Cochlear implants vs. hearing aids; pulmonary hypertension; tick outlook: Upstate Medical University's HealthLink on Air for Sunday, Dec. 18, 2022
Audiologist Erin Bagley, AuD, tells about cochlear implants to improve hearing difficulties. Pulmonologist Krithika Ramachandran, MBBS, describes pulmonary hypertension and how it differs from the more common, or systemic, hypertension. Microbiologist and researcher Saravanan Thangamani, PhD, looks at how big a problem ticks are likely to be this winter and spring.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air": an audiologist tells all about cochlear implants.
Erin Bagley, AuD: ... People can become very proficient users of cochlear implants, but they do sound very different, especially at first. ...
Host Amber Smith: A doctor of pulmonology and critical care explains why pulmonary hypertension can be dangerous.
Krithika Ramachandran, MBBS: ... In most patients, it's the slow, sort of, "Oh, I don't feel good." "Oh, I'm just feeling worse." And then over the course of several months to a couple of years is when they truly start to feel the disease. ...
Host Amber Smith: And a tick researcher gives an outlook for winter and spring.
Saravanan Thangamani, PhD: ... TIcks don't die during the winter. They clever to find warm places for them to hide and wait until the spring warm weather comes up. They start to come out and try to find a human to feed on. ...
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 what's important to know about pulmonary hypertension. Then we'll get a tick outlook for winter and spring from a researcher who specializes in ticks. But first, who's a candidate for cochlear implants?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
People with significant hearing loss who cannot be helped by traditional hearing aids may be candidates for cochlear implants to improve communication and quality of life. Here to explain how they work is Upstate audiologist Erin Bagley.
Welcome back to "HealthLink on Air," Dr. Bagley.
Erin Bagley, AuD: I thank you for having me again.
Host Amber Smith: Now, can you explain the difference between a hearing aid and cochlear implants?
Erin Bagley, AuD: Sure. A hearing aid amplifies sounds in the environment. Without getting too technical, we hear sounds through vibrations in the air, and hearing aids pick up those sound vibrations, amplify them to a particular level that they're set to, to help a person hear those everyday sounds at a higher level.
A cochlear implant works differently. It actually uses electrical stimulation, so it picks up the sounds of the environment, and it changes it to an electrical signal. And it uses tiny, tiny electrodes, implanted in the inner ear, to stimulate the hearing nerve directly. So it bypasses a lot of the typical parts of the ear that we typically would hear with.
Host Amber Smith: So which one gives a person a more clear sound? Which one sounds more natural?
Erin Bagley, AuD: Well, in terms of sounding more natural, a traditional hearing aid would sound more natural because it amplifies sounds and produces them in a way that we're already familiar with, that we already know how to interpret, just at a higher volume, versus a cochlear implant. There is a learning curve with a cochlear implant. People can become very proficient users of cochlear implants, but they do sound very different, especially at first.
Host Amber Smith: So who are hearing aids designed for, and who is best for a cochlear implant?
Erin Bagley, AuD: Hearing aids are typically fit for people with anywhere from a mild hearing loss on up.
We kind of categorize hearing loss into different categories or degrees of hearing loss, and even some people with a very significant, severe to profound, hearing loss may do OK with hearing aids.
Cochlear implants are kind of the end of that continuum. So, as people start to have significantly more difficulty or less benefit from their hearing aids, a cochlear implant may be just the next step on that journey to help them hear better.
Host Amber Smith: Well, you started explaining how cochlear implants work, but I want to ask a little bit more about that. Do they go in one or both ears?
Erin Bagley, AuD: That depends. So, some people have a cochlear implant in just one ear. Some people actually have a cochlear implant in one ear and a hearing aid in the other ear. We call that bimodal listening.
And some people have a cochlear implant in each ear. So it really depends on the person's hearing loss. Perhaps they're still getting some benefit from their hearing aid in one ear, and they want to keep using the hearing aid on that side, and then we implant the other ear so that they get the best of both worlds.
So, it really is just a case-by-case basis, whatever is most appropriate for that patient.
Host Amber Smith: Most people who come for cochlear implants, have they tried hearing aids in the past?
Erin Bagley, AuD: Most of the time, and it is a good idea. So, think of it like a muscle that you don't exercise. If you, have, say, your arm in a cast, and you're not able to exercise that muscle, when you get the cast off, that muscle on that side would be a little bit weaker than your arm that wasn't in a cast.
So, it's the same thing with hearing. If you have an ear that hasn't been getting sounds, it may take longer to adapt to hearing again in that ear. We want to keep that hearing nerve exercised and healthy as much as possible.
Host Amber Smith: So what are the realistic expectations for what a cochlear implant can and can't do in terms of providing hearing for someone?
Erin Bagley, AuD: The important thing to know is it's not a quick fix. So a lot of people come in hoping that, "You know what? Geez, I'm not benefiting from my hearing aid anymore. I'm going to get this cochlear implant, and it's going to fix everything."
