Mammography guidelines; exercising when it's hot: Upstate Medical University's HealthLink on Air for Sunday, June 25, 2023
Radiologist Ravi Adhikary, MD, discusses new mammography recommendations and how they apply to women with dense breast tissue. Exercise physiologist Carol Sames, PhD, offers precautions for exercising in hot weather.
Host Amber Smith: Up next on Upstate's "HealthLink on Air," a radiologist explains the new guidelines for breast cancer screening.
Ravi Adhikary, MD: ... When they looked at what they could gain by starting screening earlier, they did find that they would have an effect on mortality. So their new recommendation is to start at 40. ...
Host Amber Smith: And an exercise physiologist offers some precautions for working out in hot weather.
Carol Sames, PhD: ... Maybe I start to feel, like, hot, and I start to feel maybe a little dizzy, and I'm just not feeling well. That's your body saying, "This is not the right situation for you." You have to listen to your body. The body usually tells us, and it's just when we try to ignore our body that we generally run into issues. ...
Host Amber Smith: All that, then an eye doctor answers whether carrots improve vision, and we have 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 explore the impact heat can have on people who exercise outdoors. But first, women are urged to begin mammograms at an earlier age, and a radiologist explains the reasoning.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Mammography recommendations have been in the news recently, so I'm turning to Dr. Ravi Adhikary for an update on what we need to know about breast cancer screening. Dr. Adhikary is an assistant professor of radiology at Upstate, specializing in diagnostic radiology and breast imaging and intervention.
Welcome back to "HealthLink on Air," Dr. Adhikary.
Ravi Adhikary, MD: Thank you very much.
Host Amber Smith: Previously, women at average risk for breast cancer were told to start annual mammograms at age 50, but the U.S. Preventive Services Task Force is now urging all women to get screened starting at age 40. What prompted this change?
Ravi Adhikary, MD: The Task Force looked at more recent data and found that the incidence of breast cancer was increasing in this group -- in women who were in their 40s -- and when they looked at what they could gain by starting screening earlier, they did find that they would have an effect on mortality. So their new recommendation is to start at 40.
Host Amber Smith: And why is this expected to be especially important for Black women?
When they looked at the data, the effects on mortality seemed to be especially high in Black women. It crossed over into all groups, but especially in Black women. Do they think that that's because Black women were not getting mammograms early, or not getting mammograms routinely?
Ravi Adhikary, MD: The reason why Black women have a higher mortality from breast cancer in general seems to be due to a number of factors, and one of them could be due to access. So this could help address the access issue by getting them in early and starting screening while they're young.
Host Amber Smith: Now the task force advises every other year for mammograms, rather than annually, which, I think that's a change too. Does that apply to all women or is that just for those in their 40s?
Ravi Adhikary, MD: The task force itself has always recommended screening every other year, for everybody from the age of 40 to until they're 75. Other organizations have slightly different recommendations. For instance, the American College of Radiology, they recommend starting at 40 and doing it every year, whereas something like the American Cancer Society, there is a little more nuance, where they say, from 40 to 45, you can discuss it with your doctor. From 45 to 55, do it every year. Then after that, do it every couple of years. Essentially what they're trying to do is kind of get the best aspects of mammography, while trying to minimize any risks that mammography may pose.
Host Amber Smith: So with all of these different organizations having slightly different recommendations, what does a patient follow?
Ravi Adhikary, MD: Part of that is individual, and one of the reasons why the task force indicates that patients should have it every other year is because they want to try to minimize what they think are the risks of mammography. And these risks include anxiety that a patient may feel from having to have additional testing. It may be that a patient has a biopsy that is negative, and they consider that a risk. Or they also consider another risk of overdiagnosis, where a cancer is found that may not affect the patient in their lifetime, which is very hard to kind of really quantify, but they consider that a risk. And so, their idea is we can minimize the risks but harness most of the power of mammography by having a patient come every other year.
