Ticks and diseases; understanding cluster headaches; vascular surgery: Upstate Medical University's HealthLink on Air for Sunday, Jan. 1, 2023
Microbiologist and researcher Saravanan Thangamani, PhD, explains the dangers of ticks that carry multiple disease-causing agents. Neurologist Ioana Medrea, MD, tells how cluster headaches are diagnosed and treated. Vascular surgeon Palma Shaw, MD, describes her hospital role and a podcast she cohosts called "Sisterhood in Surgery."
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an expert in ticks explains what can happen when a tick carries multiple pathogens.
Saravanan Thangamani, PhD: ... When the ticks are co-infected, it alters the tick behavior in such a way that it'll probably make the tick a little bit more aggressive feeder. ...
Host Amber Smith: A neurologist goes over the diagnosis and treatment of cluster headaches.
Ioana Medrea, MD: ... They've been estimated to be more severe than active labor or passing kidney stones, so, probably one of the most severe conditions that we, in terms of pain, that we encounter in medicine. ...
Host Amber Smith: And a vascular surgeon tells about her role and the patients she cares for.
Palma Shaw, MD: ... We're there to help diagnose the problem, offer them some counseling and help them modify either their behavior or maybe some of their medications first. And then if that doesn't work, then we can talk about more invasive options. ...
Host Amber Smith: All that, and a visit from The Healing Muse, right after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll learn about cluster headaches and how they're treated. Then, a vascular surgeon tells about the types of patients she cares for. But first, what happens if you get bit by a tick carrying more than one pathogen?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Dr. Saravanan Thangamani's tick surveillance program at Upstate has tested more than 27,000 ticks since it began in 2019, and about a third of those ticks have been found to carry a pathogen or pathogens. Recently, some ticks have been found to carry up to four pathogens. Here to help us understand what this means is microbiology and immunology professor Saravanan Thangamani. Welcome back to "HealthLink on Air," Dr. Thangamani.
Saravanan Thangamani, PhD: Thanks for having me.
Host Amber Smith: We've spoken before about your lab and the community-engaged tick surveillance you're doing. Does the fact that three or four years into this project you've now come across ticks carrying multiple pathogens mean anything?
Saravanan Thangamani, PhD: Yes, of course. There are two things that I'm trying to highlight from our program is that the number of ticks that we receive in the lab are increasing. In addition to that, the number of pathogens that we detect within the tick is also increasing, which means the rate of prevalence is also increasing. So on one hand, number of ticks are increasing. The other hand, number of pathogens in the ticks are also increasing.
Host Amber Smith: Are you still, is it about a third that have at least a pathogen?
Saravanan Thangamani, PhD: Yes, it hovers around between 33 and 37%. Again, we are normalizing throughout the state of New York, but if I bring it down to this county level or ZIP code level, the numbers vary from each other. So there are some counties that go all the way up to 60% of prevalence of pathogen in the tick, versus other counties that are 33%. So it varies, but if we can average it throughout New York state, yes, it's one third of the ticks carry at least one disease-causing agent to humans.
Host Amber Smith: Now across New York state, which is the most prevalent pathogen that you find?
Saravanan Thangamani, PhD: The Lyme disease-causing agent is still the most prevalent pathogen that we are detecting in the ticks.
Host Amber Smith: And when you talk about co-infections, or ticks that carry more than one pathogen, is there a geographic area where that happens more than not?
Saravanan Thangamani, PhD: So I must tell that 18% of the infected ticks are co-infected with at least two pathogens, right? And then 3% of the infected ticks actually carry three pathogens. So if I can break it down, the ticks that are coinfected with the Borrelia burgdorferi, the Lyme disease agent, and Babesia microti, the agent of babesiosis, they are actually prevalent in Central New York and lower Hudson Valley. The same goes for the ticks that are co-infected with the Lyme disease agent and the anaplasmosis-causing agent. That is all in the Central New York and Lower Hudson Valley. However, the ticks that are co-infected with the Powassan virus are all centered in the lower Hudson Valley. So we are starting to see a geographic separation of these co-infected ticks as well.
Host Amber Smith: Is it pure coincidence for one tick to become infected with multiple pathogens when the tick next door is infected with none?
Saravanan Thangamani, PhD: I wouldn't say pure coincidence. It is a matter of these ticks that actually feed on wildlife. If the particular wildlife, like a mouse or a squirrel or a groundhog, if they carry multiple pathogens, when the ticks feed on them, they also acquire those pathogens from the mammal. But you have to understand that ticks feed on mammals at different stages. Like when they are larvae, they feed on a host. Let's say for example, if that host is a mouse that has a Borrelia burgdorferi, the Lyme disease agent, the larvae now will acquire this Borrelia, and they, when they become nymph tick, they already have the Borrelia in them. And then if that nymph tick feed on another mammal that has babesia, then it'll take the second pathogen. So it has more opportunity to acquire additional pathogen throughout its lifecycle. And that is, unfortunately, the biology of the tick because it encounters a mammal for blood feeding every single stage. In addition to that, we know from our own research that mammals in the wildlife can carry multiple pathogens, which means that a single tick can feed on them, acquire multiple pathogens.