Cochlear implants are wonderful, and there are people who do extremely well with them, but it does take time, so it's just important to be realistic that there is a learning curve. There'll be follow-up appointments and rehabilitation to get used to hearing with that new device in a new way. So I think, No. 1, that's a really important expectation for patients. The other limitations are, it doesn't sound like your natural hearing. Some people can follow speech very well, but music just doesn't sound the same as it used to.
Unfortunately we're just not quite there yet, in terms of technology, to hear music the way that we used to perceive it. So some people report that that's a really big difference between a cochlear implant versus their hearing aids or their natural hearing.
Host Amber Smith: Will cochlear implants remove tinnitus, or ringing in the ears?
Erin Bagley, AuD: There have been some studies on that. For some people, they do notice their tinnitus much less when they're using their implant because, again, they're getting, they're hearing, they're getting stimulation to their brain, and so they're not as aware of that annoying tinnitus as they were before.
But it's hard to know who is going to have that benefit and who isn't.
Host Amber Smith: How long do implants last for? Are they good for life?
Erin Bagley, AuD: So, there are two parts to a cochlear implant. There's the actual implant part, which is under the skin, and that is ideally there for a lifetime. I have patients that received their device in the late '80s that are still using the same internal device.
We try not to remove and replace that internal if we don't have to because the inner ear is a very delicate organ, but the external processors, those get replaced approximately every five years. And that's the part that's on the outside that looks, in some cases, more like a hearing aid.
And there are some smaller devices now, processors that actually sit off the ear, so they're a little bit more comfortable to wear. And those last, like I said, about five years.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Erin Bagley. She's an audiologist at Upstate, and we're talking about cochlear implants.
Does Medicare and health insurance cover the cost of implants?
Erin Bagley, AuD: One of the key parts of finding out if somebody is an implant candidate is that we have to do specific testing. So if a person meets Medicare criteria, then yes, Medicare covers 80%. And if they have, like, a secondary insurance or a benefit plan, there may be some additional coverage there.
As far as private insurers, typically, yes, they are covered by insurance. To what degree varies by insurer. We do have to get prior authorization before we move ahead with that process.
Host Amber Smith: What are the potential risks to consider with implants?
Erin Bagley, AuD: Like any surgery, there's always some risks like infection and things like that, although that tends to be pretty low.
Some people do experience a little bit of dizziness right after the surgery that typically goes away pretty quickly. In terms of other risks, there could be a worsening of hearing in the ear that's implanted. That's always a risk of the surgery. surgical techniques have gotten better and better over time.
Some people don't have any change in their hearing, the residual hearing, we call it, or what's left of their hearing after the surgery. But some people do lose more hearing after the surgery.
Host Amber Smith: Does the addition of implants change a person's life in terms of their ability to go swimming or to be able to hear when they're asleep?
Erin Bagley, AuD: So, just like hearing aids, we recommend that people take their implant off at night. The implants have rechargeable batteries, so I always say, "Recharge your batteries." Well, you're recharging, so you're going to take it off at night and recharge your batteries. So, in terms of hearing at night, I know many people are concerned about things like hearing the fire alarm or hearing the phone ring or hearing a loved one perhaps in the night.
There are some other technology solutions that we can talk about, or you can talk about with your audiologist, to help with those situations when you're not able to wear your implant. What's really cool is that you can get a waterproof cover so that you can actually wear them swimming or to water aerobics or while you're fishing or boating so that you can still enjoy those activities without worrying about getting your processor wet.
Host Amber Smith: Let's talk about how a person goes about obtaining implants. Do they need a referral from a primary care doctor? Do they go to an ear, nose and throat doctor? How does that all work?
Erin Bagley, AuD: Typically, the process is a patient is referred here by their primary care physician, to our office. In our office, we do the audiology portion first.
I do some specialized testing with my patients, with their hearing aids, if they have them. And we determine whether or not they meet the FDA and/or insurance criteria for a cochlear implant or implants. If they do, then they would follow up with our neurotologist, Dr. (Charles) Woods in our case, and he would do some more investigation as to whether they are a good surgical candidate, like doing imaging and making sure they're healthy enough for surgery.
And then we collaborate. And we make sure that we're on the same page. If we are, we go ahead and get insurance authorization, and the patient gets scheduled for the surgery.
Host Amber Smith: So before the surgery, you measure their level of hearing loss, or does it have to be a certain degree before they would qualify for the surgery?
Erin Bagley, AuD: It does. So it needs to not just be a certain degree of hearing loss, but also we measure their word understanding, and we do it in kind of a tricky way. So we measure with their hearing aids, and we measure their word understanding of certain types of sentences, in quiet and also in background noise.
And that's the No. 1 thing a lot of people complain about, is that they do OK one on one, but they really struggle when there's background noise. So we want to really measure that and make sure that we're looking at different aspects of how someone is hearing before we make that decision.
Host Amber Smith: So, how do you tell patients to prepare for this surgery?
