxious or nervous, that writing could be a means, a bridge of getting from this kind of time to the future time, if you let yourself write everything that you're thinking.
And I'll give you an example. My mother is 97, OK, and she's having some cognitive difficulties. And she's aware of the pandemic and she's been given her shots and boosters. But she said to me one day, "you know, this crow virus is very scary."
And, I thought, OK, I mean, I could correct her and say, "it's COVID, it's whatever." But we had been looking at birds. She's finding that very relaxing to sit and look in my backyard at birds. And we had seen crows. And immediately my writer's mind was like, oh my gosh, crows usually are symbols of death, whatever, and here's my mom talking about the crow virus, and she's always asking, "is your brother safe from the crow virus? So, I'm starting to jot that stuff down. And if I were a poet, I would try and write a poem about crows and viruses and how this particular time could be encapsulated in that image.
So it's things like that, that I guess I would encourage people that you don't know where it's going to go, but if you hear something, write it down and think about it a little bit and then go back to it. And I think writing every day is a wonderful exercise, anyway. Some people call it a diary, some people call it a journal, it could be a meditation, but I think the pandemic has, it's turned our world upside down. We really don't know anymore what normal is. We keep talking about, let's go back to normal. And then some people say to us, it will never be normal again. We're going to have a new normal. So, I would like to have a record of what the old normal was, what it is I miss, and then what it is I'm compensating with now. And then later on, we'll see where that goes.
Host Amber Smith: Well, I know there are a lot of people that are probably already keeping photo albums or scrapbooks, or like you say, journals, and I know that you got a lot of submissions that had sort of a pandemic theme for The Healing Muse recently. In terms of like, how would someone who's not really a writer, how would you advise them to sit down and get started? I liked the suggestion you had with starting with a kernel. Maybe it's a crow, and just sort of let it percolate in your mind for a little bit. Do you have any other advice for someone who's just not used to doing a lot of writing?
Deirdre Neilen, PhD: Yeah. I think the biggest thing the biggest barrier with writing is our own self-judgment There are so many people that think, I can't do that. And so of course, the minute that you tell yourself you can't do something, it's very true that you can't do it as well. OK So the first thing is, no judgments. You get a little notebook, get something special, and you just make a commitment that at a particular time in the day, you're going to give yourself 10 minutes. When I'm teaching my writing courses, we do what we call automatic writing. And we sit together in silence. I might throw them out a few words, like "the door began to creak," or something like that, and then I say go. And we just all started to write. And we just go for 10 minutes, and then I ask them to be brave enough to read it. And when the course first starts, of course, there's usually one person that's always willing to read and everybody else is like, no, no, no, no, I couldn't read yet. But they see that there's a value. They start to really know each other better by what it is that they're writing about. And their writing gets longer and longer. And the 10 minutes, they fill a whole page.
So my advice for people is don't be worried that this is not going to be perfect. It's not about being perfect. We could work on perfect, if that's what you want to get to. But what you really want is the freedom to say what I'm feeling inside, which we rarely say aloud, the freedom to read it without judgment And just, like you said earlier, Amber, let it percolate. Let it just, what did that feel like? You know, if you have children at home, just describe something that they're doing. I mean, they are fascinating with the way they use language when they're learning, or the way they're talking with their friends. Just write a phrase down. And then just sit quietly. Although I just said you had children, so probably that's almost next to impossible, but work with me. We'll envision they've gone to bed, and you're sitting up for your 15 minutes of automatic writing. And we would just see, where this might go.
Host Amber Smith: So start with something that's an inspiration in some way. And the exercise you described, writing about the door creaking open, that sounds like one of the stream of consciousness, kinds of things that people just sort of tap into whatever's happening in their brain at that moment.
Deirdre Neilen, PhD: Yes. Yes. I have another example that I can give you also from the latest copy of The Healing Muse. We have a wonderful writer, who's also a teacher. Her name is Gloria Heffernan. And she's an excellent, excellent poet. And a family member had to go to the hospital for what we would call a day surgery, inpatient/outpatient but it was during the pandemic and you know, how awful that was especially in the beginning. And we're still having these aftereffects of what are the visitation policies allowed in hospitals, and what does it mean to, can we have surgeries, etc But what Gloria did was, she took that notion of outpatient surgery and just listened to what she did with it, OK?
"I have made the bed
"and washed the breakfast dishes.