Host Amber Smith: I know women who had normal mammograms, and then 12 months later their next mammogram revealed cancer. And I hear you about the anxiety, but it might work the other way too. If women are afraid of this, maybe getting them annually would help reduce anxiety?
Ravi Adhikary, MD: That is true. There are interval cancers that will develop if you do have screening every other year. And that is what some of the critics say about screening every other year, that on the flip side, if a patient has a cancer that has more time to develop, and they have a larger cancer, the anxiety from having a larger cancer and having worse outcomes has to be considered as well, because the patient may not have as good a cosmetic outcome or need more treatment because the cancer has been given more time to grow. So that is one of the reasons why there are some guidelines that say, get screened every single year, to find the cancers as early as possible when they're as small as we can find them.
Host Amber Smith: Well, let me ask you about what determines if someone is of average risk versus higher risk.
Ravi Adhikary, MD: Sure. There are some models out there that examine this, and if a patient is concerned, they can actually talk to their physician or see a breast surgeon. And the models take into consideration different factors.
There are some risks that are softer risks and some that put a patient in an especially high-risk category. And so some of the highest risk patients will have genetic mutations. The BRCA (tumor suppressor gene) mutation is one. There are others that also put a patient at higher risk for breast cancer.
Other risk factors include family history of breast cancer. There are patients who have had a biopsy with atypia (abnormality in cells in tissue) in the past and that can put a patient at higher risk. The time that a patient is exposed to hormones, which essentially means if they had an early menarche and had a late menopause, that is an additional risk factor, as well, that is somewhat softer than some of the other ones, but that's another risk factor. If a patient did not have a child, that is another risk factor, and there are others.
Host Amber Smith: So, how does weight impact risk, and does breastfeeding history have a difference?
Ravi Adhikary, MD: So, weight ... obesity is a risk factor, and it's thought to be a risk factor because fat itself can produce estrogen, and obesity may cause inflammation in the body. And so these factors may cause cancers to develop -- not only breast cancer, but other types of cancers -- to develop.
Breastfeeding is thought to be somewhat protective against breast cancer development. It's thought that when a patient is breastfeeding and they are not having regular menstrual cycles, this reduces their hormone exposure. And so they have a little bit of benefit from that. So that is potentially protective.
Host Amber Smith: I know that breast cancer in men is really rare, but are there any screening guidelines that apply to men who may be at higher risk, who have a family history of breast cancer, say? Does that put them at higher risk?
Ravi Adhikary, MD: It can. And the actual screening method would be an individual one, where the person would talk to their doctor. But if a patient does have a BRCA mutation, and they have family history, they may undergo mammographic screening, especially if they have gynecomastia, which is development of breast tissue in a male. But that is really pretty individual, and so they would want to talk to their doctor about what they can do.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Ravi Adhikary about some changes in mammogram recommendations.
Why does having dense breasts increase your risk for breast cancer?
Ravi Adhikary, MD: The exact reason is not known, but some people think that it may just be due to the fact that you have more fibroglandular tissue, and the chances that there is a mutation that will lead to cancer is higher since you just have more tissue itself. The other thing about having dense breast tissue is that it makes a mammogram harder to read, potentially, where the tissue itself can mask a small cancer. And so we may not see a cancer as early as in a patient who has more fat within their breast.
Host Amber Smith: How would a person know if their breasts are made up of dense tissue? Can you tell by feeling?
Ravi Adhikary, MD: You cannot really tell by feeling. The best way is mammographically.
When we look at a mammogram, we see a mixture of fat and a mixture of fibroglandular tissue. And so we try to get an idea of the ratio. And we assign every patient who has a mammogram, a density. And that is actually, if it is in the heterogeneously dense or extremely dense level, we will actually send the patient a letter so they will know that they have dense breast tissue. This is a state mandate and is soon to be a federal mandate. But a patient, if they do have a mammogram and they have dense breast tissue, they will know, by getting a letter.
Host Amber Smith: Does the density of breast tissue change with age?