Host Amber Smith: And do they transmit the pathogens to humans the same way they would another animal if they were feeding on, I mean, we're all mammals, right?
Saravanan Thangamani, PhD: Exactly. They would transmit the same way as they would transmit a singly infected tick, as well. In fact, when the ticks are coinfected, it alters the tick behavior in such a way that it'll probably make the tick a little bit more aggressive feeder, as well. So we have found that in our own lab that Powassan virus-infected ticks, together with Borrelia burgdorferi, it alters its behavior, and it actually injects more virus to the mammal. So it actually can exacerbate the clinical outcome as well.
Host Amber Smith: That's a little frightening. Now, Central New Yorkers are generally familiar with the bacteria that causes Lyme disease. I'd like to have you tell us about the other three pathogens that you found together. Let's start with the one that's a bacteria.
Saravanan Thangamani, PhD: So the most common one that we find together with the Lyme disease agent, is the anaplasma phagocytophilum bacteria that causes anaplasmosis. The initial symptoms for this particular disease are mostly nonspecific acute febrile illness, such as fever, chills, severe headache and myalgia (muscle pain). And rash is uncommon with anaplasmosis, but it has been reported in less than 10% of the cases. The case fatality rate for patients who seek care for the illness is almost 1%. But in an immunosuppressed individual, this number can go higher as well.
The second most dominant in co-infection we see in the ticks that we receive is the Babesia microti, which is a causative agent of babesiosis. And again, babesiosis, the common symptoms are nonspecific flu-like illness, such as fever, chills, headache, body ache, loss of appetite. But I must tell that Babesia microti is closely related to malaria parasite. So it is a protozoan. It is a parasite, and it's not a bacteria. It's very similar to the malaria parasite. And it can cause anemia in humans as well. But this one has a high case fatality rate. It's up to 5% case fatality rate.
The third one that we encounter with the coinfected ticks, or the Borrellia co-infected ticks are the Powassan virus. The Powassan virus is a neuroinvasive virus. If a human gets infected with this virus, the virus eventually ends up in the brain, causing meningitis, or meningo-encephalitis. The case fatality rate for Powassan enchephalitis is very high. It's between 10% to 15%. In the worst-case situation, 50% of the survivors who got infection but recover will have long-term neurological sequelae (consequences). So these are the three primary pathogens that we observe together with the Lyme disease agent intakes.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Saravanan Thangamani. He's a professor of microbiology and immunology at Upstate, and we've been talking about tick co-infection. And before we get back to the interview, I'd like to let listeners know they can learn more about tick-borne disease research at NYticks -- that's N Y T I C K S -- .org (nyticks.org)..
Now you just told us about a bacteria, a virus, and a parasite that are co-infected along with the bacteria that causes Lyme disease in certain ticks. How do those three pathogens get along together?
Saravanan Thangamani, PhD: So that is a very interesting question. That is one of the subjects of research in our lab to see how the co-infection alters the clinical outcomein humans. Obviously these three pathogens, when they're in the tick, they compete for the same resources. And obviously, what happens is that it alters the tick behavior in one way or the other. It will actually cause severe disease in humans. That will actually add more complications for the treatment. Because instead of treating one single agent, now you have to treat for multiple agents.
For anaplasmosis and babesiosis, treatments are available, as long as it is diagnosed during the acute phase of infection. If it's not diagnosed during the acute phase of infection, it could be lethal. When it comes to the virus, there is no specific treatment. Supportive therapy is the only option at this time we have. And obviously for the Lyme disease, there are treatments available as long as it's diagnosed at the early stage as well. Definitely having more than one pathogen in a tick that bit a human or that bites humans, it only complicates the disease outcome.
Host Amber Smith: So if a person is bitten by one of these ticks that is co-infected, is it guaranteed that that person's going to contract all four of those pathogens, or not?
Saravanan Thangamani, PhD: It depends on how long the tick has been feeding on the human. Viruses are transmitted immediately, as soon as tick attaches to a human. Viruses are transmitted at the skin. The others -- the bacteria and the parasite, including the Lyme disease agent -- they take anywhere from 12 hours to 48 hours to transmit to the human. So if the tick is found and removed right away, you have less chance of acquiring the pathogen,acquiring the disease-causing agent. So it depends on how long the tick is attached on the human.
Host Amber Smith: So prevention is still really important here.
