Preventing a second stroke; diversifying medical research; examining TB's threat; Upstate Medical University's HealthLink on Air for Sunday, June 26, 2022
Neurologist Gene Latorre, MD, explains new guidelines for preventing secondary strokes. Geriatrics chief Sharon Brangman, MD, and community research liaison Kathy Royal unveil an initiative to increase diversity in medical research. Infectious disease specialist Elizabeth Harausz, MD, discusses the threat of tuberculosis.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a neurologist explains new guidelines for preventing strokes in patients who have already had strokes.
Gene Latorre, MD: ... It is a pretty big problem that amounts to approximately 200,000 people a year, and a majority of the strokes can be prevented. ...
Host Amber Smith: Then we hear about an initiative to increase diversity in medical research.
Kathy Royal: ... You've got to sit down, you've got to build relationships, they've got to be able to trust you. ...
Host Amber Smith: And an infectious disease doctor discusses tuberculosis.
Elizabeth Harausz, MD: ... TB is also one of the first things that can kind of breach even a somewhat weakened immune system. So that's why people with HIV are a particular risk of TB. ...w
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 explore why it's important that medical research include more people of color. Then we'll learn about tuberculosis, which remains a global threat. But first, a neurologist walks us through new guidelines he helped create for preventing secondary strokes.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Two Upstate Medical University doctors were part of a national team that wrote a new practice advisory about stroke treatment for the American Academy of Neurology. With me to explain the significance of this new guideline is Dr. Gene Latorre. He's a professor of neurology at Upstate and the medical director of neurology for the stroke team at Upstate University Hospital. Welcome back to "HealthLink on Air," Dr. Latorre.
Gene Latorre, MD: Thank you, and good to be back, Amber.
Host Amber Smith: Now, these guidelines have to do with preventing secondary strokes in people who've already had a particular type of stroke. Is that right?
Gene Latorre, MD: Yes, you are correct. This guideline specifically targets intervention to prevent another stroke from happening in patients who already experienced a prior stroke.
Host Amber Smith: So how big of an issue are secondary strokes?
Gene Latorre, MD: About one out of four strokes in the United States are actually due to recurrent stroke. It is a pretty big problem, that amounts to about approximately 200,000 people a year. And a majority of the strokes can be prevented.
Host Amber Smith: Are they the same type of stroke that the person might've had the first time, or do secondary strokes have different characteristics?
Gene Latorre, MD: Usually, these secondary strokes are resulting from the etiology (cause) of the stroke that they had the first time. So if your stroke is related to atrial fibrillation, then your recurrent stroke, your secondary stroke, is most likely going to be related to the same cause.
Host Amber Smith: So, let me ask you how this has been commonly treated before the new guideline. What did doctors typically do to try to prevent secondary strokes?
Gene Latorre, MD: Well, the current guideline for preventing strokes from happening again involves a multidisciplinary approach, including prevention and maximization of risk factor controls. These risk factors include hypertension, diabetes, physical inactivity, obesity, as well as maintaining patients on anti-clotting medication, such as aspirin, and also, lowering cholesterol, with the use of a statin. And these are all very important in stroke prevention. And that also includes reducing your exposure to smoking. Quitting smoking is probably the best approach to preventing another stroke from happening.
Host Amber Smith: So it sounds like it would be very individualized to the person. I mean, some of those would apply to some people more than others.
Gene Latorre, MD: That's correct. And the more risk factors you have, the more intensive the treatment should be. These risk factors can be controlled by either medication or just by other, nonmedical maneuvers, such as regular physical exercise, weight reduction, watching the diet and having a healthy lifestyle.
Host Amber Smith: So, what is the new treatment guideline that you worked on?
Gene Latorre, MD: So this new treatment guideline addresses the best treatment we have for this type of stroke, related to narrowing of the blood vessels inside your brain. This type of stroke is quite hard to treat because it is a progressive condition, and it's related to a number of risk factors.
In the past, because this looks like a mechanical problem, where your blood vessel becomes narrow, it was intuitive to think that opening up the narrow blood vessel could work with reducing the chance of having another stroke. And people have used a number of procedures, such as stenting (inserting a tiny tube to keep an artery open) or surgery, to clean up the artery.
These procedures are being done in other parts of your body, OK? If your blood vessel in your leg gets narrow, you can go to a vascular surgeon and have it cleaned up, or have a stent placed. The same for your heart. When your heart blood vessel gets narrow, you can have a stent placed toopen up the artery, and then, you're like good as new.
Unfortunately, the evidence has shown that if you do the same thing with the blood vessels in the brain, the result is not as good as what we experienced in other parts of the body, so this guideline specifically addresses the current best treatment we have, which is medical therapy.