Ravi Adhikary, MD: Generally, yes it will get less dense over time, and some patients will get dramatically less dense. Some don't change much at all, and it could be due to just involution of normal tissue and replacement with fat.
Host Amber Smith: Can you tell us about a recent study in the medical journal JAMA Oncology? It focused on changing breast density.
Ravi Adhikary, MD: Sure. What these researchers did was, they looked at patients who eventually developed cancer and compared them to patients who did not. They looked at their mammograms and evaluated how the density of their breast changes over time. What they found is that in the affected breast of a patient who developed cancer, the density did not change as much. It did not get as fatty over time. So that is, potentially, another tool that we could use. It's kind of a starting point. It's not something we could potentially use right away, but it may be at a point where we could do more research and figure out what we can do with this information. Can we use it to put those patients in a higher-risk category and do additional screening? It's kind of a starting point, but it is an interesting observation.
Host Amber Smith: So I know radiologists typically will compare a current mammogram with previous ones of a particular patient. Do they routinely compare the densities of both breasts?
Ravi Adhikary, MD: What we do is we look at the density, and we can kind of see the density change over time, in most patients. What they did in this study was used computer analysis to get very fine detail on how the ratio of fibroglandular tissue to fat had changed over time and how it was different in each breast.
It's probably more detailed than we can just tell from simple analysis with our eyes. So it may be something where if we wanted to use this information, we may need additional tools to help us get that data. And then we could then take those patients that fit this characteristic and perhaps do additional screening with them.
Host Amber Smith: Most of us have heard of a clinical breast exam where a doctor feels for any lumps or abnormalities. And we're familiar with the mammogram, X-ray of the breast. Can you talk about other methods of breast cancer screening and diagnosis, like ultrasound? I've heard that's used sometimes.
Ravi Adhikary, MD: One thing about mammography that makes it unique is that it does have decades worth of trials and hundreds of thousands of women that have undergone studies, and we have shown a mortality decrease. Other types of modalities don't have as much data, but they are useful.
So ultrasound, where we use sound waves to examine the breast, one nice thing is there is no ionizing radiation. And we can see through dense tissue with ultrasound better than with mammography. So it can be a supplemental tool in a patient who has dense breast tissue, and especially in a patient who has a higher risk than average and has dense breast tissue. Using ultrasound can be a good supplemental tool. It is also widely available, so that makes it a good surveillance tool as well.
Host Amber Smith: When might a breast MRI be used?
Ravi Adhikary, MD: MRI is a very sensitive modality. It is quite costly, and a patient has to get intravenous contrast, so it makes it less accessible. But it is utilized in the highest-risk patients, for instance the patient with a BRCA mutation or other genetic mutation, or the patient who has a very strong family history, or who has had atypia on a prior diagnosis. Those patients may get additional screening with MRI. And using mammography and MRI in conjunction will give us the most power to find a breast cancer early.
Host Amber Smith: What is a PET scan, and do you use these for diagnosis?
Ravi Adhikary, MD: So a PET scan, a patient is given a specific radioactive material called a radio tracer, and the radio tracer will go selectively to very active tissue, so it will go toward cancers. PET scans are not traditionally used to diagnose cancer. It is used when a patient has metastatic cancer, to look for deposits in other parts of the body.
The actual radio tracer will go toward a breast cancer, and so we can see it, but the field of view is just so much different. We don't get as much detail because the PET scan will actually scan the entire body and not just zoom in on the breast. But the radio tracer actually does go toward the breast cancer. It's just that we don't use PET scans to look for breast cancer.
Host Amber Smith: For someone who has had breast cancer and survived breast cancer, do they go back to screening, or do the screening guidelines change for that person?
Ravi Adhikary, MD: Some of that depends on the institution. Here, at Upstate, we generally will examine the affected side more closely for a couple of years. So we may do six-month interval mammograms to see that there's no immediate recurrence. After that, they can have standard screening. They may want supplemental screening, especially if they had breast cancer diagnosed early. And the supplemental screening can be done with ultrasound or MRI.