Saravanan Thangamani, PhD: Exactly. And I know that in many human cases that I know personally people who actually contracted three -- Lyme disease, anaplasma and babesiosis -- from a single bite. So it is possible that if the tick attached on a human for a good amount of time, they can contract all three diseases as well.
Host Amber Smith: Do you know, do all of these get transmitted to dogs as well, potentially?
Saravanan Thangamani, PhD: Yes, of course. It will. So that you know When ticks are infected, they transmit the agents to any mammal that they actually feed on. So they will be transmitting to dogs, cats and any other mammal that they encounter.
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 tickborne diseases at NYticks -- that's N Y T I C K S dot O R G. And you can learn more about his research on tickborne diseases at nyticks.org. I'm Amber Smith for Upstate's. "HealthLink On Air."
How are cluster headaches diagnosed and treated? Next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Headaches are among the most common of medical complaints. Today we'll be talking about a specific type of headache, called the cluster headache, with Dr. Ioana Medrea. She's an assistant professor of neurology at Upstate, and many of the patients she cares for have headaches.
Welcome to "HealthLink on Air," Dr. Medrea.
Ioana Medrea, MD: Hi, thank you for inviting me. This is a topic I'm very passionate about, and I'm very happy to discuss this so that people have more awareness of this. Thank you.
Host Amber Smith: Now, headaches are so common. When is it time to make an appointment with a specialist like you?
Ioana Medrea, MD: Yeah, about 80% of people have headaches at some point. The time to see me is when your headaches are interfering with your ability to lead your life.
So what does that mean? How would that look like? A lot of people I see have trouble doing their job because their headache is making them have to miss work or, when they're at work, have to step away and not be as productive as they could be.
Another manifestation would be issues with your ability to do, your jobs at home. So running errands, cleaning the house, maintaining the house. When you're having significant enough headaches that you're finding yourself avoiding those tasks, that's another sign that it may be time to see a headache specialist.
And the last thing is when it's interfering with your social activities. You are shying away from seeing family, friends or participating in things you would normally participate (in) because your headaches are severe enough that you don't want to leave your house.
That would be another sign that you need to see someone for your headaches.
Host Amber Smith: Now, before we get into the details of cluster headaches, can you first help us understand the difference between cluster headaches and a couple of other types of headaches we've heard of: tension headaches and migraines. Are the symptoms the same? Does the headache feel the same for all of those types of headaches?
Ioana Medrea, MD: Generally, no. The difference is in severity as well as other characteristics, so the way that we usually think of tension headaches are, they're very common, but they tend to be mild or at most moderate. They generally also occur across the forehead or at the back of the head -- bandlike headaches, and they're your typical headaches that you get when you're a little dehydrated, a little tired, a little stressed, but they're not associated with nausea, vomiting, light or sound sensitivity. And that's where migraines come in, when you have nausea, vomiting, light and sound sensitivity.
Migraines also tend to be more severe than tension-type headaches, and generally they're what brings a patient to medical attention. Now, cluster headaches are different than migraines in that they're probably the most severe headache condition that we treat. They've been estimated to be more severe than active labor or passing kidney stones, so, probably one of the most severe conditions that we, in terms of pain, that we encounter in medicine. They tend to be around one eye specifically. That can happen with migraines. But the telltale sign of this being a cluster headache is that they're briefer than migraines, typically three hours or under, whereas migraines tend to be over four hours.
And then they're also associated with tearing from the eye, redness of the eye, runny nose, congestion of the nose, flushing of the face, and also agitation. Whereas with the migraine, you'd go lay down in bed, with a cluster headache, you might rock, you might find yourself pacing.
And then the last thing that I would say is that with cluster headaches, patients can become so disturbed that they might think of harming themselves, and that also tends to be a characteristic of cluster headaches.
Host Amber Smith: So are all of these headaches you described, are they caused by different things?
Ioana Medrea, MD: The cause of most of these disorders is being investigated, but what we know about tension headaches is they're just a sort of common response to environmental stressors. But in some people who have a propensity for migraine, which tends to be genetic, probably what happens is there's a threshold where the headaches become severe enough that they become migraines.
Now, cluster headaches, the cause is probably very different. There is a genetic link with cluster headaches, and not everyone who has cluster headaches has a family history of it. In fact, most people don't. But it can cluster familiarly in some patients, so there is a genetic link, and we think that a part of the brain, which is also involved in migraine, in a different way, though, the hypothalamus, probably is a trigger for cluster headaches.
So, they're not all caused by the same thing. They're all caused probably by different genetic factors. And migraines have, again, different genetic links than cluster headaches and also tend to occur in families.
So, all of them have somewhat different causes.
Host Amber Smith: Now, when you see a first-time patient complaining about a headache, how do you determine which type it is?