Host Amber Smith: So medication has been proven, then, to be better or more effective than a surgical intervention?
Gene Latorre, MD: That's correct. Part of our guideline development involves gathering all of the available evidence to support or refute the efficacy of one type of intervention or the other.
And the current evidence suggests that best medical management, which includes a multimodal approach with multiple risk factor prevention and control, are as good, if not better, than doing some type of surgery.
Host Amber Smith: So, neurologists and primary care doctors in America, do they generally follow these guidelines from the American Academy of Neurology?
Gene Latorre, MD: For the most part, they do. I mean, most neurologists would try to be adherent to the most current guideline recommendation. The art is in individualizing these guidelines through their specific patients. The guideline is the guideline. It's there to provide you with a framework of diagnosing and treating your patient in general, but individual patients have individual risk factors that require individualized patient management. And so, there is some level of individualization that may need to be done.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Gene Latorre. He's a neurologist at Upstate and the medical director of neurology for the stroke team at Upstate University Hospital. And he was one of the authors of a new practice advisory about stroke treatment.
Now, let me be clear: Does this apply to someone who had a stroke that was caused by a brain bleed, or is this just applicable to someone who had a clot that causes stroke?
Gene Latorre, MD: Yeah, it's a very good qualification. This guideline applies to a patient who had an ischemic (blockage-related) stroke, OK? So these are patients who did not have any hemorrhage or a hemorrhagic stroke. This is specific to ischemic strokes.
Host Amber Smith: OK, so the new guidelines for anti-clotting medications, medications to reduce blood pressure, (and) cholesterol, paired with safe levels of exercise. How do you know for sure that these measures work?
Gene Latorre, MD: Good question. Well, part of our guideline activities involved gathering all of the available evidence we have. And I'm happy to say that multiple studies have been published, and they're actually included in the summary of evidence in this guideline, showing the positive impact of this intervention, including the multiple risk factor management, which results in reducing recurrent stroke, with the control of these various factors.
And these are all part of our guideline recommendation: medications to lower cholesterol, medications targeting the control of blood pressure, controlling diabetes and blood sugar, medications for anti-clotting, including aspirin and other blood-clotting preventive medication, as well as a healthy dose of regular physical exercise. These are all interventions that our guideline committee have found to be quite effective.They're effective in and of its own, but if you combine all of these, interventions, their effect is significantly increased, more than what you would expect for individual interventions.
Host Amber Smith: Do the interventions, is the goal to eliminate the plaque buildup, or is it just going to prevent new plaque from forming, or how do these actually work?
Gene Latorre, MD: Unfortunately, we don't have any medication that makes the plaque disappear, OK?
These interventions are primarily designed to prevent further buildup of plaques. And so, what you have there, you're probably going to have there for some time. But the intervention is designed to prevent progression of the disease. Sometimes we see some reduction in plaque formation, but we believe that this is probably your body's mechanism of repairing itself.
We don't think it's the medication per se, but if your medication is helping to prevent plaque from buildup, then your body's able to optimize its ability to repair itself. And then, over time, sometimes we see a reduction in the plaque or an improvement in the lumen (blood-flow passageway) of these blood vessels.
Host Amber Smith: Are there some patients for whom stents or surgery may still be recommended to prevent secondary strokes?
Gene Latorre, MD: Yes. Not all patients respond to this intervention. In fact, there are patients who continue to experience stroke despite (the) best medical management. So these are patients who could be considered for either stenting or surgery as a last resort, OK? So the guideline states thatour first option would always be to maximize medical management. Some patients look like they are failing medical management, but if you look at them closely, they might be noncompliant with either their blood pressure medication, or they might not be doing as much exercise as you would want them to.
So, sometimes it could be that, just emphasizing to the patient the importance of having not just one strategy, but multiple strategies. Some people swear that they're taking all their medications, but they're also continuing to smoke. So sometimes, you may think that they're doing very well, you know, they're exercising, but then you can sometimes see, like, one risk factor that you could optimize further. And so it's very important to have a good, expanded review of all the risk factors that are present in your patient before you can say that they're failing this medical management, and only then would you need to consider additional intervention, such as stenting or surgery.
Host Amber Smith: So regarding medical management of people who've had previous strokes who are taking these medications, how often do they check in with a neurologist, or are they followed by primary care doctors, or what does their management look like, going forward?