"Because you have been fasting since midnight.
"Standard pre-surgical procedures.
"In and out by noon, they tell us.
"Nothing to worry about.
"But I do worry,
"because I am not there where I should be,
"sitting in a hard plastic chair
"drinking coffee that has cooled to lukewarm
"while I wait for someone in scrubs
"to come out and tell me
"you are fine.
"Instead of holding your hand
"as they wheel you into the O.R.,
"I squeeze it once and let go
"as a masked nurse escorts you
"from the car to the lobby
"before I drive off to wait
"for the phone to ring.
"Necessary precautions, they tell us.
"This is how we flatten the curve.
"They call it out-patient surgery.
"But I am the one who is out,
"and anything but patient
"as I wait here at home
"for news of you."
Host Amber Smith: That really captures this moment in time.
Deirdre Neilen, PhD: Yes. It's perfect. Plus, she just took that notion of outpatient surgery and broke it down. So that's something that all of us can do. We use language, obviously, every single day, but if you really listen to a phrase that you said, and you thought, what does it mean? How does it, you know, reflect this particular time? You might come up with this kind of wonderful poem that speaks to love and what it's like to be loving someone, and then you can't be there, and it's, it's terrible.
Host Amber Smith: We've talked a lot about the written word. Are there other ways that people might express themselves that would be lasting or meaningful?
Deirdre Neilen, PhD: Oh yes. I think people are always on their phones and snapping pictures. In New York City, I remember all the pictures when we were banging pans and applauding to thank the health care workers for what they were doing. And there were lots of very beautiful videos of that. So, if you're a person who is visual, obviously you can paint, sketch, draw. Music, why not get some of the songs that are so popular right now? I mean, we could have a compendium. You could make a mix tape for your family in the future to say, this is what we listened to. This is what got me through. These are the songs that when I lost someone, I mean, we have lost so many people. I think that music, painting, I haven't seen too many plays, but obviously there have been plays that, Syracuse Stage, you can dial in and get to see their work. So the arts are great for that, I think.
I said knitting earlier. That's something that I've never been able to do. I mean, I literally have not been able to do that, and, I suppose it'd be very interesting to see what knitters have come up with.
Host Amber Smith: There are probably lot of different ways people are filling their time that they didn't anticipate.
Deirdre Neilen, PhD: Maybe, like, recipes. What about a cookbook? Because you go to the grocery stores, and you cannot find the ordinary things that you used to take for granted. Or perhaps the prices of the things you like have risen so high. What are you substituting? That would be really fun to get a little notebook of, this is what we made, five days a week. We were eating this stuff. That could be something, too. I hadn't thought about that till now. I know that there's some weeks that I think, really, am I going to eat this again? It's like, yes, you are, because that's all that there is right now.
Host Amber Smith: Well, that's a good suggestion. And I really appreciate your time. I hope that someone will find this sort of inspiring, to try to start keeping track of their memories of this time as well.
Deirdre Neilen, PhD: And tell them to send their work to The Healing Muse, then. Who knows? It could lead to a publication.
Host Amber Smith: My guest has been Dr. Deirdre Neilen. She's editor of Upstate's literary and visual arts journal, The Healing Muse, and an associate professor of bioethics in humanities at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- treatments for arthritis of the hands.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Today. I'm discussing arthritis of the hands, whom it affects and what can be done about it with Dr. Brian Harley. He's an orthopedic surgeon who specializes in hand surgery and trauma reconstruction at Upstate.
Thank you for making time for this interview, Dr. Harley.
Brian Harley, MD: You're very welcome, Amber.
Host Amber Smith: Before we talk about treatments, I first want to ask you some basics about arthritis. Can you describe what it is?
Brian Harley, MD: Sure. It's a really common condition because we all have bones, and where the bones join together, there's things called joints.
And that's what allows us to be flexible and to move. And at the junction of these joints, there's cartilage, which is that smooth, fibrous tissue that you see when you're dissecting your turkey at Christmastime or whatever, and taking it apart. And those smooth surfaces are what allow us, our joints to move so nicely and so well for most of our lives.
And what arthritis is, is that those smooth surfaces start to get rough. And it's a little bit like some rust in our joints. And as that progresses, it starts to typically hurt, and then you start to get typically some stiffness. And then that's that arthritis that everybody starts rubbing their joints and complaining of that starts to make their lives more difficult or miserable at times.