Erin Bagley, AuD: On their end, once we determine that they are a candidate, like I said, they usually have imaging and as long as that looks good, in preparation for the surgery itself, there's not a lot that they need to do leading up to the surgery. The hard work really comes after.
Host Amber Smith: Where does the surgery take place? Is it in the office, or is it in the hospital?
Erin Bagley, AuD: It's in the hospital. It is outpatient for most of our patients, so the surgery is a couple of hours, and then they typically go home the same day.
Host Amber Smith: And then what is recovery like?
Erin Bagley, AuD: For the most part, patients complain of just a little bit of pain at the incision site, which usually feels better fairly quickly. They may have a little bit of dizziness after the surgery, but typically they recover pretty well and pretty quickly.
Host Amber Smith: Now the implants are not activated immediately, right? There's some time that lapses between the surgery and when they're activated?
Erin Bagley, AuD: Correct. So we usually wait four weeks from the time of the surgery until the day of activation, because we want to make sure that everything is healed up nicely before we add anything to it.
In that meantime, the patient sees the surgeon just to make sure that the surgical site is healing well and just to check and see if they have any other concerns, like I said, then typically they're cleared at that point to come back for their activation in four weeks.
Host Amber Smith: Now, once the activation takes place, I wanted to ask you about the audiologist's role in that, and then that's when the hard work begins, right?
Erin Bagley, AuD: It is. That's when the fun begins on my end, too. It's really great to be able to guide patients through this experience.
The surgeon does their job in the operating room and immediately after, and then the audiologist really takes over from there to do a lot of the work with the patient. I spend a lot of time with my patients, especially in the beginning, going over how to care for their device, how do we have to set their device, and it sounds very different than anything that they've heard before. So, we take our time to go through fine tuning and refining how things sound and helping patients relearn to listen with the implant and relearn what things sound like again, and also helping them along the way with everything from the fit of the device to accessories.
There are accessories that can pair with the implant. Patients can get phone calls right to their implant, or they may have a microphone that a loved one can wear to help them hear better when there's background noise so that their loved one's voice goes right to their processor.
So I help the patient and their family learn how to use all of those tools to really maximize their hearing.
Host Amber Smith: Is there anything a person can do to improve their chances that the implant is going to really restore their hearing for them?
Erin Bagley, AuD: Yes. I always tell patients, wear it consistently all day, every day.
You want to get used to all those little sounds. It's a noisy world, and sometimes patients forget that because they haven't heard their shoes squeak on the floor, and they haven't heard their dog's toenails on the floor, or the refrigerator running. They haven't heard leaves rustling. So the more you can wear the device all day, every day, and relearn what all those sounds are in your world. And also talk to people, as much as possible.
My patients that are more actively engaging with others tend to progress more quickly than patients who are a little more introverted, maybe live alone and don't interact with people on a day-to-day basis as frequently. So for those patients, we talk about other things if they do live alone, like audiobooks or podcasts, or other ways to be listening to speech and practicing.
And, I just too wanted to add that there have been some great new developments, in just the last year. Traditionally, cochlear implants were for patients that had a significant hearing loss in both ears. And now the FDA (Food and Drug Administration) has approved certain devices for patients with single-sided deafness, or who have deafness in one ear and normal or near-normal hearing in the other ear. In the past we've had some limited options for those patients to help them hear better, but now those have been approved and the research is really promising for those patients. I think it's going to be a really good thing. It's just more patients that we can help.
Host Amber Smith: Dr. Bagley, thank you so much for taking time to tell us about cochlear implants.
Erin Bagley, AuD: Oh, you're welcome. Thank you for having me.
Host Amber Smith: And I want to point out that a transcript of this interview is available on our website at upstate.edu/informed.
My guest has been Upstate audiologist Erin Bagley. I'm Amber Smith for Upstate's "HealthLink on Air."
What are the symptoms of pulmonary hypertension? Next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Pulmonary hypertension is high blood pressure in the arteries in your lungs.
Today, I'm talking about this condition with Dr. Krithika Ramachandran. She's an assistant professor of medicine at Upstate who specializes in critical care medicine and pulmonary diseases. Welcome to "HealthLink on Air," Dr. Ramachandran.
Krithika Ramachandran, MBBS: Thank you, Amber, and thank you for having me.
Host Amber Smith: Now, when we talk about the pulmonary arteries, we're talking about the arteries in the lungs and also those on the right side of the heart. Is that right?
Krithika Ramachandran, MBBS: That's right. So when we're talking about the pulmonary arterial system, we're talking about the blood vessels that come out of the right side of the heart and go into the lungs. So the flow of the blood, the way it flows, is the body sends back the blood, which is deoxygenated -- from which all the fresh oxygen has been used up -- back to the right side of the heart. And then the right side of the heart pumps this blood into the lungs, from where they can get the oxygen they need.
And then this oxygenated blood goes back to the left side of the heart, from where it's then sent to the rest of the body. It's like this neat little circuit. And what happens in pulmonary hypertension is the pressures in the blood vessels of the lungs, to which this right side of the heart is pumping blood, the pressures there are higher than they should be, which poses a problem for the heart when it's trying to send this blood across.