Gene Latorre, MD: Patients who have had a previous stroke, and especially strokes related to a narrowing of the blood vessels in the brain, they're typically followed by both the primary doctor and the stroke neurologist. Sometimes a different type of stroke neurologist would be following them, the neurointerventional neurologist, because these are other specialties within stroke who are expert in not only following up at managing these patients who are having a specific type of stroke, (such as one one caused by) intercranial stenosis, and these patients normally would require some type of follow-up imaging to determine if their blood vessels continue to be open, whether their blood vessels are having more narrowing,related to the plaque buildup. And so that allows for individualization of management, you know, sometimes maybe the blood pressure control might need to be tightened up a bit more. Your diabetic control might need to be controlled even further. You may need to have a different type of anti-clotting medication. Some blood tests might need to be ordered to determine how well your body is responding to the anti-clotting medication. We now have a blood test that determines whether you are responding to aspirin. Sometimes, when you are taking a medication such as clopidogrel or ticagrelor, there are blood tests that allow us to determine whether your body is responding to it, or whether you have some genetic condition. Maybe your body's just not designed to respond to this type of medication. So there is a new way of following these patients by making sure that they are responding well to the treatment. So they are typically followed by both the primary doctor and a stroke neurologist.
Host Amber Smith: Now the guidelines say "safe levels of exercise," but I'm curious about what that means for someone who has survived a stroke. Because I imagine the idea of exercising may be really scary for someone that maybe feels a little fragile. So how do you counsel your patients?
Gene Latorre, MD: Safe levels of exercise means that you are doing what your body can tolerate, or what your body can do. Patients who have survived a stroke can have some physical limitations that prevent them from doing one type of exercise or another. So it's very important to work with a physiatrist (doctor specializing in physical medicine and rehabilitation), with a physical and occupational therapist, to help to design an individualized exercise program that would be not only safe for the patient but also can optimize their rehabilitation potential as well as their recovery. Symptoms of lightheadedness or shortness of breath or worsening of their weakness after an exercise are symptoms that they are probably overdoing it. When you're on that level of exercise where you're very exhausted, you're almost out of breath, that level of exercise probably will need to be downgraded or adjusted to a more tolerable level. Some other equipment might be a factor as well. So, some patients might think of maybe investing in a treadmill to do some exercise at home. If you are limping on one side, and if you do a treadmill, this treadmill is continuously running, and so you might not have enough time to adjust your balance, and so people who are having difficulty with balance, they probably would be better off not doing the treadmill. Instead, regular walking would be better because you can adjust your pace, and you can hold on to your family, if you're there walking with them. Other things would include using a dumbbell. If you are doing some weight training and you have weakness in your hand, or you're unable to grasp because of the stroke, using a dumbbell might, make you drop those dumbbells, which could result in an injury. So those things are typically things that I'm wanting to be cautious about when they're starting their exercise program. And as I said, a consultation and working with the physical, occupational therapist, as well as the physiatrist, would be the best bet in making sure that their exercise program is not only safe, but also designed to optimize their rehabilitation.
Host Amber Smith: Well, Dr. Latorre, I really appreciate you making time for this interview.
Gene Latorre, MD: Of course. Happy to be here.
Host Amber Smith: My guest has been Dr. Gene Latorre. He's a professor of neurology at Upstate and the medical director of neurology for the stroke team at Upstate University Hospital. I'm Amber Smith for Upstate's "HealthLink on Air."
An initiative to increase diversity in medical research -- next on Upstate's "HealthLink on Air."
I'm Amber Smith. This is "HealthLink on Air." Life-improving and lifesaving medical advances come about because of medical research, which historically has focused on middle-aged white men. That's starting to change. With me today to talk about a diversity in research initiative at Upstate are Kathy Royal and Dr. Sharon Brangman. Ms. Royal is the community research liaison at Upstate , and Dr. Brangman is chair of Upstate's department of geriatrics and the director of the Upstate Center for Excellence for Alzheimer's Disease. Welcome to "HealthLink on Air," both of you.
Kathy Royal: Thank you.
Sharon Brangman, MD: Thank you.
Host Amber Smith: Dr. Brangman, I know you're working toward changing this, but historically, why has medical research focused on white men?
Sharon Brangman, MD: Well, basically, because researchers are usually white men who know their area of expertise very well and may not consider it in other groups of people. So over the years, we've seen lots of research that has come out that has excluded women, older adults, people of all races. And that makes it very hard when we get medications or devices that haven't been tested in broad populations of people, to know how to apply it to the people we actually take care of.
Host Amber Smith: And so that's why it's important to include people who are Black and Brown in medical research. Otherwise you don't know how this treatment might work in those populations.
