How hearts should beat; explaining monkeypox; medical instrument cleanliness; Upstate Medical University's HealthLink on Air for Sunday, June 12, 2022
Normal and abnormal heart rhythms are discussed by electrophysiologist Kiran Devaraj, MD. Infectious disease chief Elizabeth Asiago-Reddy, MD, tells about monkeypox. Ophthalmologist Mark Breazzano, MD, shares a study that looks at coronavirus on medical instruments.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an electrophysiologist discusses heart rhythm disturbances.
Kiran Devaraj, MD: ... If left untreated, coronary artery disease can then lead to dangerous heart rhythm problems, like ventricular tachycardia and ventricular fibrillation. ...
Host Amber Smith: An infectious disease doctor explains what you need to know about monkeypox.
Elizabeth Asiago-Reddy, MD: ... It takes between five days to even up to a couple of weeks after exposure before someone actually gets sick. ...
Host Amber Smith: And an ophthalmologist tells about his coronavirus research.
Mark Breazzano, MD: ... There was a dramatic decrease in the number of patient visits and care that was being performed, especially in ophthalmology. ...
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 learn about monkeypox. Then, an ophthalmologist shares research into the coronavirus. But first, an electrophysiologist discusses some of the most common heart rhythm disturbances.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
If your heartbeat is too slow or too fast or irregular, you might be referred to see an electrophysiologist. Today, we'll talk about what to expect at an electrophysiology appointment with Dr. Kiran Devaraj. He's a cardiologist at Upstate who specializes in electrophysiology. Welcome to "HealthLink on Air," Dr. Devaraj.
Kiran Devaraj, MD: Thanks for having me.
Host Amber Smith: I'd first like to ask you to explain the background of an electrophysiologist. You're all medical doctors who specialize in cardiology, and then you subspecialize in electrophysiology. Is that right?
Kiran Devaraj, MD: Correct. Yes. Usually an adult cardiologist will train in adult medicine, or a pediatric cardiologist will train in pediatric medicine, followed by subspecialty training in cardiology, and those who have an interest in heart rhythm problems will then go on and do additional subspecialty training in what we call clinical cardiac electrophysiology, which means that we treat heart rhythm problems for patients.
And our research colleagues are called a basic science electrophysiologist. They do more experimentation and cell-based research and molecular research. So my full title is a an adult clinical cardiac electrophysiologist, which is a bit of a mouthful for most patients.
Host Amber Smith: It is. Well, when someone's doctor, their primary care provider, flags an irregular or a fast or a slow heartbeat and says they need to see an electrophysiologist, how would you advise that person to prepare for that visit?
Kiran Devaraj, MD: Sure. So most of my referrals come from patients who already have, at a minimum, a primary doctor, but even a cardiologist.
So a lot of these patients have already had some form of testing. They might've had an electrocardiogram to look at, which is a basic test that a lot of patients are offered by their cardiologist or by their primary doctor. They may be offered a heart rhythm monitoring such as a Holter monitor that they wear for a few days to catch heart rhythm problems or event monitors, which are longer heart rhythm monitors. They can be worn for weeks at a time.
And then they may get other testing, too, before they come to see me. They may get things like an echocardiogram, which is an ultrasound of the heart, or a stress test to look for any signs of underlying coronary artery disease or heart rhythm problems.
Host Amber Smith: So would a person be referred to someone like you, if those tests that they've already undergone don't offer an answer? I'm imagining that it might be a little bit scary to be told, "Well, you know, we've gotten all these tests, and now we need you to go see this other specialist."
Kiran Devaraj, MD: If anything, it's the other way around. If the testing is abnormal, if it's not normal, so if it shows signs of a heart rhythm problem, then they'll typically see me. But if someone's having palpitations, but the arrhythmia testing is actually reassuring, so there's no signs of a heart rhythm problem on a Holter monitor or an event monitor, uh, they're less likely to be referred.
There are non-cardiac reasons why someone can have palpitations or racing heart rate. Common things include things like thyroid problems or anemia or anxiety. So typically that's why, when a patient sees their primary doctor for those kinds of symptoms, they won't just be looking for heart problems. They can also look for other problems, too.
Host Amber Smith: So what is the first visit with you typically like?
Kiran Devaraj, MD: It depends, partly because, as I stated earlier, a lot of patients already have, to some degree, been diagnosed before they see me, whether through their primary doctor or through their cardiologist. They've often already had testing like the electrocardiogram or the Holter monitor or the echocardiogram. Usually at that point, a lot of information's already been gathered. And so what I try to focus on for people who already have a diagnosed heart rhythm problem is to go over their symptoms and essentially to explain to people what's going on, how worried they should be about that problem and what are next steps, versus for people who don't have a diagnosed heart problem, like, say, they have a symptom, but they don't have any testing confirming a heart rhythm problem -- then we talk more about further testing.