Usually, the way I explain it to my patients is, I tell them to imagine, like, a balloon with a straw attached to the end of it. And if the diameter of the straw just keeps getting smaller and smaller, that balloon has to be squeezed harder and harder to send flow through the straw.
That's essentially what's happening with the right side of the heart in this situation.
Host Amber Smith: That's a good visualization. Well, let me ask you, does a person necessarily have to have high blood pressure throughout their body before developing pulmonary hypertension? Or can you have pulmonary hypertension and no problem with general high blood pressure?
Krithika Ramachandran, MBBS: Correct. That can happen. So, as we get older, since a substantial amount of the population develops high blood pressures, they can develop a form of pulmonary hypertension known as pulmonary venous hypertension. Now, that is not the classic pulmonary hypertension that we talk about when we say pulmonary hypertension.
The classical pulmonary hypertension, or what is now called Group 1 pulmonary hypertension, there, the pressures in the lungs are elevated separate from the pressures in the rest of the body. So to answer your question in a yes-or-no format, no, you do not have to have high blood pressure to have high blood pressure in the lungs.
Host Amber Smith: So what are the symptoms a person would experience if they have pulmonary hypertension?
Krithika Ramachandran, MBBS: That's a great question. and it's one of the things that makes it a harder condition to diagnose because the symptoms are very nonspecific. Typically, you know, you feel short of breath, you feel tired, you feel like you're just kind of running out of oomph.
It's only when the disease progresses, and you kind of get later in the stages of the disease, when the symptoms of right heart problems start to come into play. You can get swelling in your legs. You can get swelling in your belly. You may start to retain fluid everywhere. And then one of the most ominous signs is when you start to pass out.
So that indicates that you have really severe advanced disease and potentially could die any minute.
Host Amber Smith: Well, would people, if they go for, like, regular annual physicals, would their primary care doctor necessarily pick this up, or would someone develop a crisis and end up in the emergency room before they learn that what they've got is pulmonary hypertension
Krithika Ramachandran, MBBS: No, not necessarily an emergency room situation, but typically, the time frame ends up being about six months to a year before we figure out that that's what's going on. Because they go to their primary care doctor, and the classical patient, again, they tend to be younger women or middle-aged women. Sometimes their symptoms get written off as, "Oh, you're anxious" and "Oh, you know, you're just tired from doing all of these things." Sometimes it gets treated as asthma, and it takes a while before you come to the realization that, "Hey, we've looked at all of these other common things, and we haven't really gotten to the root cause of this."
And that's when an echocardiogram gets done, and you come up with, "Oh, my gosh, this is what's been going on this entire time." It does take a while.
Host Amber Smith: An echocardiogram is what is done for diagnosis?
Krithika Ramachandran, MBBS: An echocardiogram is your screening test. That would be where you pick up clues to whether this is what's going on.
Let's say I go to my doctor, and I say, "Hey, you know, I haven't really been feeling very well. I'm short of breath. I could, you know, run four miles before, and now, I'm just really having a hard time walking a mile."
And I get asked all these questions. I'm not wheezing, I'm not coughing, I'm just nonspecifically tired. They look to make sure I'm not anemic or something, and then they're like, "You know what? Let's just get an echocardiogram. That might show."
So an echocardiogram can actually indirectly measure pressures on the right side of the heart, and that will give you this clue to, "Hey, maybe the pressures in your lungs are high."
And so that's what we call a screening. test. Now, about 10% to 20% of the time, the echocardiogram can either underestimate or overestimate the pressures, which is why you always have to confirm the diagnosis by what's called a right heart catheterization, where you actually go into these blood vessels, into the lungs and the heart with a little catheter (hollow tube), which has a balloon at the end of it, and that measures the pressures all the way and tells you for sure that, "Hey, yes, this pressure is up," or "No, the echocardiogram was a red herring."
Host Amber Smith: Why is pulmonary hypertension dangerous?
Krithika Ramachandran, MBBS: Pulmonary hypertension is dangerous because it causes you to have congestive heart failure, so the end result of untreated pulmonary hypertension, just like the end result of untreated systemic hypertension, is that you end up with these big dilated heart chambers, which are unable to push blood forward through the lungs anymore.
So now you have lack of blood flow forward, blood flow to the rest of the body, because the left side has inadequate blood to send forward. So you have low oxygen everywhere. Your brain is not getting perfused (properly supplied with blood), your kidneys are not getting perfused. So you can actually end up with congestive heart failure, and terminally with cardiogenic shock, which is when, essentially, all your organs are shutting down.
Host Amber Smith: I've also heard some people might have a problem with anemia if they have pulmonary hypertension?
Krithika Ramachandran, MBBS: Anemia can worsen pulmonary hypertension because you have low blood counts, right? And there are fewer red blood cells to carry oxygen everywhere, but pulmonary hypertension and congestive heart failure, because of the chronic inflammation they set up, can cause anemia also.