Host Amber Smith: So is this inevitable for all of us as we age, that we're going to get some degree of this?
Brian Harley, MD: Well, yes and no. Typically, our bodies are fragile, and over time, things do wear out, but there's definitely people that are more prone to get arthritis. So there's a genetic predisposition to it.
And then on top of that, there's people that may have injured themselves or a joint got roughened or traumatized during their youth or their young adulthood. And then that can over time degenerate. So there's what we call primary arthritis, where you just genetically are predisposed to some things breaking down sooner.
And then there's post-traumatic changes, where there was some scuffing or injury that continues to deteriorate. So there's a couple of different ways to get it and not every patient's arthritis is the same.
Host Amber Smith: Well, how common is it to show up in the hands, as opposed to some other joints?
Brian Harley, MD: Hands are quite common, mostly just because there are so many joints in the hand.
You only have one, well, two, hips, one on each side, whereas in the hands, you've got five fingers and 17 joints just in those ones alone, so there are some predispositions. So we know that in the hands specifically, women get arthritis moreso than men, especially at the base of their thumb and their fingers.
And so I see a higher population of women coming in with arthritis in their hands than men, but when men get it, the pattern is a little different. Women tend to get it more in the bases of their thumbs men, get it at their, what they call their metacarpal-phalangeal joints, in their knuckles, there.
It's a variable presentation, and everybody's not predestined to get it, but we do see some trends.
Host Amber Smith: Why do you think it's different between men and women? Is it a function of how we use our hands differently?
Brian Harley, MD: No, it's probably just there's some theoretical concepts, and there's some reality.
Women tend to be a little more flexible than men. There's more laxity. And so when we examine thumb bases, especially, the way the joint is constructed, if it's really a little looser, then the cartilage can wear out over time sooner. So that's what we see. Typically, probably just some hormonal differences.
The sexes have some differences in our makeup, and then the way we use our hands, not really sure that's the case because I have people that come in and tell me they use their hands all their lives for different things, but the reality is everybody uses their hands for all their lives.
Some men are on jackhammers for 25 years, and they don't get thumb basal joint arthritis. So it's, like I said, some things are just predispositions to things. And then again, there's other genetic factors. And then just things that some we don't know.
Host Amber Smith: So is pain the only warning sign, or how would we know that we've got arthritis?
Brian Harley, MD: Everybody's presentation is a little bit different. I like to tell my patients that everybody's a snowflake, everybody's just a little bit different. Some people come in, and they have, on X-rays, really bad arthritis. I saw a gentleman yesterday in his early 70s, and his hands looked terrible on X-ray, but he tells me they feel pretty good, and he can do most things, and they don't look very good, but they still function, and they're a little stiff. Other people come in, and the X-rays don't look that bad, but they're very symptomatic, and they have a lot of soreness, and they have swelling. And so again, everybody's experience with their own pain is sometimes different, and the way their arthritis presents is different.
Host Amber Smith: So with someone who comes in with stiffness or pain or swelling, are there nonsurgical treatments that you start them on or that you recommend?
Brian Harley, MD: Sure. As a surgeon, people typically get to me after they've tried a lot of the nonoperative modalities, but mainstays, antiinflammatories, things like ibuprofen, Naprosyn, and then there are some other prescription anti-inflammatory medications. That's sort of the mainstay first treatment, and that's the things that, when we're 20 and 30 and we do too much on a weekend and things start hurting, we use those anti-inflammatories. And they're certainly the most effective, basic first treatment for arthritis.
When it progresses or when you're taking that regularly, and you're starting to get some breakthrough, then yes, there are some times braces or injections can be tried. Injections are typically what we call steroid injections. And they're just an anti-inflammatory steroid that we try to inject in or around the joint to do the same thing that the ibuprofen is doing, but just more in a concentrated form and right at a joint. Because when you take an anti-inflammatory by mouth, it diffuses through your whole body, and it doesn't necessarily get always where you want it. And so that's the advantage of an injection, but of course, an injection needs a needle, and some people don't really like those. Braces are sometimes used, but the problem with braces is the way they work is they prevent that joint from moving as much, which helps that roughness of the joint from causing the inflammation. But at the same time, our joints are meant to be moving. And once you start bracing, people's hands, for example, if you can't move your thumb as well, then you're less dextrous. And then there's often less you can do, so it might help with your pain a little bit, but then you can't be as functional.