Ioana Medrea, MD: The most important part, as in most of neurology, is listening to the patient describe their symptoms. So, where is the headache occurring? How long is it lasting? Does it have other associated features, such as nausea, vomiting, light/sound sensitivity, for migraine? Is it associated with tearing and the other autonomic symptoms, which is the runny nose, tearing, facial flushing, the agitation that we talked about. And then, the duration of the headache would be another clue.
That is sort of the way we diagnose these headaches. It's generally a clinical diagnosis.
Host Amber Smith: So you rely on the patient's history, the story that they tell you about how they've experienced it.
Ioana Medrea, MD: Yes.
Host Amber Smith: I'd like to learn more about cluster headaches in general. how do your patients describe their cluster headaches when they come to see you?
Ioana Medrea, MD: Everyone who comes with cluster headaches generally has a very pronounced sort of pain with their headache. Some of them describe it as a searing pain in the eye. Some have said that it's like a hot poker. Some have said that it's a knife trying to poke out their eye. And generally it's very, very severe pain. And the adjectives used to describe it are generally that.
The other thing that they described are also, you know, the autonomic features, which we listed, and also a lot of agitation with the headache.
Host Amber Smith: Do you see anything specific in your patient population, or do cluster headaches affect people of all ages and genders?
Ioana Medrea, MD: They do affect people of all ages and genders generally, but the gender predisposition is such that there are more men than women, somewhere of a factor of 3 to 1. And then it tends to be more in middle ages. So for men it's 30 to 50, and then women maybe a little bit later, when these headaches are occurring.
And the last thing would be that there's an association with smoking, so smokers are far more likely to have cluster headache than nonsmokers, and about 70% of patients with cluster headache are smokers.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Ioana Medrea. She's an assistant professor of neurology, and we're talking about cluster headaches.
Are there theories about what causes cluster headaches?
Ioana Medrea, MD: We know that a part of the brain, the hypothalamus, is involved in cluster headaches, and we know that there is a periodicity (occurrence at regular intervals) to most patients with cluster headaches, and they tend to happen with a seasonal sort of preponderance.
Commonly, the seasons that they occur in are spring and fall, but sometimes the people have also a summer sort of seasonal prevalence of the headaches. We think that there is a sort of mechanism that turns on in the hypothalamus, which has to do with the seasonal preponderance of cluster headaches. And when it turns on, it starts causing headaches from the hypothalamus, and we have found some genetic risk factors for this, and we think that that might be a part of it.
Another consideration would be if this is something that comes on with other illnesses or masses, rarely, which are in the area of the hypothalamus or very rarely in the brain stem.
Host Amber Smith: So, genetics may play a role in this. Is there anything else that might make a person more susceptible to cluster headaches?
Ioana Medrea, MD: So, as I mentioned earlier, also smoking. That is one of the big associations that we see, and, in fact, we discuss often: If patients stop smoking, their cluster headaches might improve.
Host Amber Smith: Are cluster headaches considered a chronic problem, or is this something that you have the ability to cure?
Ioana Medrea, MD: Unfortunately, we don't have a cure for cluster headaches. They are chronic in that they tend to continue for a long period of time, but they're not continuous in most people. In most people, they're episodic, and they tend to last between four to 10 weeks, and they tend to happen seasonally, as I had mentioned.
Rarely, about 10% to 20%, of cluster headache patients do become chronic cluster headaches, which means that they're having them continuously with no break in between the periods of cluster headaches. But that's not most patients. In most patients, it tends to be an episodic pattern.
Host Amber Smith: Well, let's talk about treatment strategies. Once you diagnose someone with a cluster headache, do you first have to rule out something like a brain tumor or aneurysm?
Ioana Medrea, MD: Yeah, so we will always order an MRI (a scan) of the brain to ensure that there isn't a mass, in either the hypothalamic area or the brain stem area. And, once we do that, we can proceed to treatment. In fact, I often will start with treatment even before the MRI is done because they're such painful conditions that I don't want my patients not to be treated.
The way that we treat is a multi, sort of, dimensional approach. So we have acute treatments, which is for attacks as you're having them, transitional treatments to immediately decrease the frequency of your attacks and longer-term treatments that take a few weeks to kick in but take over from the transitional treatments.
So in terms of acute treatments, we'll use triptans, which are also used in migraines. But we want to have triptans such as sumatriptan injectable or nasal spray, or zolmitriptan injectable. The reason why is because these triptans are very fast onset, usually 15 to 30 minutes, and so the headache relief is much quicker than taking them by mouth. The next treatment that we use is oxygen. And usually we want this at high flow, preferably over 12 liters per minute and up to 15 liters per minute. There's a lot of evidence that this works as well as triptan, and this we will use in conjunction.
Host Amber Smith: So you talked about oxygen and the medication, the triptans. Do those stop the headache, or are they providing pain relief? How do those work?