Host Amber Smith: Of the dangerous heart rhythms that people may be walking around with, which ones require treatment most urgently?
Kiran Devaraj, MD: The urgent ones are usually people are headed to the hospital already. So the most common cause of dangerous heart rhythm problems is coronary artery disease in the U.S., in adults.
Kiran Devaraj, MD: The incidence of coronary artery disease is 6% to 7% in the United States. And if left untreated, coronary artery disease can then lead to dangerous heart rhythm problems, like ventricular tachycardia and ventricular fibrillation. And those are somewhat common reasons why people end up in the hospital due to dangerous heart rhythm problems as a result of heart attacks and untreated coronary artery disease. So I see patients like that on a semiregular basis.
And then other common heart rhythm problems, like atrial fibrillation or SVT (supraventricular tachycardia), those are a little bit more variable because you were talking about how serious these things are. Some patients with atrial fibrillation, we see them in the office. Some patients with severe symptoms get admitted to the hospital. It depends a little bit on the particular patient.
Host Amber Smith: It sounds like there's quite a range.
Kiran Devaraj, MD: There is, yes. The same heart rhythm problem can present very differently from patient to patient, which is why I'm being a little bit vague intentionally.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Kiran Devaraj. He's a cardiologist who specializes in electrophysiology at Upstate.
If someone's heart rate is too slow, what might concern you, and what types of things would you be looking for?
Kiran Devaraj, MD: Sure. First, I want to state that "normal" is a loaded term when it comes to heart rate, as it is for a lot of other medical measurements, because what's normal for one person might actually be not normal for another person. Like for instance, a newborn baby, their resting heart rate could easily be 160 beats a minute, which for an adult is obviously very different.
And for a professional athlete, their resting heart rate may be 50 beats a minute or even 45 beats a minute, which would be considered too slow for a normal adult, but would actually be considered an entirely appropriate for a highly trained athlete. So with that in mind, I mean, technically the lower limit of normal for heart rate is 60, but as I just stated, it's considered acceptable for people to have heart rates in the 50s, particularly if they are athletes or if they have an underlying medical problem that might make their heart rate a little bit slow. Typically if people have heart rates in the 40s, that's considered somewhat more unusual, but even then, some athletes do have heart rates in the 40s.
And then in terms of symptoms, things to look out for would be things like fainting, passing out, having lightheaded spells. Those are signs that those slow heart rates are actually not allowing enough blood to reach the brain and therefore affecting cognition, or if you generally just feel tired and unable to have enough energy to do normal things like walk up flights of stairs and do normal activities of daily living, that's a sign that slow heart rates could be effecting your physical activity. And that's usually confirmed by things like an electrocardiogram to look at your resting heart rate, a Holter monitor to see what your heart rate ranges during an entire day, and then sometimes even a stress test to see what your heart rate does both at rest and with exercise.
Host Amber Smith: Is it normal for a person's heart rate to become slower as they age? And maybe they're not as active as they used to be, or maybe they do have some heart disease. Is it normal for the heart to kind of slow down?
Kiran Devaraj, MD: Yes, in a word. So your natural pacemaker is called your sinus node, and that typically governs your heart rate, in conjunction with your brain and your brain stem and a certain part of your nervous system, which is called your autonomic nervous system. And those heart rates governed by your natural pacemaker and your brain. Those do actually slow down with age. So typically people develop what's called sinus node dysfunction or slowing of their natural pacemaker, as they get older. It doesn't happen to everyone, but that's why it's the most common ages for a pacemaker implantation are older adults in their 70s and 80s, due to age-related sinus node dysfunction.
And then secondly, heart block, or AV (atrioventricular) block, is where the electrical system of the heart becomes aged and calcified. And the conduction system, the wires that control signals inside the heart, can sometimes fail and cause some slowing of the heart rate. And that also is most commonly in people in their 70s and 80s.
Host Amber Smith: I know it varies from person to person, but what about rhythms? Do you see rhythms that are too fast? A person whose heart is just beating too fast, constantly?
Kiran Devaraj, MD: Yeah. The two most common scenarios for that are superventricular tachycardia, which is often abbreviated down to SVT, and then atrial fibrillation. SVT is not just one heart rhythm problem; it's actually a family of different regular fast heart rhythm problems. SVTs, statistically speaking, most of them are due to some kind of abnormal loop or re-entrance circuit, as we like to call it, inside the heart. And that endless loop can allow the heart rate to go too fast. And whether that's 130 or 140 beats a minute, or sometimes even as fast as 250 beats a minute, that can cause someone palpitations and racing heart rate.