Host Amber Smith: We've talked about a lot here with mammograms. And I guess the overarching was that the preventive task force is recommending that they start earlier for women in their 40s. Does Upstate follow that, or does the institution have a guideline in place? Or what should patients ask their doctors about?
Ravi Adhikary, MD: So at Upstate, we generally will recommend what the American College of Radiology recommends, which is starting at the age of 40, having a mammogram every year. If a patient is not comfortable with that, they can also talk to their doctor about modifying that. And if a patient has a strong family history or other sorts of high risk factors, they can talk to their doctor about starting early or using supplemental tools like ultrasound or MRI, potentially.
Host Amber Smith: Dr. Adhikary, you've really helped us understand this. Thank you for explaining it so well. I appreciate you making time.
Ravi Adhikary, MD: You're welcome. Thank you for having me on.
Host Amber Smith: My guest has been Dr. Ravi Adhikary, an assistant professor of radiology at Upstate, specializing in diagnostic radiology, breast imaging and intervention. I'm Amber Smith for Upstate's "HealthLink on Air."
Coming up next on Upstate's "HealthLink on Air," an exercise physiologist addresses warm-weather workouts.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
More Central New Yorkers tend to be active outdoors in the warmer months, running, biking, kayaking, hiking. With exercise especially, sometimes it's tricky to know if we're pushing ourselves too much. Here to discuss warm-weather workouts is Upstate exercise physiologist Carol Sames.
Welcome back to "HealthLink on Air," Dr. Sames.
Carol Sames, PhD: Thanks so much, Amber. Great to be here.
Host Amber Smith: Is there an outdoor temperature that's just too hot to be active in?
Carol Sames, PhD: Well, there's not necessarily a specific temperature because there's a lot of other conditions such as humidity, am I out in direct sunlight? The ground has conduction. If you've walked across hot asphalt on a summer day, you can feel that coming off. There's thermal, there's solar radiation. So all of that really impacts how we feel and what is a hot temperature for each individual.
Host Amber Smith: So it's all the conditions, but it's also dependent on the person themselves, it sounds like.
Carol Sames, PhD: Very much so. We could also have, like, how acclimatized am I to hot weather? Is it windy? And so, it's very difficult to say, "This is the temperature." There are people that can actually hit heatstroke, and it's been documented, in a marathon when the temperature was 43 degrees to start, but the humidity was quite high.
So therein lies the problem.
Host Amber Smith: So guidelines have got to be tricky for this.
Carol Sames, PhD: Yes.
Host Amber Smith: Workouts are meant to be strenuous and sweat-inducing, but of course we want to be safe about it. So how do we tell ourselves, or how do we learn, how hard to push?
Carol Sames, PhD: We all have to listen to our body, right? So if it's really hot, and I'm out there, and maybe I didn't really hydrate well, I'm out in the sun, I'm maybe running on some type of asphalt, and I start to feel, like, hot, and I start to feel maybe a little dizzy, and I'm just not feeling well. That's your body saying, "This is not the right situation for you."
You have to listen to your body. The body usually tells us, and it's just when we try to ignore our body that we generally run into issues.
Host Amber Smith: So you just have to be aware of the signs and symptoms you just gave us.
Carol Sames, PhD: Exactly.
Host Amber Smith: Now, during stretches of days where it's super hot for days on end, does it make more sense to try to work out in the early morning, when it might be cooler?
Carol Sames, PhD: Certainly that's an option. The way we protect ourselves and keep our body temperature low, the primary mechanism is evaporation of sweat. So when sweat is rolling off of us, we are not evaporating. And if we're not evaporating, we're not cooling, because that evaporation is going to cool the blood that is at the surface.
When we're dripping, we're not evaporating. And so in the morning, usually the sun is lower, so you don't have that direct thermal heat on you, and it's usually cooler out. It could still be high humidity, but it's cooler, and so, we are able to evaporate.