Ioana Medrea, MD: Those provide pain relief, and that's the first sort of thing we do. And then the transitional treatments are either steroids by mouth or steroids by injection. The injection is in the occipital area at the back of the head and usually do high dose steroids for that, preferable by-mouth steroids just because you have less systemic exposure to steroids if you do just an inch at the back of the head. So you tend to have less side effects, and that's a transitional treatment, but it only lasts a few weeks, and then the headaches would come back.
So because of that, we also do a long-term treatment. Typically it's either verapamil, which is usually a blood pressure pill but has been shown in trials to work very well for this specific condition to stop the headaches from occuring, or the other thing we might do is Emgality, or galcanezumab, which is a new medication which you inject once a month. Both of them work very well at stopping the headaches from occurring but take some time to have an effect.
So, because of that, we have the transitional treatment with steroids, either by mouth or by injection at the back of the head.
So, generally, that is our approach to care, and as I said, it's multipronged, with the acute treatments for when you have a headache, the transitional treatments in the short term and the longer-term treatments.
Once someone has been outside of a cluster cycle for about a month, we start tapering them off of the longer-term medications so that we have those medications to use at a next cycle.
Host Amber Smith: I'd like to ask you about the steroid injections. Is that something that is done in the hospital or can you do that in the office?
Ioana Medrea, MD: So I do that in the office, and I will make sure that I get my patients in within a day, once I know that they're in cycle, so we can do that. And generally it works very well. Within about 72 hours, most patients have a resolution of their headaches.
Host Amber Smith: Are there any lifestyle modifications that can help?
Ioana Medrea, MD: So the most common thing that I always talk to my patients about is smoking cessation. As I mentioned, a lot of these patients are smokers, and there's been studies showing that this is very helpful if you stop smoking. And that is the most common thing. Additionally, we do talk about stress reduction, and we talk about ways to accomplish that, but generally with cluster headaches, that has less of an effect than in something like migraines.
So, the main one would be smoking cessation.
Host Amber Smith: Are there any foods or vitamins or supplements to add or to avoid if you have cluster headaches?
Ioana Medrea, MD: There hasn't been any sort of work done on a lot of supplements. There is a trial going on about starting vitamin D and whether this helps or not with cluster headaches, but we don't have data from that yet.
What I would say is that we know that nitroglycerin can provoke cluster headaches, so there has been maybe some recommendation on avoiding processed meats because sometimes they have nitro added to it. And then nitroglycerin patches that are used in cardiac disease can sometimes bring on episodes in people.
So those are things to consider.
Host Amber Smith: Does having cluster headaches put a person at higher risk for stroke or anything else?
Ioana Medrea, MD: So, there hasn't been any data that I'm familiar with about that specifically. If I had to warrant just an educated guess, I would say probably not, since there's no cardiovascular mechanism for cluster headaches.
Host Amber Smith: For someone with known cluster headaches, are there any red flags that signal that they need to seek emergency care?
Ioana Medrea, MD: Yes, I'd say if they have any new neurological symptoms, that would always be worrisome. So those would include loss of vision, missing chunks of vision with dark spots, double vision, problems with speech becoming garbled or nonsensical, problems with numbness or tingling affecting a part of the body that's prolonged, problems with weakness affecting a part of the body that's prolonged, and problems with ambulation (walking or moving around), so any new neurological symptom would be concerning.
Host Amber Smith: I appreciate you making time for this interview. Thank you.
Ioana Medrea, MD: Thank you for your time.
Host Amber Smith: My guest has been Dr. Ioana Medrea. She's an assistant professor of neurology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- when might you need a vascular surgeon?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
If you develop a disease that affects your arteries or veins, you may require care from a vascular surgeon. Here with me to talk about this surgical subspecialty is Dr. Palma Shaw. She's a professor of surgery at Upstate specializing in vascular surgery, and she will be president of the International Society of Endovascular Specialists in 2023.
Welcome back to "HealthLink on Air," Dr. Shaw.
Palma Shaw, MD: Thank you so much, Amber. It's really a pleasure to be here today.
Host Amber Smith: Now, do I understand correctly that vascular surgeons like yourself may treat a fair number of patients who don't require surgery?
Palma Shaw, MD: That is true. Not everybody that we see requires a surgical intervention.
Oftentimes, we're there to help diagnose the problem, offer them some counseling and help them modify either their behavior or maybe some of their medications first. And then if that doesn't work, then we can talk about more invasive options.
Host Amber Smith: Let's talk about some of the common problems that patients come to you with.
Peripheral artery disease -- that's one of them. What is peripheral artery disease, and how is it handled, typically?
Palma Shaw, MD: Peripheral arterial disease is generally a narrowing of an artery. We sometimes call it a blockage. It may be partially blocked, maybe 50% blocked, or it could be 100% blocked, and it could be a long blockage or a short blockage in the arteries that go from the groin all the way down to the foot.