And while that sounds scary, SVT is actually considered a benign heart rhythm problem. It doesn't cause heart attack or stroke or heart damage. And people are usually treated for their symptoms, versus another rapid heart rhythm problem, which is called atrial fibrillation.
That's more common as people get older. That typically happens to people in their 60s and 70s and 80s. The typical incidence starts to be about 10% in people in their 60s, and that's associated with common things like high blood pressure and being overweight and snoring and sleep apnea and a variety of different heart and lung problems. And atrial fibrillation is more medically serious because that's actually associated with a risk of stroke, and the risk of stroke is the find based on other clinical risk factors.
Host Amber Smith: If someone comes to you with an irregular heart rhythm, or it's too fast, or it's too slow, how do you determine whether that is caused by a medication that they're taking?
Kiran Devaraj, MD: That's a great question. It mainly comes down to figuring out the timeline of symptoms. Most commonly, if they started a medicine recently, whether it was a few weeks ago or a few months ago, and then the patient may not have connected it for themselves, that their symptoms started after the medication was given.
And then we walk through those kinds of timelines. And that's most common with things like antidepressants can cause slow or fast heart rates; some other psychiatric medications can do that. Oral contraceptives are a common reason why people cannot feel racing heart rates. Honestly, I see all kinds of medication side effects that I happen to diagnose in daily practice (chuckles).
Host Amber Smith: You mentioned the word "pacemaker" when we were talking about the slow heart rhythms. Are pacemakers only for when the heart's too slow, or are they sometimes used if the heart's too fast?
Kiran Devaraj, MD: Yeah. The purpose of a pacemaker: It's a medical device that's implanted in the body, and typically there's at least one or more wires, which are implanted inside the heart, to regulate the heart rate to prevent it from being too slow. So in that sense, the pacemaker is primarily a treatment for slow heart rhythm problems. The main reason why it would be offered to someone with a fast heart rhythm problem is that if they're having a fast heart rhythm problem, and for some reason they can't get the right medicines, they need to slow their heart rate down. So they need a pacemaker to prevent any slow heart rates and to allow them better medical therapy. But yes, the pacemaker is mostly for people with slow heart rhythm problems.
Host Amber Smith: So do electrophysiologists install the pacemakers?
Kiran Devaraj, MD: Yeah, historically. Well, I mean, pacemakers have been around now for almost 50 years. When they originally came out, they were typically implanted via open-heart surgeries. A lot of the first pacemakers were implanted by surgeons. And that slowly evolved. It started to be more cardiologists were doing them. And then my field, cardiac electrophysiology, is actually relatively young, and it was essentially born by the fact that these pacemaker systems became more complicated.
And we were learning about all of these different heart rhythm problems, and they require more specialized treatments. So that's how my field was born in the last 30-40 years.
Host Amber Smith: How long does the pacemaker last, if you install one for someone today? Do they last many years, or do you have to change batteries?
Kiran Devaraj, MD: There's two components to a pacemaker system. There's the actual peacemaker itself, which houses the electronics, and the battery for the device. And then there are the pacemaker wires, which are implanted in the body permanently. The typical lifespan for a pacemaker is eight to 12 years, and that's governed by the battery life.
And, by contrast, there's a different kind of device that we implant that's called an implanted cardioverter-defibrillator; the battery life on those devices is a little bit lower, more like five to 10 years. And then the wires that go with a pacemaker, the lifespan of those devices is a little bit more variable.
The pacemaker wires can break down over time, which is rare. I tell people it happens about 1% to 2% per decade at first, but typical pacemaker wires can last 20, 30 years. And that's partly based on just most of the modern pacemaker wireshave only been around for 20 or 30 years (chuckles).
Host Amber Smith: So while someone has a pacemaker, they continue to have checkups with you as long as they have the pacemaker?
Kiran Devaraj, MD: Yes. Usually if you have a pacemaker, you have a cardiologist or a cardiac electrophysiologist who has the monitor of the device. The best analogy that I give to patients that it's like owning a car; you have to take it in for regular maintenance. So, checkups to make sure that it's working properly. And then the service is essentially replacing the battery, as I said, eight to 12 years for pacemakers and five to 10 years for defibrillators.
Host Amber Smith: This has been very interesting. I appreciate you making time for this interview, Dr. Devaraj.
Kiran Devaraj, MD: It was great to be here. Thanks for having me.
Host Amber Smith: My guest has been Dr. Kiran Devaraj. He's a cardiologist specializing in electrophysiology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
What you need to know about monkeypox -- next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Central New Yorkers may have heard about an outbreak of monkeypox with cases in Europe, Canada, the U.S. and e lsewhere. And while we're not in imminent danger, this does spark some curiosity about a disease most of us have probably never heard of. With me to tell us about monkeypox is Dr. Elizabeth Asiago-Reddy. She's the chief of infectious disease at Upstate University Hospital. Welcome back to "HealthLink on Air," Dr. Asiago Reddy.