Sharon Brangman, MD: The interesting thing is that race is a social construct that was invented by people, to group people into categories for lots of political and other reasons. It's not necessarily a biological designation, but we then take physical characteristics and try to make biological determinations about that. And if we don't have information about how people respond to different treatments, then we don't really have enough information to know what might be helpful or might be harmful.
Host Amber Smith: Now, why do you think people of color may be hesitant to participate in clinical research?
Sharon Brangman, MD: Well, we have a long history of using people for reasons that may not necessarily benefit them, exploiting them or excluding them from treatments that might be helpful. And everybody knows about the Tuskegee experiment, but that's really just one of many, many instances where the medical community has not had the best interests of other people, other races, in mind when they are trying out new drugs or new devices.
And there are many examples of things that we use today that still have a negative impact on African Americans, for example. An example of this is the way we figure out kidney function in our country. We adopted an algorithm that was really done with flawed research on a small group of Black people that then made the false claim that all Black people had bigger muscle mass. So therefore, when we were figuring out their kidney function, we had to do it differently than we would for white people. It didn't include any other race, and it was based on very bad science. As a result, this has led to the delay in the diagnosis of chronic kidney disease in many African Americans and has also put them lower on the list for kidney transplants, because it makes their kidney function look better than it actually is.
And this was all based on bad science. That has started to change. Since about 2017, many hospitals across the country have started to eliminate using this false premise to determine kidney function. So that's just one example, but my expertise is in Alzheimer's disease and in memory problems and a lot of the medications that are under investigation right now for treating Alzheimer's disease have not been tested in large groups of diverse people.
Host Amber Smith: Well, Dr. Brangman, please tell us about your initiative to increase diversity in research.
Sharon Brangman, MD: So we have a grant from the National institute of Aging, with our co-principal investigators at Mount Sinai (health system in New York City) to look at ways of improving the participation of Black and Brown people in clinical research.
And the key part of this is relationship building and trust building. And our important person in this has been Kathy Royal, who is our community research liaison, whose expertise is in outreach, community contacts and communication, and building that trusting relationship.
Host Amber Smith: Let me remind listeners:
This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with community research liaison Kathy Royal and chief of geriatrics Dr. Sharon Brangman. And we're talking about an initiative to make medical research more diverse and reflective of the population.
Ms. Royal, what does your role as the community research liaison involve?
Kathy Royal: My job is to go into the Black and Brown community, my community, to educate them, to motivate them all into research and give them a little history on research. What was then and what is now, and just encourage them to get involved because we're dying slowly by side effects of what's already out there. And we're trying to stop that.
Host Amber Smith: So what are some of the hurdles you routinely encounter? Do you ever get people who just say no, they don't want to do it?
Kathy Royal: I get people who say no, but I still follow them. They may say no Monday. When I'm back on a Tuesday, what's your answer for Tuesday? And if it ain't Tuesday, it's a Wednesday, and if it's a Wednesday, I got 'em! (laughs)
Host Amber Smith: It's life challenges. There's barriers before they even want to talk to me. They want somebody to help them with what they're going through. So it's a "coffee and a cookie," bench approach. You've got to sit down, you've got to build relationships, they've got to be able to trust you. Because I had one say, "Oh, you're coming in now? Just like the ones before." No, no, no, I'm different. I'm here to help, talk. Let's sit down and talk. And I usually get them, but they'll say yeah today, but then they'll be hesitant tomorrow. And I just got to go back and say, OK, you want to talk again today? It sounds like you invest time to build a relationship with these people.
Kathy Royal: It takes time. You just can't go out on the street. Like in Tuskegee, our men was walking, and they just stopped, grabbed them and put something in their arm. And ain't no more of that today. We're respected. We're going to be heard. We just did a Black Lives movement. Come on, people. We want to be heard, we want to be respected. So we got to get out there and show them who we are, through research.
Host Amber Smith: Dr. Brangman, I wondered how this initiative is being received by your physician and scientist peers. Are they noticing that Ms. Royal is out there recruiting for a variety of research projects?
Sharon Brangman, MD: Well, another piece of what we're doing is, we've created a research accelerator for diversity here at Upstate. And this is comprised of members of the community, everyday people, as well as leaders, part of our community partners, as well as researchers at Upstate. And the goal is to have researchers come and present their research ideas, preferably while they are under development, to this community accelerator so that they can get input about their protocol design and what they want to do. So we're really trying to change that mindset where researchers sit in a little room with each other, come up with a proposal and then go out and try to find people to recruit. We really think that community engagement is an important piece of any research project.
And it's no longer acceptable to just drop in and drop out of a community. When you have a particular question that you want to have answered, you have to have community buy-in and community participation. And that's what our research accelerator is doing, along with the efforts of Kathy as our community research liaison.