Some people like later, like early evening.
And it's really just a matter of what fits into my time frame, and where am I going, et cetera. But generally speaking, unless you acclimatize to running at noontime in the summer, you're going to run into trouble. Yes, you can see people outside; I see noon runners all the time, but they have been doing that consistently. And so they have acclimatized to training, and there's actual changes that occur in the body that your body gets used to not producing as much salt-laden sweat. You tend to conserve. And we're also assuming these individuals are hydrating themselves properly before they go run at noon.
Host Amber Smith: I wanted to ask you about hydration. Is drinking extra water or the sports drinks, is that protective against heat injury?
Carol Sames, PhD: Absolutely, especially if you're going longer, right? Or it's high humidity. Water actually gets out of your stomach the quickest. But sports drinks usually have some electrolytes in them, sodium, chloride, those salts that we need. And some of the sports drinks also have a little bit of sugar in them. If you're out on a long, kind of arduous activity, after about two hours, you're running out of the stored energy that you have in your muscle and liver. And if you're not replenishing that, you're going to start to feel fatigued, and you're going to have to start using other energy sources, like fat. And when you start to use fat, it requires more oxygen, and it releases energy slower, so you're not going to be able to maintain the same performance.
So, having some type of replacement fluid, that if it's a longer distance or longer activity that also has some sugar in there, that can be really helpful to enable you to continue.
But with sugar, it's going to take just a little bit longer to get out of your stomach.
Host Amber Smith: Does the fabric of our clothing make a difference?
Carol Sames, PhD: It actually can, again, especially when it's hot. The old days, when we ran in 100% cotton clothing, when you start to sweat, it just sticks to you. In fact, it can hinder evaporation.
So, having clothing that is lighter in color, having clothing that is loose fitting, that's not tight fitting. because if you have tight-fitting clothing on, evaporation is hindered. Having clothing that has some of the newer materials that are very wicking, moisture wicking, can actually help with evaporation, so clothing really can matter.
Host Amber Smith: What about sun protection, and I'm thinking about sunscreens at the same time I'm thinking about hats or long sleeves? How does that play into keeping us safe when we're working out?
Carol Sames, PhD: So, a hat can be fantastic, keeping those direct sun rays off your head. I don't want the hat, though, to be so tight fitting that I can't evaporate off of my scalp, either.
But when I was younger, there was no sunscreen, right? Well, there probably was, but nobody used it. We used oil so that we could get a nice, nice tan, and we know now that that is the worst recommendation, that regardless of your skin tone, we can get sunburn, and that can lead to skin cancer.
We also know that excessive. outdoor exposure to sun can also exacerbate wrinkles. We can get sunspots. It's not healthy for the skin, so we want to use sunscreen, and we, if we're active, we also want to use sunscreen that is water resistant, because if you don't, it's just as soon as you start to sweat, it's rolling right off of you.
And apply liberally.
Host Amber Smith: Can you go over the symptoms and signs of heat illnesses and what to do if we start experiencing them?
Carol Sames, PhD: Yes. So, heat cramps are probably, if you've been out and you've done something that's fairly strenuous, you're used to heat cramps. It's almost like night cramps, where you have a muscle group, sometimes the calf muscle or the upper leg muscles, they just start to cramp. And it is very uncomfortable. Sometimes they'll continue to cramp. They won't relax. And that's a heat cramp, and really, it occurs because there's an imbalance between body fluid and electrolytes. What you need to do is stop, and you need to drink water or sports drink.
That should resolve. It's not going to resolve immediately, though. You're not going to just drink and be like, "Heat cramps are gone!" Most likely, what you're going to have to do is, if you were running, you're going to need to walk. If you were cycling, and it's bad enough, you're going to have to get off that bike. But that's what you need to do to resolve that situation.
The next two are what we consider more extreme heat illnesses. So, heat exhaustion, and that's when we don't have enough circulation to evaporate that heat that we're building up, and so, we start to lose blood volume, and we start to lose body volume.