So, it's almost like this vicious cycle. In recent years, they've been screening patients for anemia and iron deficiency, and it's been shown that patients who are iron deficient actually have a higher chance of having bad outcomes from pulmonary hypertension or even from regular congestive heart failure.
So, we look to see if they are iron deficient, and we can actually supplement them, which improves their functional status, and it also helps improve their disease and their overall mortality.
Host Amber Smith: What about blood clots? Are they a higher risk for someone with pulmonary hypertension?
Krithika Ramachandran, MBBS: This is a little bit of a controversial field. So, earlier the thought process was that because the blood flow through the pulmonary blood vessels is slow in pulmonary hypertension, because the heart's not doing a great job of pumping blood, you can form blood clots in the lungs, and so they used to place all of these patients with pulmonary hypertension on blood thinners to make sure that that doesn't happen
More recently it's been shown that this actually doesn't affect outcomes, so we've moved away from putting all patients with pulmonary hypertension on blood thinners, but a patient with pulmonary hypertension who develops blood clots in the lungs on top of already having pulmonary hypertension, they can really get into very bad trouble, because all of a sudden, now, this heart, which has already been struggling with pumping blood through these small, narrow tubes, has this big blockage on top of it, which has completely cut off areas that it can pump blood through. So this back pressure can actually make it balloon out, dilate and sometimes cause cardiac arrest.
Host Amber Smith: I wanted to ask you something else about the echocardiogram.
Krithika Ramachandran, MBBS: Uh-huh.
Host Amber Smith: Are you able to see the vessels, and do they look smaller on the echocardiogram?
Krithika Ramachandran, MBBS: No. So the way they kind of indirectly measure it is, where the right heart pumps blood, there's this little valve in between the two chambers of the right side of the heart. And when the heart pumps blood, it's supposed to flow forward into the lung arteries. Instead, because the heart's not pumping efficiently, some of the blood flows backwards into the smaller chamber of the right heart, and so they can use this measurement of the velocity of this backward flow to determine how much pressure is being faced by the right heart because of these smaller blood vessels. So you can actually sometimes kind of see when the blood vessel looks larger, because what happens is not that the pulmonary arteries get smaller and smaller in their size. It is that the internal diameter, or the hole through which the blood flows, that starts to shrink because the vessels start to scar down. So while the artery itself might look bigger, when you, say, do a CAT scan or an MRI or something, the actual size of the vessel through which the blood is flowing, the surface area of that decreases, which is where you have the trouble.
Host Amber Smith: What sorts of arrhythmias may develop because of pulmonary hypertension?
Krithika Ramachandran, MBBS: So the most common arrhythmias that you'd see are what we call supraventricular arrhythmias. So they originate from the atria. So you can have atrial tachycardias, like atrial flutter, atrial fibrillation, multifocal atrial tachycardia.
The terminal rhythm for everyone, of course, is a ventricular tachycardia, but usually, the patient's dying at that point. But the onset of arrhythmias, again, is a bad prognostic sign for patients with pulmonary hypertension.
Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more of our discussion about pulmonary hypertension.
Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with Dr. Krithika Ramachandran. She's an assistant professor of medicine at Upstate specializing in critical care medicine and pulmonary diseases.
We've been talking about pulmonary hypertension.
Now, how does pulmonary hypertension develop? Does it take a lot of time to develop or does it appear overnight?
Krithika Ramachandran, MBBS: No, it certainly doesn't appear overnight.
It's a slower process than most, I would say. It typically happens over the course of at least a year or two, and the patients I would say who are at higher risk for these kind of explosive developments of pulmonary hypertension are patients with scleroderma.
They can sometimes have very rapid onset of very severe disease, but in most patients, it's the slow, sort of, "Oh, I don't feel good." "Oh, I'm just feeling worse." And then over the course of several months to a couple of years is when they truly start to feel the disease and when you'll truly diagnose it.
Host Amber Smith: So other than scleroderma, are there other conditions that would increase a person's risk of pulmonary hypertension?
Krithika Ramachandran, MBBS: There's always this category of idiopathic pulmonary hypertension, which is we don't know why they have it, but they have it. We can't find any risk factors for it.
Then there are patients who have inherited pulmonary hypertension. There are some genetic factors which can predispose you to get pulmonary hypertension. Other than that, the most common causes would be the use of stimulant drugs like methamphetamines. Back in the '60s, '70s, there was an epidemic of pulmonary hypertension caused by diet pills, like pills that they used to take to lose weight, phentermine, fenfluramine. So they were all taken off the market at that time.
Cirrhosis is a big risk factor. HIV. And then, you can have some blood conditions, like myelofibrosis, thrombocytosis.
There's really a very long list of autoimmune problems like scleroderma; that's a big one ... lupus, rheumatoid arthritis. These are all risk factors for having pulmonary hypertension.
Host Amber Smith: What happens to someone if this condition develops, and it goes untreated?
Krithika Ramachandran, MBBS: Like we talked about before, they would develop right-sided congestive heart failure, so they'd start to see swelling.