Elizabeth Asiago-Reddy, MD: Thank you very much for having me.
Host Amber Smith: Now first of all, if I understand correctly, this has nothing to do with monkeys?
Elizabeth Asiago-Reddy, MD: Not completely nothing. The virus was originally identified after an outbreak associated with laboratory monkeys. So monkeys are one of the reservoirs for this infection, but they're actually thought not to be the main reservoir. So it looks like within the natural world, this virus lives more frequently in rodents, such as wild mice, rats and squirrels.
Host Amber Smith: Well, how similar is it to smallpox?
Elizabeth Asiago-Reddy, MD: It's in the same genus. So that's one of the ways that we subdivide viruses. So it's almost like it's in the same family, and it's even closer than just being in the same family, but clinically it's much milder than smallpox is. So smallpox is associated with a high risk of death and severe complications. And monkeypox, as we'll learn, is definitely no fun, but it is definitely less severe overall than smallpox.
Host Amber Smith: Would the smallpox vaccine, if someone's already been vaccinated against smallpox, would that protect them against monkeypox?
Elizabeth Asiago-Reddy, MD: As far as we can tell that would offer a decent degree of protection. There's some evidence of that from an outbreak that occurred in the U.S several years ago, which was related to prairie dogs imported from Africa. So in that case series, there were individuals who had been previously vaccinated against smallpox, and they appeared to have much milder disease or to avoid disease altogether, despite exposure. So we think that yes, the smallpox vaccinations stopped in the U.S. In 1972, but individuals would have received it prior to then, and in all likelihood they would have some degree of protection, if not complete.
Host Amber Smith: Well, what can you tell us about this monkeypox disease? What are the symptoms that would tell someone that maybe they're infected?
Elizabeth Asiago-Reddy, MD: So the most classic is the pox themselves. So this is a very unique rash to the particular group of viruses. So the pox viruses have a rash that becomes raised. But when the infection first starts out, it starts out as so many infections do, with just more of the fever and malaise. So feeling poorly for a few days before the rash actually starts. The rash tends to focus itself on the face and then spreading to the arms and legs. It can be present on the palms and soles, and importantly, it is frequently present in the genital area and also can be present on the oral mucus membrane, so within the mouth and along the lips. That's kind of the general feature of how the illness goes. It's also important to know that symptoms don't usually develop for almost a week after someone's exposed. So it takes between five days to even up to a couple of weeks after exposure before someone actually gets sick.
The rash, as I mentioned, goes through phases, and it starts out as a flatter rash. Then the lesions become bumpy. So they get raised. And they often become pustular, meaning that if you look at them, it looks like there's pus inside of them. They often have a very well circumscribed, circular appearance to them. And sometimes they have an indentation in the middle, which is called an umbilication.
Host Amber Smith: So how does this disease spread from person to person?
Elizabeth Asiago-Reddy, MD: The main way that it spreads is through direct contact with the rash lesion. So the rash lesions themselves have a lot of virus in them. And, in addition, as the rash matures and people are obviously lying down in bed, sleeping on covers, the lesions can open up, and so exposure from bedclothes or other clothes also can be a form of transmission. So, close contact is by far and away the most important means of spread. Droplet spread from respiratory secretions is also likely because if you test the respiratory secretions of individuals who are infected, there are high levels of virus there. So even though this is not a classic respiratory illness, in the sense that it doesn't usually make you cough or sneeze, if there was kissing, for example, or someone did cough or sneeze and you were in close proximity, that would be considered a way that it could be transmitted.
It is very, very unlikely that it could be transmitted at a distance from anybody. So that's obviously quite different from COVID.
Host Amber Smith: So I'm wondering how infectious monkeypox is and whether someone with monkeypox needs to be isolated?
Elizabeth Asiago-Reddy, MD: Yeah. Isolation is definitely recommended and the reason for that is because of the close contact. So you wouldn't want to come into close contact with, as I said, clothes, bedclothes direct contact with the rash lesions, etc But when you talk about the degree to which it's contagious, It is a lot easier to contain than again, for example, COVID, because the illness is much more obvious. So one of the most difficult features of COVID is how different people's symptoms are ranging from absolutely none to very mild -- like, oh, I'm maybe I have an allergy or something -- whilst the person is highly infectious.