In terms of "How do I know I'm kind of moving from heat cramps to heat exhaustion?" -- if I would take my pulse, it would be weak and very rapid. Usually when we're exercising, you can feel your pulse. It's nice and hard and steady. But with heat exhaustion, it's weak. You also might start to experience a headache because you're not getting enough blood flow to your brain, dizziness, and you just generally don't feel well.
You need to stop exercising. You need to move to a cooler location, under a tree, somewhere where there's shade. If you can get indoors where there's some type of air conditioning, that's even better, and you need to replace fluids. You might even need to go to the hospital and get an IV (intravenous fluids) -- kind of depends on how depleted you are.
The worst heat illness is heatstroke, and it is an immediate medical emergency. This is not something where people are like, "Should I go to the hospital or not?" because it's a cascade of events. Basically we have no more heat regulation going on, so we're no longer sweating. Our skin is hot to the touch. It is not moist anymore. Core temperature is at about 104 degrees or higher, and the body does not tolerate that type of extreme temperature. You end up with central nervous system failure, so a person might start to look very uncoordinated. All of a sudden, they can't stand. They may stumble and fall. You're starting to get organ failure, kidney failure, and people can progress really quickly from delirium to convulsions to coma. That's why this is a medical emergency. They need to get immediately to the hospital. They need to be immersed in cold water, ice, they need immediate fluid, IV immediately.
And you'd be surprised; even highly trained athletes have died from heatstroke. It is really problematic because when it starts, it's like a downhill car. It moves quickly.
Host Amber Smith: Can you tell when you have heatstroke, or do you not realize it, because that's part of the mental confusion?
Carol Sames, PhD: That's the problem.
That's why, like, at all major races there will be like race stewards. I can't speak for anything but running. I don't know if they have them out for cycling. Cycling, you usually don't get into that issue because you do have air currents because they're moving pretty quickly.
But you have to look at people, and if you start seeing people that it's warm out, and they're no longer sweating, usually a race steward would go up to them and kind of see. And if you feel that their skin is hot, you're going to pull them off the course. Do you remember the one female who was doing the Ironman in Hawaii, and she was, like, a hundred meters from the finish, and she was just, like, all over the place, motor-wise, and she crashed, and she fell to the ground, and she was trying to get up, and she ended up getting disqualified because the medical team had to go out and get her? She was at heatstroke.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Carol Sames. She's an exercise physiologist at Upstate, and we're talking about working out in warm weather.
We covered heatstroke, which is an emergency, but I'd like to talk now about another condition that can be very serious. Can you explain what rhabdomyolysis is? And I'm not even sure I'm pronouncing it right.
Carol Sames, PhD: That's the correct pronunciation. A lot of times we just call it "rhabdo." All it really is, is damage to skeletal muscle.
So, how can we damage skeletal muscle? Well, I could be in a car accident, and I have the steering wheel hit my legs, and I have damage to that muscle. It could be that I want to start an exercise program, and I'm really excited, and I just, I go "from zero to hero," and I go out, and I do some long activity, and I'm just not accustomed.
It could be that I have a lack of blood flow that could occur to muscles. It could be my electrolytes. I have sodium and potassium that I've become dehydrated, and that's a problem. There can be different diseases, like some muscle dystrophies. There's infections. It can be statin medications. Statin medications, a lot of us use to lower "bad" cholesterol. So there's a lot of reasons that you can develop what we call rhabdo. The thing that makes it challenging is, if I start to strength-train, and I've never lifted weights before, I'm going to have a little bit of rhabdo. I'm going to have delayed onset of muscle soreness.
Those muscles haven't been used before. And when we strength-train, we actually do have micro tears in muscle fibers; proteins are broken down. What sets that apart from clinically relevant rhabdo is that this is a normal physiological process; I'm going to have some soreness, but in a few days, that soreness is going to get less and less.