Patients at most risk would be those who smoke. Additionally, patients with diabetes are also at higher risk, particularly for blockages in the calf.
Patients who present with peripheral arterial disease may also have other problems in their heart or in their carotid arteries in their neck, so we have to be aware that those patients have other risk factors, and oftentimes those risk factors are modified through medications to try to address their blood pressure and their cholesterol.
In addition to that, we then evaluate the patients and try to determine where these blockages in the arteries may be that are causing the problems that may make them either walk or be unable to walk or develop pain in their foot or an inability to heal a wound over a period of time.
Host Amber Smith: When someone is suspected of having an abdominal aortic aneurysm, is that something where they would be referred to a vascular surgeon?
Palma Shaw, MD: Yes, that is true. They are often referred to us either from their primary care doctor or their cardiologist, and sometimes even the urologist, who may have done a screening ultrasound or an ultrasound to evaluate a different problem, and then an aneurysm is seen.
Additionally, Medicare, for any male that ever smoked cigarettes over the age of 60 can have a screening abdominal ultrasound to try to see if this is present.
Oftentimes, these are asymptomatic, and when they become large, they're a threat to life for that patient.
Host Amber Smith: Now, how do you describe aneurysms for patients? Because I'm not sure everyone understands what an abdominal aortic aneurysm is.
Palma Shaw, MD: The aorta is a tube that comes off of the heart in the chest and looks like a candy cane, actually, coming off and then running down the back in the abdomen, behind the stomach.
And when this becomes enlarged, it may look like a circular enlargement, maybe one or two times the normal size of the artery. And when it reaches a large size, such as 5 centimeters, we start discussing repair options with the patient.
Host Amber Smith: How common is carotid artery disease?
Palma Shaw, MD: Carotid artery disease is fairly common, although we don't see good yield with screening ultrasounds, so we don't look for that disease unless we hear a noise when we listen to the neck or if the patient were to have a symptom.
But generally, when we do detect that, if we hear a noise or if the patient has any symptom, if they have dizziness or weakness or numbness, for example, we may get a carotid ultrasound because one-fifth of all strokes are related to blockages in the carotid arteries that are in the neck.
Host Amber Smith: So that's where plaque builds up in the bloodstream?
Palma Shaw, MD: Yes. I tell patients sometimes it's like if you had your driveway, and you had it repaved, it has an extra layer on it. And if you've ever been on the road in New Hampshire and seen a frost heave, it's sort of a billowing up of the road. Well, the plaque can rupture, almost like volcano appearance, and then a little bit of debris can break loose and then go to the brain, and that's when they become symptomatic.
And a stroke can occur.
Host Amber Smith: Do you care for a lot of people with what's called chronic venous insufficiency?
Palma Shaw, MD: Over 10 million Americans have chronic venous insufficiency. It's an extremely common problem. It's certainly not life threatening, but it is very much a nuisance for a lot of patients. Many of them may feel fatigue in their legs. They may have bulging veins, they may be sore. They eventually may even develop ulcers and wounds on their inner calf that generally results in long-term problems and repeated visits to see the doctor, and those things can affect your work and your day-to-day life.
Host Amber Smith: Is chronic venous insufficiency related to varicose veins?
Palma Shaw, MD: Yes, oftentimes. Varicose veins are actually one description of the venous insufficiency. It depends where the diseased vein is. So chronic venous insufficiency can be in the deep system or the superficial system. And I tell patients it's as if you had a ladder, and there's two sides to the ladder, and one would be the deep, which is closer to the bone in the leg, and then there's the superficial, and those two rungs of the ladder have the bars in between, and you can walk up the ladder.
Well, that's just like the valves that are in the venous system. And if you go to step on one rung and it breaks through, that's a broken valve in the vein. So as you walk and you pump the blood up, back up towards your heart and the muscles contract, and then as the gravity pulls the blood back, if the valve is broken, that blood will go down to the next functional valve, and if all the valves are broken in the leg, they're crashing down at the ankle level, and that's why you get swelling down in the (lower leg area).
Host Amber Smith: So it sounds like varicose veins, it's not just a cosmetic thing, it's actually a medical issue.
Palma Shaw, MD: It is. There are patients who do have prominent varicose veins that truly have no symptoms, and for the most part just don't like how they look.
For example, patients may have those tiny little spider veins, we also call them reticular veins. And those little spiders the patients don't like the appearance of are cosmetic. They're not covered by most insurances, but patients may perceive that they're giving them discomfort, particularly if there's a large cluster of spider veins in a specific area of their leg, and they may benefit from use of compression stockings.
Host Amber Smith: Now, regarding diabetic foot care, why might a vascular surgeon be involved?