That is not the case for monkeypox. So, as far as we know, there is no asymptomatic illness with monkeypox. Now, there might be some exceptions to that for people who have been vaccinated. They may have a very mild illness because of vaccination, to the point where it could potentially go unnoticed, but for natural disease, this is not something that you're going to be sick with without knowing that you have it. And the other thing is that also, as far as we're aware, it cannot be transmitted until after the symptoms develop. So if somebody is sick with it, they should know that they're not feeling well. And naturally that would result in them being more likely to isolate themselves even before they realized what they had. And then once they get to the most contagious stage with the rash that is quite obvious and a lot easier to isolate because of how obvious it is.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Elizabeth Asiago-Reddy. She's the chief of infectious disease at Upstate, and we're talking about monkeypox.
So I wonder how easily it is diagnosed and whether monkeypox could be confused for smallpox.
Elizabeth Asiago-Reddy, MD: Well, it actually is because of a longstanding preparation related to concerns about smallpox being used as a biological weapon that has allowed us to be a bit better prepared for monkeypox There have been efforts going on ever since the eradication of smallpox to make sure that in case that were ever re-introduced, that we would be prepared for it. And because of similarities between the two, as you're alluding to, there is crossover in terms of vaccines and treatments and what's effective for both viruses. So diagnosis is, there are tests that might make it initially difficult to distinguish between the two, but what's being recommended from us at this point is to do PCR based testing or molecular-based testing. And in that case, the specific target for monkeypox would be investigated, and it would be able to be distinguished from smallpox. And, again, we're in a different place than we were with COVID because COVID was, although we had coronaviruses, this was a completely novel coronavirus. So it was one that we literally had not dealt with before at all. Monkeypox, what's unique in this circumstance is the degree of spread, maybe, I shouldn't even say the degree of spread, but the number of cases that have emerged in various different areas, that's what's unique with what we're dealing with right now. But the disease itself is not unique. So we know about it. We have the capacity to diagnose it. Tests have already been created. Treatments have already been considered. So that puts us at an advantage. So New York state was able to very quickly send out information on what to do if we saw a patient who we were concerned about, how to swab the rash lesions, how to send it, where to send it, and that we would anticipate the results might come back more quickly than something that we were dealing with that was brand new.
Host Amber Smith: So how do doctors typically treat monkeypox?
Elizabeth Asiago-Reddy, MD: In many cases, it's observation alone. There have been efforts to create an antiviral, and because the disease is relatively rare, we don't have large studies giving us information about exactly how well this antiviral works. There are a couple of case series that go over a likelihood that it reduces the level of virus, and it is recommended in cases where individuals appear to be particularly ill. So that's an antiviral called tecovirimat. But actually, because of the incubation period that I mentioned, the main quote unquote treatment is actually prevention, which is to vaccinate as soon as possible after an exposure. So people who have had a high-risk exposure at this point are being recommended for vaccination. And to a large degree -- you'd have to evaluate, are they appropriate candidates for vaccination based on any of the risks and benefits associated with the vaccine and the age groups that it's approved for -- but basically that is the scenario right now is to consider a true high-risk exposure as an individual that might benefit from vaccination as soon as possible. Because if it can be given in that period before illness actually develops, which like I said, can be up to two weeks, then you have the opportunity to nip it in the bud. So you would actually want to get that vaccine in within five days of an exposure.
Host Amber Smith: So do most people recover from monkeypox if they're infected?
Elizabeth Asiago-Reddy, MD: Yes. Most people do recover. There have been case fatalities associated with monkeypox and the percentage is still, I would say, of concern. There's some variability when you look through case series, potentially up to 3% of cases could result in death. Again, that varies when you look at different reports, and some of those individuals are being treated in resource-limited settings. So overall it's considered to be a milder illness, and people who recover will recover fully. The disease can last a while. So it is definitely, like I said, it's not fun. It looks like it takes three to four weeks for most people to get better, for those lesions to go away. You know, the lesions themselves can become painful, and you feel pretty miserable with a lot of malaise and fatigue throughout a lot of the course of the illness. But yes, the available data show that people recover fully once all those lesions have crusted over.
Host Amber Smith: Well, how concerned are you, as an infectious disease doctor in Central New York, about monkeypox? I mean, how concerned should we be?
Elizabeth Asiago-Reddy, MD: I think right now we're in a decent place, which is that the WHO (World Health Organization) and the CDC (Centers for Disease Control and Prevention) are very carefully tracking cases. And we have so many more tools available to us right now to try and mitigate the spread of the illness than we did with COVID. That relates, as I said, to the nature of the illness itself, not having an asymptomatic spread, and then also to the ability to isolate people and then hopefully give them this post-exposure prophylaxis to prevent ongoing disease. So, yes, of course I'm concerned because it looks like, in this case, there were a series of exposures that probably happened very early on. This is looking at as something that maybe started to spread at a location where a number of people got together all at the same time and were traveling internationally, and then as they went back home, their symptoms emerged. So, that would help to explain the number of different countries that we're seeing with cases. So I think that it's just a matter of clear communication and making sure to identify people based on that clear communication. And then we will be able to get a handle on this.