With clinical rhabdo, what happens is that you have serious damage, and that damage is extreme pain. A person will also notice, potentially, that they have very dark-colored urine. It is not straw colored. It's nowhere in the family of yellow. This is red-browns, and that's telling you: A, that I am probably dehydrated, but B, I have a protein that exists in skeletal muscle called myoglobin that is now being filtered through the kidneys, and it's coming out in my urine, and that is problematic.
Host Amber Smith: Are there things that increase a person's risk of developing this?
Carol Sames, PhD: The first known cases occurred in the military, where you had individuals maybe who weren't very trained, and they went into military training, or they wanted to do specialized training like the Navy SEALs or the Army Rangers, where they just had a dramatic increase in intensity of their activity. And that certainly can cause rhabdo.
Or you can have somebody, again, who's never been active at all, and they decide they want to become active, and they just do too much in a very short period of time. You see it more common in males versus females, and again, you can see it in low fitness and high fitness, so it can occur either way.
You also see it when people strength-train, when they do what we call more lengthening contractions. So if you go downstairs, OK, when you go downstairs, that is a lengthening contraction of quadriceps, and that can increase soreness. So for people maybe that are hiking, and they are not used to going downhill, if they've climbed, and now they start going down a long hill, a couple of miles of downhill, that could be rhabdo. It could be if it's a long enough hill, and they're going hard enough, they could experience that. And then, as I had mentioned, there's some genetic factors. There are certain diseases that can also predispose you to that.
Host Amber Smith: Does heat or a high temperature outdoors, does that bring it on quicker, or does it influence it in any way?
Carol Sames, PhD: It absolutely does because it's dehydration, right? And so, once we start to become dehydrated, we run into all kinds of problems. The kidneys aren't happy. We can't clear that muscle protein and other toxic substances, and then what happens is, we start to have reduced blood flow to the muscle, and the muscle is trying to work.
We can also get swelling. And then that can lead to compartment syndrome, and so, again, it can be a cascade of events that occurs, and really the concern is kidney failure because if somebody has rhabdo, pretty serious rhabdo -- and there's some blood markers that you can use to check -- if that is not reversed with an IV, a specific IV with some bicarbonate, you can have damage to your kidneys, and we don't want to damage our kidneys because that can lead to a whole other set of problems.
Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more information about warm-weather workouts.
Welcome back to "HealthLink on Air," from Upstate Medical University. This is your host, Amber Smith, and my guest, Dr. Carol Sames. She's an exercise physiologist at Upstate and we've been going over the dangers of exercise in extreme heat.
Well, you've kind of talked about some of the signs and symptoms, the very dark-colored urine, the muscle soreness or pain. Are there other signs and symptoms that would make a person think, "Oh, maybe this is more serious. Maybe it's rhabdo"?
Carol Sames, PhD: Your soreness is not dissipating with time, like it is extreme pain that is not getting better.
Again, delayed-onset muscle soreness, which is normal, is going to dissipate over days. Rhabdo is not. Once you start having more than one episode of urine, That's the sign, "I need to get checked out. There's something that's not right here."
And I did mention compartment syndrome can happen because when we start to have lack of blood flow to muscle, that's problematic. That means we're not getting oxygen to muscle. We don't get oxygen to muscle, muscles are not going to contract well, they're not going to move. And you're going to start to experience those symptoms also. It's kind of really like a vicious cycle of tissue death that goes on long enough, you have more and more areas of muscle that are dying, and you're going to know that. You're not going to be able to move. You're going to be in extraordinary levels of pain.
Host Amber Smith: So compartment syndrome is equivalent to muscle or tissue death? Is that what is happening?