Palma Shaw, MD: Patients with diabetes should pay a lot of attention to their foot care. They often can develop neuropathy, which is disease in the nerves of their foot, and when that happens, they can have sensory or loss of feeling or pain, actually. They can have changes in the distribution of the muscles impacting the bones in their foot, so they get deformity, so they don't have the normal composition of the foot, and it may wear incorrectly in a shoe, so they may need special shoes that accommodate the problems of the foot.
And they also have autonomic problems, which is another component, and that means that they don't have good function of the sweat glands, so they get a lot of calluses and dry skin. So the combination of dry skin, which can crack, extra pressure on specific bones in the foot, and then, loss of sensation, put those patients at risk of wounds. And not a little wound, but a wound that may actually go all the way down to the bone and put them at risk of losing their foot and bad infections, depending upon how well the diabetes is controlled. So it's really important that they have a good podiatrist, and they follow with that podiatrist routinely, who's skilled at identifying the changes that keep them out of trouble.
The patients also may develop vascular disease, particularly below the knee in the little vessels called the tibial vessels. There are three, and the diabetics who smoke are at the highest risk of limb loss. We say every 20 minutes a limb is lost in a diabetic in a nontraumatic way. And this is usually related to blockages in the arteries.
And those people who smoke will have blockages above the knee, more often, and then the diabetics will have blockages below the knee. So it's really a double whammy, and it's a huge problem for them, and we try to counsel the patients.
So once the podiatrist or somebody detects that there's a decreased pulsation of the pulse in the foot, that they can't feel the pulse, the patient should see a vascular surgeon, so we can evaluate the patient so that we can keep them out of trouble or potentially have to revascularize them and bring better blood supply to the foot, so the wound that has developed can heal.
Otherwise they could lose their foot.
Host Amber Smith: You helped organize a conference at Upstate recently teaching about limb preservation.
Does that tie into the diabetic foot care?
Palma Shaw, MD: Absolutely, Amber. I recognized a few years ago while I was doing my Master's of Business Administration, that we needed to develop a limb preservation program at SUNY Upstate Medical University. No one else in this region has a limb preservation group, and we have everything we need.
We have an outstanding wound care group. We have diabetology, we have podiatry, we have all the endovascular and vascular specialists that we need. We just needed to bring this together so that we could benefit our local community as well as the surrounding regional hospitals that need care.
So we just held our first limb preservation symposium, which was really successful, and we decided to do it hybrid so that it could reach as far as Albany or as south as Ithaca if people couldn't come.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Palma Shaw. She's a professor of surgery at Upstate specializing in vascular surgery, and she was elected for 2023 to be president of the International Society of Endovascular Specialists.
We've been talking about her role as a vascular surgeon, but now we're going to talk to Dr. Shaw about a podcast she's been co-hosting.
I understand you have a podcast with another vascular surgeon from Houston called "Sisterhood in Surgery." Can you tell us about it?
Palma Shaw, MD: Sure, Amber. I'm really happy to do that.
This was actually the idea of one of my colleagues who was the original president of the ISEVS, or the International Society of Endovascular Specialists, Dr. Alan Lumsden, who's the chief of cardiovascular surgery at Houston Methodist Hospital. And his partner Linda Le and I have started this webinar, which we hold monthly, 10 months of the year.
We started in March of 2020, right at the beginning of the pandemic, when everything pivoted to virtual. Initially he came up with this idea, and we thought, well, let's talk about issues that are interesting to female surgeons. So one issue is being pregnant and being a female surgeon. So we did an episode on that, and then we did one on radiation exposure and being a female vascular surgeon, because in our job, oftentimes we work with radiation, and we have to wear lead. And we have done over 30 different webinars on a variety of topics, some of which are vascular- or medical-related, and some are not.
For example, the one last week was on self-care, mind and body, and we had a yoga instructor and a mindfulness adviser. And we had a really good time with that webinar. And then next month we're doing one with a company called Phairify, that Dr. Randy Green (a Syracuse surgeon) has started, trying to help physicians estimate their value and what is our worth. And there's going to be a collaborative effort with one of the big societies in vascular surgery. And so we're going to have them on the show to talk about how vascular surgeons can be more valued for what we do.
So this is something also important to vascular surgeons. It's not exactly medically related, but it's important to our careers.
Host Amber Smith: So it sounds like you get your story ideas or your episode ideas based on things that are important in your life.
Palma Shaw, MD: A lot of the shows are all my life, so I'm a single mother, so we did one on single mothers.
A lot of women have problems with fertility. I didn't, but a lot of women did. So we did one on fertility. I had a fertility specialist. Another one was on women who had challenging pregnancies and complications of pregnancy, and we reached out to different female surgeons, and they were able to talk about what their experiences were, and it was remarkable how that sharing of your experience helps other younger female surgeons feel like they're not alone, and they feel invigorated by the sense of a community of women in surgery.