So there's always that balance between what are we doing to try and help make your symptoms less, but not get in your way of doing what you want to during the day.
Host Amber Smith: This is Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with Dr. Brian Harley. He's an orthopedic surgeon specializing in hand surgery and trauma reconstruction, and our topic is treatment options for arthritis of the hand.
What types of surgery are options for treating arthritis of the hands or thumb or even wrist?
Brian Harley, MD: Sure. Well, all of those are kind of different sites. So I think we just would go through each one.
So, the wrist: it's a little less common to get primary arthritis in the wrist. It was often more of a post-traumatic arthritis. So people accumulate damage from some wrist sprains and falls, and just, minor trauma that over time builds up. And then, you start to see some arthritis in the wrist. And when that happens, sometimes some bracing works. And then if you start doing surgery for the wrist, then that's often some pretty big surgeries where you have to start either removing bones or fusing bones together.
And then that fundamentally changes the way the wrist works. So wrist arthritis sometimes can be a bad one just because it's going to change. I have, especially in men who are in their 50s and working and doing labor-type activities, once we start doing surgeries on that, it's time to get out of the labor pool sort of thing and get a desk job sort of thing. So wrist arthritis can be a bad one.
In the hand, the thumb, as we talked about, very common for women, and so we do have some surgeries for that, where we can really restore motion and just take out the little bones that have worn out and give them a pretty functional thumb, and they can maintain a lot of things that they do.
Brian Harley, MD: So the thumb is a really common surgical site, and we have some really reliable surgeries for that, that have really been time tested.
And then as you move into the hand, then out into the fingers, there's a variety of different options for that. Sometimes you can just clean a joint out and do a fusion.
So out at the distal end, at the fingertips, if the arthritis was really bad there, you don't have a lot of motion if we just fuse the joint together, which is just to scrape those surfaces out and put it together, then that takes care of the pain and the hand can be very functional.
As we get into the first and second knuckles of the finger, those have a lot of motion. And so those are sometimes challenging because sometimes people have some pain, but their motion looks really good. And then you don't want to go in and do fusions or joint replacements because they'd actually be better off with what they've got. So, especially in that central part of the hand, spend a lot of time just doing value judgment, and really pressing the patients to decide: Is this bad enough that we start having to remove parts of them or can they live with it longer? Because often living with it longer is actually the best thing.
Host Amber Smith: So it sounds like you need to really talk with the patient about what their goals are and what they want to be able to do with their hands.
Brian Harley, MD: It absolutely is. The most frustrating arthritis for most patients is the ones where they have pain, but they have still a lot of motion left because that's the challenging ones. Some of the easiest arthritis patients are the ones where the pain is significant, but the joint's gotten really stiff on them. Because then when you either do a fusion, which takes away their pain, or you offer them a joint replacement, which restores some motion, then that's a real bonus for them.
So the patients that just come in with: It's sore and it's swollen, it really slows them down, but really their hand looks and functions pretty well, those are the most challenging patients.
Host Amber Smith: Is there ever concern about whether a person is actually a candidate for surgery, or would most patients be candidates for this type of surgery?
Brian Harley, MD: Yeah, again, it depends. The risk is more major surgery out in the fingertips. Sometimes it's just the last knuckle; those can be done under almost local anesthesia, if there's little surgeries for that. So yes, and especially we do see more elderly patients, that often have more health problems, and so you do have to obviously take that into consideration, but the good news is, especially operating on people's extremities, even if I need a general anesthetic, because you're operating on their hands, there's not as much risk even with a general anesthetic. So in most cases, there's low risk from surgery.
Host Amber Smith: What is recovery like?
Brian Harley, MD: Again, totally depends upon the surgery, but in most cases, it's six to 12 weeks of a typical recovery of the initial postoperative pain. And then usually there's a splinting involved. And then in most cases, especially with the hand, because you're trying to get back motion, there's a degree of physical therapy involved for a month or two.
And then most people, by two or three months, for most of these surgeries where they're either taking out little parts of their bones or putting a little joint replacement in, or even fusing it and the bone starts to heal, by two to three months, most people are usually pretty happy that they're on the road to recovery.
Host Amber Smith: So if someone undergoes a joint replacement or a fusion, how common is it for arthritis to return to that area? Do you ever see th?