So, I think to say I'm not concerned would belie my, of course, I'm an infectious disease doctor, so I see an infection cropping up and I become concerned, but is it something where I've changed anything that I do in my personal life or that I think the vast majority of us need to think about changing anything that we're doing in our personal life? No. It's a matter of being alert to that kind of classic presentation, and then seeking assistance if we were to ever see anything like that.
Host Amber Smith: Well, that's good to know. Thank you so much for making time for this interview, Dr. Asiago-Reddy.
Elizabeth Asiago-Reddy, MD: Thank you for having me.
Host Amber Smith: My guest has been Upstate's chief of infectious disease, Dr. Elizabeth Asiago Reddy. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air": what an ophthalmologist learned about coronavirus.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Ophthalmologist Mark Breazzano worked with researchers at Johns Hopkins University School of Medicine to research the presence of coronavirus on medical instruments, and their work was published recently in a medical journal for eye doctors. Dr. Breazzano is a Central New York native who got his medical degree from Upstate Medical University. And he's been on the faculty at the Wilmer Eye Institute at Johns Hopkins in Baltimore.
He's returning to Upstate this summer and joining the practice of Retina-Vitreous Surgeons of Central New York in Liverpool. Welcome to "HealthLink on Air," Dr. Breazzano.
Mark Breazzano, MD: Thank you so much for having me.
Host Amber Smith: This study goes back to the beginning of the pandemic, when we had so many unanswered questions. Did you and other eye doctors see fewer patients because they were afraid of being infected with the coronavirus early in 2020?
Mark Breazzano, MD: Yeah, I think that's exactly right. There was quite a bit of hesitation on the part of patients and doctors to limit the spread of this disease that we knew so little about. And we did find that there was a dramatic decrease in the number of patient visits and care that was being performed, especially in fields such as ours, in ophthalmology.
We actually, together with some colleagues across the country in vitreoretinal diseases, like myself, we actually did publish, in (the journal) JAMA Ophthalmology, a study that showed how there was a decrease in these procedures that are known to be critical for saving vision, like retinal detachment repairs and intravitreal injections. That seemed to decrease from March through May of 2020, which, as you recall, is when the pandemic was really at its height here in America. And specifically in New York City is the first epicenter.
Host Amber Smith: Yeah, it was certainly scary times. Is there, or was there a specific risk of transmission of the virus through the instruments that eye doctors use?
Mark Breazzano, MD: It's a great question, and I think more evidence is definitely pointing in that direction, and that's why it's really important for many of us, you know, even the just routine patient encounters with thesesubsequent mutations of the virus. But we did know that early on, it probably all started actually with Li Wenliang, who was an ophthalmologist in China, who actually sounded the alarm bells to this whole pandemic and novel coronavirus to begin with. And so that actually set the stage for some work and research that we did in New York City while I was there, as a fellow at Columbia New York-Presbyterian and a few other collaborative hospitals, we actually surveyed residency program directors from all different specialties in New York city, because in a way, it gave us a very good cross-sectional analysis. So basically a single time point across the city with different specialties to see if there was a difference in rate of resident doctors or physicians being infected with the disease, relative to one another. And we actually published this in the Journal of Clinical Investigation in the spring of 2020 as well.
And we would actually demonstrate it was ophthalmology, emergency medicine and anesthesiology were among the three most highly infected specialties across medicine. And we hypothesize that this is because of the nature of it being a little bit higher risk. So aerosolizing procedures with emergency medicine and anesthesia make sense. So, as we know, novel coronavirus is primarily a respiratory disease that's spread with aerosolized particles. The ophthalmology part may not be quite as obvious, but given Li Wenliang in China and our own experience, a couple of my colleagues were some of the first to be infected I knew of in New York that triggered this study,it actually makes sense pathophysiologically because ofjust the nature of the anatomy.
Host Amber Smith: Do you know of any cases where it's been documented that a person contracted the coronavirus through their eye?
Mark Breazzano, MD: Li Wenliang was actually a good example, supposedly in the contract tracing, I believe anecdotally, some of the information surrounding this isn't widely known, but it is thought that he was performing gonioscopy, which is basically this lens we put on top of the eye to look at the drainage system in the front of the eye. And so, there is quite a bit of evidence to that effect. That's why it's actually very important in treating COVID-positive patients, that there's eye protection. And so it's been a pretty much standard safety measure for a lot of our practice.