Host Amber Smith: Could you see in the future that this community, or people in this community, might bring forward some ideas for some research?
Sharon Brangman, MD: So ideally that would be the goal because we need to be listening to the community. As Kathy was saying, we have to listen before we ask and find out what their priorities are. And what barriers or challenges they have, so we can come up as a researcher with a protocol that would encourage participation because we have buy-in from the beginning. But we have to overcome many, many years and decades, if not centuries, of mistrust, and even current relationships have to be strengthened because we want people to feel confident in coming to Upstate for clinical care, as well as for research. And so one of the things that we're doing is we're listening to what their challenges are and what their roadblocks have been when they've been trying to seek care so that we can respond to that. That helps to build trust and makes people more open to considering participation in research. That helps them and their community.
Host Amber Smith: Well, let me ask you a little bit about the research of drugs to treat Alzheimer's disease, since that's one of your specialty areas. Is there adequate diversity among clinical trial participants now?
Sharon Brangman, MD: No, there absolutely is not. And one of the more recent drugs that got approved had an international trial to evaluate the removal of amyloid plaques in the brain. They had 19 Black people in that study. They had a small group of Asians because they had a group that they looked at in Japan. They had one Pacific Islander and a small handful of Latinos. That is completely unacceptable when Alzheimer's disease has significant impact in African Americans and Latinos, but they are not represented in the clinical trials.
It's also very cynical and unethical, I think, to have so much diversity in your marketing materials to promote the drug, but you actually did not have that kind of diversity in your clinical trials when you were studying the drug. So I think that pharmaceutical companies and other researchers are starting to understand that this is no longer acceptable. And recently the FDA said that all drugs or devices that require FDA approval have to have a diversity recruitment plan, and it has to be submitted early on. So now we have federal support for having diversity in research. We think that our accelerator with the work of our community research liaison is an excellent model to address these issues.
Host Amber Smith: With the Alzheimer's research in particular, age would be a concern, right?
Are you getting people across the age spectrum?
Sharon Brangman, MD: Many of these trials have cutoffs of people who are 80 or maybe 85. And again, the patients that I take care of are often in their 80s. So, how can we do a trial for a medication that is going to primarily be treating older people if we don't include them in the trials either?
But that has been part of the history of medications in this country. They're tried on younger, relatively healthy people.
And then, people who are geriatricians like me, my colleagues across the country, have to figure out if this drug that works well in a 40-year-old is going to work well in an 80-year-old. So we have to really try these drugs on real-world people, because that's who we take care of.
And that doesn't matter if it's your age, your gender or your race. We take care of people across the board. We have to be confident that the medications we're prescribing are appropriate.
Host Amber Smith: Well, Ms. Royal, if a listener is inspired to get involved and wants to join a clinical trial or look into it or participate in research in some way, who should they contact?
Kathy Royal: To learn more about our clinical trials, they can call 315-464-3285. Or they can call me. My cards are in the community. My research cards are in the community. I'm getting calls as well as I'm getting referrals. So we're here to help because we know everybody is different, but "every body" is different. So that's what we're trying to spread, the message.
Host Amber Smith: Well, let's share your email address too, if that's OK. Royal K -- email@example.com ?
Kathy Royal: Yes, ma'am. That's it.
Host Amber Smith: All right. Well, I appreciate both of you making time for this interview.
Kathy Royal: Thank you.
Sharon Brangman, MD: Thank you for having us.
Host Amber Smith: My guests have been Kathy Royal, the community research liaison at Upstate, and Dr. Sharon Brangman, who's the chief of geriatrics at Upstate University Hospital and also the director of the Upstate Center for Excellence for Alzheimer's Disease. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air": what's important to know about tuberculosis.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Tuberculosis was the leading cause of death in the United States in the 20th century. And even though this bacterial infection does not kill as many people today as it used to, it remains a disease of concern. Worldwide, it's one of the leading causes of death due to infectious disease. Here to talk about diagnosis and treatment of tuberculosis is Dr. Elizabeth Harausz. She's a doctor who also has a master's of public health, and she specializes in internal medicine and infectious disease. Welcome to "HealthLink on Air," Dr. Harausz.
Elizabeth Harausz, MD: Thank you.
Host Amber Smith: When I think of tuberculosis, I recall that a patient toward the end of the 1800s was likely to be sent to a tuberculosis sanitarium. Was that so the patient wouldn't infect others?