They'd start to notice severe shortness of breath, weight gain, arrhythmias, and, eventually, it progresses to death.
Host Amber Smith: So it is something where if it gets diagnosed, there are some things that you can do to try to manage it?
Krithika Ramachandran, MBBS: Absolutely. So the landscape for treating this disease has changed dramatically in the last, I would say, 10 to 15 years. Earlier, and by earlier I mean maybe back in the early '90s, late '90s, it was almost like a death sentence. If you were diagnosed with it, more than 50% of patients were dead before three years were out. But now, it can be one of those diseases that you kind of die with instead of die from.
So there are multiple medicines now which help dilate these blood vessels in the lungs and bring the pressure down so that the right side of the heart feels less stress while pumping blood through the lungs. So definitely there are multiple treatments now, as compared to a few years ago, which has changed the outlook of the disease.
Host Amber Smith: Does treatment differ for someone whose pulmonary hypertension is related to lung disease, as opposed to someone with a mitral valve or aortic valve disease?
Krithika Ramachandran, MBBS: Yes. So, the way we look at it now, it's divided into five different groups. So, Group 1 is the one which we call kind of classic pulmonary hypertension, where there is isolated increase in the blood pressure in the lungs alone. And most of the medicines that we have are tailored to this specific issue. So they dilate the vessels, bring the pressure down, and so we try really hard to find those patients, so we can treat them earlier.
Now, things like mitral valve disease, aortic valve disease, these are all patients that we categorize as Group 2 pulmonary hypertension, which is also known as pulmonary venous hypertension. So this is trouble on the right side due to the left side of the heart, and these patients actually tend to comprise about 60% to 70% of the total pulmonary hypertension patient load.
They typically tend to be older, and they have what we used to call secondary pulmonary hypertension, which means that the trouble is not originating in the blood vessels of the lungs. It's originating somewhere else, and it's affecting the pressure in the lung. So in these patients, we try to treat the primary problem, and not the pressures directly. Because treating the pressure directly can sometimes have an adverse outcome. So let's say they have mitral valve regurgitation, then you would try to fix the mitral valve. Or if they have tight aortic stenosis, you would try to have aortic valve replacement. So, those patients, again, you would try to treat the contributing factors instead of trying to treat the pressures in the lungs.
Similarly, for patients who have lung problems, they have pulmonary hypertension from primary lung disease, so let's say it's from sleep apnea. So, then you try to fix it with CPAP (an assisted breathing device), or if it's from COPD (chronic obstructive pulmonary disease), then you try to treat their COPD, make sure their oxygen levels are adequate.
You try to treat the underlying risk factor.
I'm just going to add one more thing here because I want to make sure that people come away with this.
There is one form of pulmonary hypertension which is actually curable, and I try to make sure that everyone knows that. So when you develop pulmonary hypertension from having chronic blood clots in the lungs. There are people who, over a course of years, have had tiny clots in their lungs, which have gone undiagnosed, and over time, made the vessels narrower and narrower.
Those patients can actually have surgery to get these clots removed, and then they're essentially cured of the disease. So that's, again, a category of patients we try to find, because for them it can be life changing.
Host Amber Smith: Does the presence of pulmonary hypertension complicate other medical issues that may come up?
Krithika Ramachandran, MBBS: Yeah, I mean, having pulmonary hypertension makes a mess of everything, really, because there's all these medicine interactions. So, let's say you have a cold, for example, and you want to use a decongestant, right? It's hard because it's going to increase the pressure in your lungs, and it may make it harder for your heart to work properly.
Host Amber Smith: Let's talk about atrial fibrillation. Most of the drugs used to treat atrial fibrillation try to slow the heart down, which can actually end up having a detrimental effect on the right heart function because it depresses the ability of the heart to contract properly. So, for sure, having pulmonary hypertension complicates your life in multiple ways. If someone has been diagnosed with pulmonary hypertension do they need to be seeing a pulmonologist or a cardiologist regularly, or is this ...
Krithika Ramachandran, MBBS: Absolutely.
Host Amber Smith: Really. OK, so ...
Krithika Ramachandran, MBBS: Absolutely. Every three to six months is the recommended follow-up with an expert on the disease. And so, 100%, if there's someone who's got a diagnosis of pulmonary hypertension, they should be seeing either their pulmonologist or their cardiologist or whoever is comfortable managing their disease.
Host Amber Smith: Are there some general red flags that would tell a person with pulmonary hypertension that they need to seek emergency care related to their pulmonary hypertension?
Krithika Ramachandran, MBBS: Yes. So I would say if they are short of breath all of a sudden, more than normal; if they're starting to retain fluid, more than normal; if they pass out, that's a huge one. Palpitations. These would be the four big ones.
Host Amber Smith: Well, let me ask you about the general outlook for someone, because you alluded to this, that this diagnosis is life changing. So let's talk about the ways. You mentioned, a cold, and the choice of over-the-counter medications, or, I guess, even herbal products would be a concern for this person, right?