Brian Harley, MD: The surgeries that we are doing, so you just take one finger joint, and whether you do a joint replacement or whether you fuse it, that permanently removes the problem, because the joint has essentially been resected, whether you fuse the two surfaces, which means you cut out the cartilage and put the two bone surfaces together, so they knit themselves into one bone. Then you can't have arthritis, because there's no motion, and there's no joint. If you do a joint replacement, similarly, the joint has now been resected in some sort of polymer or metal and plastic has been put in to replace it. The problem with the joint replacements is those are artificial materials that obviously can break down and wear out over time, but the actual arthritis is gone because the joint has been removed.
Host Amber Smith: If a person has severe arthritis in one hand, how common is it for them to also have the same problem in the other hand?
Brian Harley, MD: Again, it somewhat depends upon the underlying cause. So if somebody just has a primary osteoarthritis from a genetic predisposition, then it's very common, it's usually very symmetric. If you take an x-ray at one hand, the other hand very much looks similar, even though one side may be more symptomatic, the X-rays are often similar. If it's a post-traumatic thing, where they injured themselves at an earlier time in their life, and then over time things have deteriorated, then obviously sometimes it can be localized to one side or one area.
Host Amber Smith: As an orthopedic surgeon, specializing in hands, do you offer alternatives to joint replacement or fusion operations?
Brian Harley, MD: Not really. I mean, as a surgeon, those are our standard surgeries. There are other holistic things and other things available for people out there, but mainstream medicine and science-based medicine typically is working with anti-inflammatories and nonoperative modalities as much as we can. And then. when things have gotten to the point where they're not being controlled with those methods, then standard, time tested and scientifically proven surgical alternatives are what I focus on, more or less.
Host Amber Smith: I've read about research into using stem cells to help regenerate damaged joints. But how soon might that be a reality?
Brian Harley, MD: You know, that's really uncertain, Amber. I remember when I was a resident, which I'm starting to date myself, but that was in the mid-90s, and one of my mentors was doing some basic science research on just cartilage regeneration, and that was over 25 years ago, and they were doing it in an animal model. And so we know a lot more about cartilage than we did 25 years ago, but other than still growing it in a Petri dish and in a lab, we're not at the stage where in any sort of reliable fashion can we inject that into a joint and then have it be long-standing or any sort of a replacement. Some of that's just, the physiologic genesis of all of this, is just, typically the cartilage is wearing out, and we just don't have a solution to some things wearing out, much like our cars rust in the winter in Syracuse, there is some just natural deterioration that's going to occur.
Host Amber Smith: Before we wrap up, how do you help someone decide what treatment is best for their particular situation?
Brian Harley, MD: Again, that's just patient education as much as possible. You try and explain, and different people have different levels of understanding, and some people really want to get to the basic science understanding and some people just say, "Please, doctor, just tell me what's best, and then we'll go with that." So working with the patient, trying to educate them to where they feel comfortable and then be realistic and telling them what the outcomes can be. Because as we talked about wrist surgery, we generally don't have a perfect solution. We're trying to find something that helps them and makes them more functional, but isn't necessarily going to be a revolution and life changing.
Whereas with thumb arthritis for that 60-year-old lady, her thumb is totally burnt out, a thumb arthroplasty option can be just a wonderful option that just makes them pain-free and very functional again. So just being realistic with patients, to say, "Hey, this is either really, really, really good, we should really go this route," or "Listen, you have to make a value decision here, and I can help, I can make this better, but we're not going to make it perfect." And so that's the challenge for me, is to help people understand that decision process.
Host Amber Smith: Well, thank you so much for making time for this interview.
Brian Harley, MD: You're very welcome.
Host Amber Smith: My guest has been Dr. Brian Harley, an orthopedic surgeon specializing in hand surgery and trauma reconstruction at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air. "
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week selection.
Deirdre Neilen, PhD: Teddy Goetz is a medical student whose goal is to help people feel seen. Their poem "Green Thumb" offers a very different take on the future dreams of a physician. Here is "Green Thumb":
As doctors, she says,
We are in the business of second chances.
We fight for those caught in the crossfire.
Yet, I wonder,
Bad capitalist that I am,
What could it mean to make the first one last?
Planting vacant lots into
Prunes gun violence.
What a jubilant day it would be
To hang up my stethoscope,
And become a gardener instead.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": the dangers of marijuana edibles. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.