Elizabeth Harausz, MD: Yeah. So patients going to sanatoriums was probably to help prevent other people from getting infected, although truthfully, I'm not sure what understanding exactly they had back then about how the disease was spread. I mean, the organism wasn't actually discovered until the 1880s. But it was also to provide the only treatment they really had at that point, which was clean air -- the cities were very polluted at that time -- and good nutrition and rest. So really, I think when you consider all of the horrible medical treatments doctors had, that they sometimes came up with back then, I think this was actually a really good idea and really the best that could have been done for people at the time. But despite that, you know, the mortality rates were still very high.
Host Amber Smith: So clean air, rest, good nutrition. That was pretty much the treatment. That's all that they were able to do?
Elizabeth Harausz, MD: Yes. ...back then.
Host Amber Smith: Well, what happened to stop tuberculosis from being a leading cause of death?
Elizabeth Harausz, MD: There did start to be some treatments back in around the 1950s, which were still medications that are used today. Truth be told, it hasn't really advanced too much. But also just public health measures -- so improved living conditions, mostly in the United States and in Western Europe, but less crowding in city slums, better work conditions, improved health and nutrition -- all helped, contributed to tuberculosis' decline. But unfortunately recently, if you remember back in the eighties and nineties with the HIV pandemic, cases of TB increased. And TB is still a leading killer in many of the poor parts of the world where access to medical care is limited, and malnutrition and crowded, poor living conditions are still common.
Host Amber Smith: You mentioned HIV, human immunodeficiency virus. How is that connected or related to TB?
Elizabeth Harausz, MD: So, HIV doesn't kill directly. What it does is it destroys your immune system. So if there were no germs in the world, HIV would have no effect on anybody. But because it affects your immune system, it makes you unable to fight disease and more likely to get infected. And for various reasons, HIV particularly affects a part of your immune system that fights TB. And because TB can also, as we know, very much kill people with healthy immune systems, TB is also one of the first things that can kind of breach even a somewhat weakened immune system. So that's why people with HIV are a particular risk of TB.
Host Amber Smith: That makes sense.Now, before we get much further, can you tell us more about what tuberculosis is?
Elizabeth Harausz, MD: I think first, I think I should talk about the difference between latent TB and active TB, because in this country, well, actually in the whole world, latent TB is actually more common, and you're much more likely in this country to run across latent TB.
So TB is somewhat of a unique infection. Unlike most infections where you become infected and develop symptoms and then hopefully recover from the infection in a fairly rapid sequence, tB is different. So when people become infected with TB, a person's immune system walls off the organism and prevents it from spreading. And in about 90% of people, they never in their lifetime develop symptoms. They never develop disease. They're not contagious. But if they were screened for TB, with the blood or the skin test, that would be positive because their immune system knows what TB is now because it's seen it. And these tests basically just look for immune recognition of TB.
They can't tell you anything about disease or not. But so these people would never have any TB disease. And so this is what we call latent, or it's kind of, you can think of it as hibernating TB. However, in about 10% of people with normal immune systems, and more than that in people with suppressed immune systems, TB can escape the immune system's control and become active and cause disease. So that is why we treat latent TB, so it never becomes active. And why, if people are going on immune suppressive medications, like rheumatological diseases, they are screened for TB first. Um, so there's kind of two different disease states there -- latent and active TB.
Host Amber Smith: How is it spread from person to person?
Elizabeth Harausz, MD: So it's only spread by people with active TB, so people that have symptoms, respiratory symptoms. And, a person coughs the TB germs into the air and someone else breathes them in. So it's actually not spread very easily, and it usually takes close and prolonged contact. So you wouldn't get it just by like walking past somebody on the street or anything like that, or quick contact.
Host Amber Smith: What are the symptoms of tuberculosis?
Elizabeth Harausz, MD: Tuberculosis is usually a lung disease, like a pneumonia, and the classic symptoms are cough, fever, weight loss, and night sweats. And that's not just like waking up kind of warm, but it's, you know, waking up your pajamas drenched, you need to like change your pajamas. And sometimes people cough up blood as well.It's important to note that this is a chronic disease. So these symptoms start and slowly progress over weeks to months. So it's not something that you suddenly come down with over the span of, like, a week. These are prolonged symptoms.
Host Amber Smith: Does it cause lasting damage to the lungs?
Elizabeth Harausz, MD: No, not usually in this country. Here, are people that are usually diagnosed and treated quickly, and they make a full recovery.In countries where there is a lack of medical care, and people are not treated for a very long time and so they have disease for a very long time, it can cause permanent lung damage and resulting heart damage, and also particularly if they have a very suppressed immune system, tuberculosis can spread to other parts of the body. That's more rare and more seen in people who are very ill or very immune suppressed, and not what we usually see, but certainly we do see it, particularly in other countries.