Krithika Ramachandran, MBBS: Absolutely. So any and everything that they ingest needs to be double-checked to make sure it's not going to affect them adversely.
The other thing that we always stress: Patients with pulmonary hypertension should never get pregnant, because their cardiovascular system cannot handle the stress of pregnancy, and it can kill them. So that's another big no-no. The other thing is a lot of the drugs that we use to treat pulmonary hypertension can cause fetal defects. So that's another reason that we advise against pregnancy and to make sure they have some method of contraception when they have this disease.
Host Amber Smith: So getting back to the over-the-counter medicines, can, like, Tylenol and ibuprofen and those types of things, can those cause problems?
Krithika Ramachandran, MBBS: Depends on the severity of the disease. So if this is someone with advanced heart failure, for example, Tylenol can affect their liver function. If they have congestive liver from their heart failure, Ibuprofen can definitely affect their kidney function, if, again, their kidneys are in a delicate balance.
And these are people taking water pills, trying to maintain their salt and fluid balance. It's a very precarious line they toe when they're trying to keep themselves healthy. So, for sure, anything and everything needs to be evaluated as a risk-benefit ratio before taking it.
Host Amber Smith: What about vaccines like the flu shot or the pneumonia shot as you get older?
Krithika Ramachandran, MBBS: They're all recommended. They should be getting them, because any sort of infection, again, is an extra stress on the system. So, certainly, vaccines are indicated and are recommended for these patients, including the COVID vaccine.
Host Amber Smith: Is their immune system compromised, though? Are they considered to have a compromised immune system?
Krithika Ramachandran, MBBS: No, they're not.
Host Amber Smith: Now what about exercising with intensity? Can someone with pulmonary hypertension train for a marathon? Can they do things like mow a large lawn? How much are they restricted?
Krithika Ramachandran, MBBS: We always recommend beginning exercise under supervision for these patients.
Lifting weights for them is usually a big no-no. Anything heavier than 10 pounds is not recommended, because, again, that is increased stress that the heart has to push blood against. In terms of cardiovascular exercise, there are no clear boundaries laid out that way, you know; it's conditioning, really.
So if they're slowly building up their exercise capacity, It's recommended that they do that. But if a patient comes to see me today, I wouldn't tell them, hey, go out and run a mile every day, because that's not how it would work. It would be a gradual buildup of exercise capacity with monitoring, making sure their oxygen levels are OK, their heart's not racing, they're not having arrhythmias.
So it's a whole bunch of multiple things.
Host Amber Smith: Would they be permitted to travel on an airplane or to vacation at somewhere in the mountains?
Krithika Ramachandran, MBBS: They would probably need supplemental oxygen if they did that. So at (high) altitude, because the concentration of oxygen is lower, hypoxia, or the lack of oxygen itself, can make the pressures in the lungs go up a little bit.
And actually we are able to do that at Upstate. It's called a hypoxia altitude simulation test, where they can simulate the altitude and see if your oxygen level drops. And if it does, we can prescribe supplemental oxygen to be used at the time.
Host Amber Smith: Well, I know this may apply differently to different patients, but in general, how should their diet be? Is there anything, any food, that they should avoid or any food that they should add?
Krithika Ramachandran, MBBS: Salt. Yes. So just like any patients with congestive heart failure, low-salt diet, less than 3 grams of salt a day, 2 to 3 grams, depending on the size of the person. Again, this kind of depends on if the patient is in congestive heart failure or not. We may ask them to restrict fluid intake to less than 2 liters a day, but otherwise, a healthy diet should be good.
Host Amber Smith: Well, it's encouraging, as you were explaining, the options for treatment are so much greater now today than they were 50 years ago or 20 years ago.
Krithika Ramachandran, MBBS: Absolutely. It's a whole different landscape.
Host Amber Smith: Well, that's really good to know and I really appreciate you making time for this interview, Dr. Ramachandran.
Krithika Ramachandran, MBBS: Oh, thank you very much for having me. It's my pleasure.
Host Amber Smith: My guest has been Dr. Krithika Ramachandran. She's an assistant professor of medicine at Upstate specializing in critical care medicine and pulmonary diseases.
I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," ticks are a concern, even in winter.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Dr. Saravanan Thangamani's tick surveillance program has analyzed more than 27,000 ticks since it opened in 2019, so he's got a good idea about what's happening among ticks in Central New York. He's a professor of microbiology and immunology at Upstate, and he's here to give us a tick outlook. Welcome back to "HealthLink on Air," Dr. Thangamani.
Saravanan Thangamani, PhD: Thanks for having me.
Host Amber Smith: We had such a warm fall this year. Does that make for a more hospitable environment for the ticks?
Saravanan Thangamani, PhD: Yes. There is a direct correlation between warm weather and increasing human/tick encounters. Because when the weather is warm, we spend more time outside doing outdoor activities, trekking and walking in the woods. And ticks are always there. When it is warm they try to stay at the tip of the grass waiting for some human to walk by, and they latch onto them. They go into hibernation only when the temperature goes below, I would say, 35 degrees Fahrenheit. They start to kind of slow down their metabolism. They try to kind of find nice, cozy places right under the leaf litter or debris so that they prepare itself for the harsh winter. And that's how they survive during the harsh winter.