And so, with ophthalmology, virtually every slit lamp will havea Plexiglas shield, that's actually very cheap and easy to implement, on the slit lamp that's placed between the patient and the examiner. Typically with our ophthalmology exams, we are only inches from the patient's eyes or in the face, and so, that's been pretty well established to reduce the rates. Now, the other aspect, too, is, it makes sense because there have been reports that have been published with the virus actually replicating from the surface of the eye and findings with the tears, so the liquid that comes around the eyes actually harboring the virus. And so, there's a lot of evidence that directly links the periocular and ocular tissue to transmitting or being a part of the transmission process. And, for those that might not be as familiar with the anatomy around the eye, the tear duct actually does open up into the nasal cavity, which directly connects it to the respiratory system. So it does physiologically make sense.
Host Amber Smith: Now, you mentioned a slit lamp. Is that different than a regular lamp that someone might have at their house?
Mark Breazzano, MD: Yeah. People who've had contact lens fittings or other type of routine sort of eye visits, but not necessarily a complex retinal detachment, but anything and everything in between, often typically involves a slit lamp exam. So it's a very specialized piece of equipment that most eye doctors will use. Some ocular plastic surgeons may use it less frequently than other eye doctors, but essentially it's a piece of equipment that helps us examine the anatomy, in great detail: the front of the eye, back of the eye and around the eye.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Mark Breazzano. He's an ophthalmologist who went to medical school at Upstate, and he's in the process of returning to his alma mater from the Wilmer Eye Institute at Johns Hopkins University.
What can you tell us about how the study was set up, and what you were hoping to learn?
Mark Breazzano, MD: Well, the study was set up because as the other studies had kind of shown were that ophthalmology did have a unique risk of potentially transmitting the disease between patients and between staff and doctors, and given this heightened risk relative to other specialties, we wanted to sort of investigate and see if there was anything, particularly with this equipment and with other aspects of the practice that might lead to that increased risk. And what we found was interesting. So with the slit lamp we were talking about and other pieces of equipment, there was actually isolation of some of these pathogens, including the coronavirus, so germs and bugs that could cause infection, not only with the coronavirus, but other commonly encountered bacteria that can be found in the environment and sometimes can be pathogenic. And this was despite normal cleaning measures that we do encounter every day to help protect our patients. And these were most likely heightened from the pandemic itself and maybe not performed as rigorously as they normally would be.
Host Amber Smith: So we have heard that the virus, the coronavirus, spreads through the air, mostly when someone coughs or sneezes. Early on, there was this fear that the virus might spread on surfaces. A lot of people were wiping down groceries or not touching things. So, I thought that was disproven, that it was mostly just airborne. Is the surface of medical instruments different, from the virus's point of view, than the surface of a countertop or a doorknob?
Mark Breazzano, MD: Yeah, it's a really good question. So certain surfaces, like copper, are actually very good at being viricidal, so it's very hard for pathogens, like the novel coronavirus, to actually reside there and not be damaged. So that we don't really have to worry about.
But other more inert objects, like plastic and whatnot, it can actually hang around for quite a bit. It can hang around for hours. Now, the question and the real limitation to all of this is, is it enough to be pathogenic? And like you suggested from the other studies and what we do know, and wiping down groceries seemed silly in retrospect, the answer to that is probably that it's very much less likely to actually cause infection, if that makes sense. But what's notable about this study is, the virus is certainly still hanging around even up to a day after that was supposedly cleaned the day before. And so it just is more of a telltale sign that we just need to make sure that we are being diligent with these cleaning practices. And I think the other aspect of it, too, is that there is a potential that other more innocuous pathogens, some might actually normally occur on our body, can actually, potentially, cause disease and colonize on the body if not already present there.
Host Amber Smith: So your study looked at 33 patients or samples from patients from one location. Is that enough to make these conclusions, or are you aware of other studies that have similar findings to yours?
Mark Breazzano, MD: Well, these weren't taken from patients. These were samples taken from different locations within different clinics. And we did do several different samples from each type of situation within those clinics, and so we felt that it was relatively generalizable. At the Wilmer Eye Institute here in Baltimore, it is convenient in the sense that there are multiple subspecialty clinics to give that external validity to other places where you might only have one kind of clinic, and so that, I think helped increase the generalizability of the findings.
And it actually also supported some findings that were done in a similar study back in 2005. Ophthalmology, the journal, actually published something similar, where they took 34 samples from across the country, using ultrasound equipment. So the same technology you would use for looking at a fetus or an unborn baby in an obstetrics clinic, we actually use the same kind of technology to look inside an eyeball that you can't look into if something's in the way. And with that equipment, there's jelly that's put on the surface of the eyelid to look into the eye, and so there's patient contact there. And a team of doctors actually looked, out of the University of Texas, and they did find that there wereabout half of samples that, despite cleaning measures, including wiping with alcohol wipes, over about half of these samples actually grew different bacteria and pathogens.