Host Amber Smith: So, TB can be deadly?
Elizabeth Harausz, MD: Oh yes. So untreated TB probably has about an 80% mortality rate, active TB. And it kills, usually, by destroying the lungs. Nobody should die of TB because there are good treatments for all, essentially all forms of TB.
Host Amber Smith: Is there a vaccine available?
Elizabeth Harausz, MD: There is, but it's not a very good vaccine. It is called the BCG (Bacille Calmette-Guérin) vaccine, and it's been around a very long time, about a hundred years. It's usually given in infancy, and it does help protect young children from the worst forms of TB. So like TB meningitis and other bad forms of TB, but it doesn't protect very well, and it has a fair amount of side effects. So it's not used here in the United States anymore because its risks outweigh the benefits, but it is still widely used throughout the world where there are high rates of TB and less robust medical systems, and it is beneficial in those places. And scientists are working on to develop a better vaccine, but haven't had much success.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Elizabeth Harausz. She's an internal medicine and infectious disease doctor at Upstate who has expertise in tuberculosis.
Now I know your research is focused on improving the diagnosis and treatment of tuberculosis. How is this disease diagnosed today?
Elizabeth Harausz, MD: Latent TB is usually diagnosed as part of routine screening. So people who may be at risk for being exposed to TB, like healthcare workers or people who are planning to go on immune suppressive medications are tested either with a blood test or a PPD, which is that little needle that they stick under your skin, and then you have to come back in a few days to see if there's a bump. If these tests are positive, and the person has no symptoms and no unusual findings on chest x-ray, then this is latent TB. For people who have active TB, so are having symptoms, TB is usually diagnosed based on symptoms. So that was a long lasting cough, fever, weight loss, or night sweats, and unusual findings on chest x-ray. If these symptoms are present, then usually phlegm is sent for a culture or PCR testing to look for the TB germ. These screening kind of blood and skin tests can also be positive in people with active TB, but those screening tests can't distinguish between active or latent TB, so in order to distinguish one from the other, symptoms and chest x-ray need to be evaluated.
Host Amber Smith: How common is tuberculosis today in the United States, and who does it mostly affect?
Elizabeth Harausz, MD: In the United States, it's not very common. So there are about 2.5 cases per a hundred thousand people every year in the United States. The rates are higher among foreign born people, compared to native born people, just because rates of TB are higher in other countries. However, lots of people who did immigrate here, as part of immigration, you're routinely screened for latent and active TB and are treated when you come. And rates can be higher among people with certain risk factors, most important factor, as we talked about, used to be HIV because it suppresses the immune system in a way that makes it particularly easy for tuberculosis to become active. But with good HIV treatments that we've had, the rates of TB among people with HIV has gone way down. And other risk factors include living in crowded settings, just because TB can spread easily if there happens to be some one there with active TB, so people who are incarcerated, people who live in homeless shelters, that sort of thing.
Host Amber Smith: What's the prognosis for someone who's diagnosed with TB today?
Elizabeth Harausz, MD: It depends where you live. In the United States, it's very good. TB is 100% curable. It's still a huge problem, though, in the rest of the world. It's actually overtaken HIV is the world's number one infectious disease killer. Actually twenty-five percent of the world has latent TB, and every year, 10 million people throughout the world become ill with tuberculosis. And despite the fact that there are good treatments, 1.5 million people die every year of TB. As I mentioned, you know, in the United States only about 2.5 cases of TB for every hundred thousand people, but in countries with high rates of TB, that's up to hundreds, hundreds of times that so 600 to 700 cases per every a hundred thousand. So a much bigger problem in other countries.
Host Amber Smith: So the treatment that's offered today, I'm assuming we have something beyond fresh air, good nutrition and rest, but are those things still prescribed?
Elizabeth Harausz, MD: Definitely. So particularly in other parts of the world, where malnutrition, especially children, is high, nutritional support is very important. This is, in fact, recommended with the WHO's guidelines for tuberculosis treatment -- the World Health Organization -- but in this country, malnutrition is not such an issue. We do have good treatments for tuberculosis, although they're all kind of relatively old. For latent TB, we do now have shorter regimens. You get either one to two medications for as short as three months, but sometimes as long as six months, depending on the medication regime that you get. And then, the vast majority of people in this country have drug susceptible TB. The treatment for that has traditionally been four medications for two months and then two medications for four months. So six months in total. But there's now actually a newly approved treatment which is only four months. And that's four medications for two months, then three medications for two months. It does take a long time to treat TB, which I think is the most difficult thing about it. The TB germ is kind of slow, and it's resting and not kind of eating a lot of the time. So it doesn't take up the antibiotic very quickly. So you need to treat for a long time to make sure you kill it. And you also need multiple medications because it can develop resistance easily. So that's why you can't just use one medication.