I must tell here that even in winter, people encounter ticks. So through our program, we have received ticks even in January and February. You'll be surprised. Because people, they do snowshoe walking. They trek. They do hunting sometimes in the winter. And they put themselves at risk of tick exposure, as well.
Host Amber Smith: But aren't people more bundled up so that their skin is covered, if they're out in the wintertime? How would ticks get to them?
Saravanan Thangamani, PhD: They start to crawl on the winter clothing first. And then they find a way to go around the head, or when you have a wool or cotton hat, these ticks can attach to them and they can try to squeeze themselves into the threads. And then they wait. When you go home and you try to take your hat and put it on your basket, and then it comes out and starts to find somebody else in the home.
Host Amber Smith: We don't know how we are carrying, actually. There are many ways how the ticks, they don't have to attach right away. They can actually wait for you, even inside the home. They can wait for you and then just wait for the right person to come by.... How long can a tick last without being fed? If a tick got in your house, and it was just sitting on a counter, how long could it live before it had to eat something?
Saravanan Thangamani, PhD: I would say at least a couple of years.
Host Amber Smith: A couple of years?
Saravanan Thangamani, PhD: Yes. So as long as there is good humidity there. In the winter we heat our homes, right? So it's a little bit dry environment, and that is not good for the ticks. But in summer, we air condition our homes. We give enough moisture and humidity inside the home, so they can live.
But ticks are very clever. They will always find a corner where it's not too dry. Obviously they will try to go away from the dry to a moisture area, like in the bathrooms. They will find ways to survive there all the time. Doesn't matter if it's winter or summer because, you know, we use water all the time, which means that is good enough for the ticks.
Ticks can be, ticks can go for a couple of years without taking a blood meal. They are very hardy. So ticks don't die during the winter They are very clever to find warm places for them to hide and wait until the spring warm weather comes up. They start to come out and try to find a human to feed on.
Host Amber Smith: So all of these ticks from the fall, the ones that are young, or babies, they're wintering over, and they're going to be waiting for us in the spring?
Saravanan Thangamani, PhD: Yes. So if they take a blood meal in the fall, they molt, they become the next stage, and they wait for us in the spring.
Host Amber Smith: Great.
Saravanan Thangamani, PhD: So the more ticks we have now means that there will be more ticks in the spring as well. So we saw 20% more ticks in the fall, which means that I'm now projecting that in the spring we will see almost at least 20% increase in the number of human-encounter ticks in the lab. And again, we are only focused on what we receive in the lab. So the caveat is that can we actually project this to the entire state in an even distribution way? I cannot tell that because unfortunately, whoever is encountering the tick and whoever is aware of our program, they actually send the tick to us. So, although we try to disseminate our tick testing information throughout the state of New York, there is a little bit of biases there, so we are trying to address that. But that's a general trend is there, that we will get definitely more ticks this 2023 spring.
Host Amber Smith: Well, Dr. Thangamani, thank you so much for giving us this update. I appreciate your time.
Saravanan Thangamani, PhD: Thank you very much for having me.
Host Amber Smith: My guest has been Dr. Saravanan Thangamani. He's a professor of microbiology and immunology at Upstate. And you can learn more about his research on tick-borne diseases at nyticks.org -- that's N-Y-T-I-C-K-S-dot-org. I'm Amber Smith for Upstate's "HealthLink on Air."
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: We lost a stalwart member of our Muse family in 2021, poet Joyce Holmes McAllister. She was a poet who proved that aging need not dim one's perspective or facility with words. Here are the last two poems she sent us. First is "A Question":
I wonder where they went, those 80 years,
In which I claimed each breath, called life my own.
A span of time when challenge held no fear
And youthful feet could feel no aching bone.
If I had known, when young, how life would speed
And leave me here, to grope my way alone,
I would have spent more time, and learned the need
To fence youth in, and keep it for my own.
I wonder if I started now to track,
With careful count, my age to backward time.
Could I keep on until my years subtract
And I am once again, just 29?
But who would know me then, with youthful face,
or minus aging wit, long-practiced grace?
And the second poem is called "things i can't write about":
to feel what it is like
to open the desk drawer,
see the blank checks
still in their box, unused
three years after your death
to wash fresh spinach,
suddenly taste vinegar on my tongue,
remember how you sprinkled it
over young cooked greens, and how i
used only butter
to see the shape of a car,
maybe the same model, year
parked in front of our house,
know someone else will step out,
turn his back, walk away
to stare at the collection of long, slim
note pads, read your name and address
printed at the top in blue; on the bottom
thank you for your continued support of animal wildlife
my writing has always been more about
what I leave out, than what I put in
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": ticks in Central New York have been found to carry multiple pathogens at once. 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 Bill Broeckel. This is your host, amber Smith, thanking you for listening.