Host Amber Smith: Do you rehearse before you record the podcast?
Palma Shaw, MD: So we do a run of the show, we come up with the idea, we find the guests. Linda and I are the co-hosts. I Zoom in; Linda's in the studio. And then, the week before, we put down some ideas. We send them to our guests and say feel free to add whatever you want.
And then we send that out to all of them, and we just sort of run through the questions. It's really informal. We feel like it's our version of "The View." And I want to say, you know, we did one called "Generations of Female Surgeons," and I had Pat Numann, who is emeritus here at SUNY Upstate and founder of Women in Surgery. And I had Leslie Kohman, who is our wellness executive here at Upstate and a thoracic surgeon, and she is the founder of Women in Thoracic Surgery, so we had five different generations of women in surgery on the show.
So we do a lot of fun things.
Host Amber Smith: Do you think most of your listeners are women surgeons?
Palma Shaw, MD: I think some men do listen, and I do actually share the links with the medical students, so our vascular surgery interest group, some men and some women also join in because, for example, we don't always have women's topics.
So I did one on how to become an editor of the Journal of Vascular Surgery because people say it's a male-dominated field. They don't have enough women that are editors of the Journal of Vascular Surgery, but I felt bad for the editors that I'm actually friends with. So I said, let's bring them on the show. Let them talk about the *women that they have promoted. Let them talk about how women can get more engaged, or anybody can get engaged to become, and now I just became, an editor of the Journal of Vascular Surgery, so I'm practicing what I preach, so to speak.
Host Amber Smith: Do you think circumstances have changed for women in surgery since you got out of medical school?
Palma Shaw, MD: Most certainly, I think we have a way to go, but I personally can say that I've been incredibly blessed, particularly in the last several years with numerous leadership roles. I started the women's section with a colleague, Audrey Duncan, and two other women for the Society for Vascular Surgery. We just started that early this year.
And I have a big role at the Society for Vascular Surgery right now and many other societies, and I feel like I've been given opportunities that I never thought I would ever have had, and I know we have more to go, and there are some women who still feel like things aren't entirely perfectly fair, but how fast can you actually change things?
I think it's like turning around the Titanic. I mean, you can only move so fast, right? But as long as you're making progress and be positive, which I think is really, really important. You know, Amber, Linda and I make a strong effort on the show to always keep things very positive. There's just no point in getting deviated to anything negative. We try to look towards the future in a positive way.
So I think that women in surgery need to still struggle with certain things. I get that. But men struggle, too. But we have to be positive and support each other because the era where women did not support women, and that was not so long ago. When I graduated there were women who didn't support me, but I was fortunate to meet Pat Numann and Leslie Kohman, and they supported me. And now, I think, most women feel like you have to support other women. It's unacceptable not to.
Host Amber Smith: Well, Dr. Shaw, thank you for making time for this interview.
Palma Shaw, MD: Thank you.
Host Amber Smith: My guest has been Dr. Palma Shaw, a professor of surgery at Upstate who specializes in vascular surgery and the president of the International Society of Endovascular Specialists, starting in 2023. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from Dr. Krithika Ramachandran from Upstate Medical University. What makes 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.
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.
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, multiple treatments now, as compared to a few years ago, which has changed the outlook of the disease.
Host Amber Smith: You've been listening to Dr. Kritika Ramachandran from critical care and pulmonology at Upstate Medical University.
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: The memories we have of those we have loved give the Muse some heartbreakingly beautiful poems. I'd like to read two of them now. The first is by writer and retired teacher and illustrator Mary Beth O'Connor. It is called "Afterward":
As October days fall into ripen and char,
I lean toward what comes next: the darkening,
the frosts, the nights full of nearer stars.
I put on your coat, venture out, harken
to the news of changing seasons -- hushed
but for crunch of boot steps toward the last
squash to gather -- then mow dead leaves to mulch,
sweep the porch, store cushions, watch the forecast....
Down by the pond the red-winged blackbirds
have departed, no more chatter and shrill.
I'll not see them until the spring return
even though I keep the bird feeders full.
I'll bring in firewood, clean the smoke-smudged glass,
light the match -- watch flames devour what's passed.
The next is from semiretired publisher and poet Jack Hopper, who has published four poetry collections. Here is "Your Presence":
Were it not for you
I'd be sitting here alone.
You're gone and I accept it
as the end at last to so much pain
you had to suffer just to die
while others whom I've loved live on,
or pass into the ether
of distance and neglect.
Occasionally we still meet
in that variant version of reality
we call dreams and you are
quite real until the sun paws
kind and quietly at the blind,
reminding me there is another world
wherein you will not walk.
I will not hear your voice,
will not lie down beside you
or reach out for what we both desired,
as you pass by.
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 Bill Broeckel. This is your host, Amber Smith, thanking you for listening.