Host Amber Smith: Is there a concern about drug resistance?
Elizabeth Harausz, MD: Worldwide there is. In this country, not so much, because we have health departments and a medical system that is very active in making sure, well, first we can test. Whenever anybody's diagnosed with tuberculosis, we always test for drug resistance, and then we have a very active health department that makes sure that people get their medications and take them. In other parts of the world, particularly in Eastern Europe and South Africa, drug resistance is a large problem. And then you have, it is more difficult to treat people. You have to have longer treatments with more difficult medications.
Host Amber Smith: Once someone recovers from TB, if they've been treated and they recover, are they protected from getting it again?
Elizabeth Harausz, MD: To a degree, but people can still get it again if they're exposed, so it's not 100%.
Host Amber Smith: Who's at greatest risk for developing TB, and is there anything that that person can do to reduce their risk?
Elizabeth Harausz, MD: So in this country, I don't think I would worry too much about contracting TB. The TB rates really are not that high. If you are in contact with someone who has active TB, the health department really does a good job of contact tracing and letting people know that they need to be evaluated. And people in high risk jobs are usually routinely screened through their work. But I would say if people are having chronic longer breathing issues, you know, unfortunately there are a lot worse things than TB that it could be. So they should definitely contact their doctor to let them know. But I just would want to say that one of the reasons that the rates of TB in this country are so low is that traditionally we've had a very strong public health system. It does provide a lot of services and works very hard to trace and treat contagious diseases, to the benefit of us all. Unfortunately, during the COVID pandemic, we have seen that our public health system is under stress due to underfunding. It's not an accident in this country that most of us, for most of our lives have not had to worry about contracting a contagious disease during our daily activities, and we have our public health systems to thank for that. And it is really important that we continue to support them and fund them.
Host Amber Smith: Well, Dr. Harausz, this has been very informative. I thank you so much for your time.
Elizabeth Harausz, MD: Yeah, thank you very much. Appreciate it.
Host Amber Smith: My guest has been Dr. Elizabeth Harausz. She specializes in internal medicine and infectious disease at Upstate. I'm Amber Smith for Upstate's HealthLink on Air.
Here's some expert advice from doctor of physical therapy Scott Hoskins from Upstate Medical University.
What can people do to reduce their risk of developing temporomandibular joint dysfunction, or TMJ?
Scott Hoskins: The easiest things are:
-- Minimize excessive chewing. So if you're somebody who is constantly chewing gum throughout the day, chewing on pens and pencils, things like that, try and minimize that, if you can.
-- Being aware of your posture -- if you're always in a slouched or forward-head position, that affects the mechanics of the jaw. So being more aware of your posture, sitting up straight, keeping your shoulders back.
-- Stress management is a big thing. If you're somebody who's always tense and holding your shoulders up, that's going to affect all the muscles in the front of your neck and your jaw. And everything's just going to be sort of tight. So stress management is a huge thing.
-- As much as you can, nighttime behavior modification. So if you're somebody who clenches her teeth or grinds her teeth while you sleep, possibly get a mouth guard, which your dentist will be able to provide, can be helpful and minimize that extra stress on the jaw throughout the night. It can be kind of a hard fix, but if you can make this your habit, it can be very beneficial. There is something that we call the resting position of the jaw. When you're not using your mouth for eating or talking or whatever, you want your habit to be, to keep your lips together, keep your teeth slightly apart and then have your tongue just gently relaxed on the roof of your mouth. So that is the position where there's the least stress on it -- the joint -- so the more you can make that your habit, the less stress there is on the TMJ.
Host Amber Smith: You've been listening to doctor of physical therapy Scott Hoskins 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: Kristen Taleen sends us a searing glimpse into her life as a young intensive-care nurse in her poem called "Intensive Care."
I hold your mother's grief in my chest
like smoke that i cannot exhale.
Her tears blur my vision
and i realize that i have no one to pray to
so i borrow her God.
If she were here, she would tell me
that you were born in the back of a taxi
23 years ago,
and that you held her hand crossing the street
until you were 13 years old.
She would tell me about your bedroom
untouched since you moved out in the spring
in case you ever wanted to come home.
Instead, her guilt lines my stomach
and rises in my throat like bile
as i sit by your bed in silence
wishing that i knew the language of your lullabies.
I have never been anyone's mother
but I have walked to the edge of the world enough times
to know how to keep your body warm
as she drives twice the speed limit
and arrives two minutes too late.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. 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.