So this isn't a new issue, and it's one that's still challenging because it comes back to the issue that it's very hard to directly link any causes of infection because of these isolated incidents, because we are not routinely looking for these, and maybe we don't need to.
Host Amber Smith: Well, let me ask you, can patients expect, or should they be able to expect, that medical instruments are 100% free of microorganisms of any sort when they come for a procedure?
Mark Breazzano, MD: There is a distinct difference between sterile and clean procedures. When you go to the operating room, that's a sterile procedure, and there are certain aspects to that that have been proven to reduce the chance of infection. So, for instance, applying iodine, 10% solution, and to the eye tissue itself, 5%, has been proven to reduce the rates of complications and infection in the surgical setting.
But other aspects, like let's say a laser procedure to the eye. You might not actually need that because you're not entering inside the eye tissue to give that chance of infection inside the eye, also known as endophthalmitis. And so anything that we do has a risk, and it doesn't matter what we're doing, everything has a potential risk. As a profession, we do what we need to, to minimize those risks, but it is very challenging to make anything a hundred percent or decrease it to zero percent.
Host Amber Smith: So the study that you were involved in, do you see it as a big reminder to your fellow ophthalmologists about the importance of being aware and making sure that things are as clean as they can be?
Mark Breazzano, MD: Absolutely. I think it is just a really important reminder, like you said. We are in a relatively higher-risk profession in terms of the spreading of the novel coronavirus and any potential future pandemics that may occur from this, but also, other organisms that have already been around and we know can also cause disease and problems as well.
Host Amber Smith: Is there anything patients themselves can do to help reduce the risk of transmission coming in for an ophthalmic procedure?
Mark Breazzano, MD: This is a great question, by the way. There is something called blepharitis that is basically inflammation or some kind of gunk around your eyelids and whatnot. And there are some basic measures that can be done to help reduce that. There have been a number of studies, whether it's an injection in the back of the eye for diabetes or macular degeneration that can reduce the chances of Infection by making sure that that's as well controlled as possible.
So, if you're someone with blepharitis or rosacea and whatnot, and just really managing those underlying issues, that can help reduce the chances of that sort of devastating infection or complication from happening, which thankfully is very rare in our field. But, if we can further decrease this rate, that would be very helpful. So, I think that's really one thing that patients can do. And for the vast majority of patients, it's usually not an issue.
Host Amber Smith: I appreciate you making time for this interview, Dr. Breazzano.
Mark Breazzano, MD: Thank you so much, Amber, for having me.
Host Amber Smith: My guest has been Upstate graduate and ophthalmologist Dr. Mark Breazzano. He's on faculty at the Wilmer Eye Institute at Johns Hopkins University in Baltimore, but he's returning to Central New York this summer to Upstate and to Liverpool at the practice of Retina-Vitreous Surgeons of Central New York.
I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from urologic oncologist Dr. Joe Jacob from Upstate Medical University. What are symptoms of bladder cancer that a man or woman should not ignore?
Joseph Jacob, MD: The main thing that you have to understand is that seeing blood in the urine is not normal. So if you have blood in the urine, you should tell your doctor, and likely you need to see a urologist. Now, sometimes you'll have a bad urinary tract infection with blood, but if you're having what we call asymptomatic blood in the urine -- so you're not having any symptoms and you're seeing blood in the urine -- then you really, really need to see a urologist. And that's one thing. The other thing is, you have to see your primary care doctor, and your primary care doctor will check your urine and check for microscopic blood as well. So this would be something you may not necessarily see with your own eyes, but they'll see this when they look under the microscope, and if there's blood microscopically, then you need to see a urologist as well.
Host Amber Smith: You've been listening to urologic oncologist Dr. Joe Jacob from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Claudia Serea is the author of five poetry collections and a founding editor of National Translation Month. Her poem "Bar-hopping" is a lovely remembrance of a father-daughter relationship.
I wonder if the water in his lungs is salty
like the waves lapping at my feet.
He once told me if I passed the entrance exam
to the university,
he'd take me bar-hopping,
and I laughed.
Why would I go bar-hopping
with my father?
I got past the exam,
and we never went to any bars,
or to the Black Sea again.
Now the sea has come back,
searching for him.
Water climbed into his lungs
and the machine pumps oxygen
to help him breathe,
in and out
like the tides.
If he were awake, I'd tell him,
When you get out of the hospital,
I'll take you bar-hopping
and to the beach again.
The sea rolls on the shore
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 neurological effects of marijuana products. 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.