Carol Sames, PhD: If you don't do anything about it, yes. And rhabdo can bring on compartment syndrome, but compartment syndrome can also come on without rhabdo. OK, so people that tend to engage in activities that are high intensity, running, a lot of jumping types of activities, what can happen is that muscles are surrounded by, like, connective tissue and as that muscle expands, that connective tissue might not expand. And so, there is pressure there, which means we have less blood flow because the pressure is getting higher, and when you have less blood flow, you're going to have tissue death. And so what happens is the person will note, and again, you can see this with individuals, maybe they're starting the beginning of a sports season, and they're not quite really in shape, and the intensity is high, they're doing a lot of activity. They can develop this compartment syndrome. It's not uncommon to occur in the lower leg. And when they stop, it goes away. But over time, it can become so painful, it interferes with the ability to continue whatever activity that is.
There is treatment. You can cut the connective tissue to allow the muscle to swell without restriction, so the blood can flow. Now, clearly, that's extreme, but that would be the case if it wouldn't resolve on its own.
Host Amber Smith: Well, I think I understood you to say that rhabdo can be diagnosed with a blood test, and then it can be treated with, did you say bicarbonate in an IV?
Carol Sames, PhD: So that's what you can do with, like, an acute case of rhabdo. Chronic is more like compartment syndrome, so that compartment syndrome is more of a chronic, it doesn't, like, just come on today. Whereas rhabdo could, if I was completely untrained, and I did something that was extraordinarily intensive for a period of time, I could develop rhabdo fairly quickly, in a day, and especially if I tried to do the same thing tomorrow.
With more chronic compartment syndrome, you can have a special MRI (magnetic resonance imagine scan) that can look at the pressure that exists in the muscle group. And if that pressure is high, then that's telling you blood flow is restricted. You can look at blood flow through there. If you see that it's reduced, most likely the pressure would be higher.
Host Amber Smith: Is there anything people can do proactively to prevent or even just reduce the risk of rhabdo?
Carol Sames, PhD: First of all, know, again, what your limits are, right? So, like, you can't go from zero to hero. If I've not been active, I need to know that it's going to be a slow and steady progress. I need to make sure that I'm not dehydrated, and that I'm taking in enough fluid.
So that might mean if I'm out doing an activity, that I bring water, sports drink, with me, or that I have stops along the way where I can drink. In terms of older adults, it's very important to understand that we lose a thirst drive as we get older. Essentially, what we say is that after the age of 65, almost every adult is dehydrated, to start.
So, if you're dehydrated to start, and then you go out, and it's warm, and you're exercising, you're becoming even more at risk of dehydration, and then, kind of that cascade of heat illness. So, that's really important.
I just really think it's always good to carry something with you, some kind of fluid. You never know, especially if you're going to go out, you don't really know how hot it's going to get. If you're going out to a new area, you don't know where the shade is, all of those things that if it's an area that you're more comfortable with, that you walk or run or bike that you're familiar with, there may be areas where there are stops where it's shaded.
If it's a hot day, and there's no wind at all, and it's humid, you need to be smart. You want to make sure you have proper clothing. I might want to have a hat on. I have fluids with me. I might want to be with somebody, or I might want to go to an area where there are other people, that I'm not completely isolated.
There's a reason why I, personally, run in the morning. I don't heat-acclimatize well. I don't feel good in the heat, and so I would much rather get up in the morning before it gets really hot and just get something done. I'm impressed by those noon runners, but it could never be me.
Host Amber Smith: Well, before we wrap up, let's go over what people can do to stay safe in the heat when they're active. You've already talked a little bit about the type of clothing and the fabric being more moisture wicking and less cotton, and to prepare with adequate fluid or bring fluid with you. Is there anything to eat or drink before or after, for recovery or for preparation?
Carol Sames, PhD: So, definitely water leaves the stomach quicker, so water is going to be the quickest coming out. If you know you're going to be doing something that's longer duration, again, if you start to talk about higher intensities, longer durations, you probably are going to want to have some type of fast-acting sugar with you, whether it be chews, or there's goos, there's all kinds of things out there. You probably are going to want that if you want to maintain that same intensity. I always suggest that.
You want to make sure sunscreen is on, if you're going to be out in the sun, because all of us have experienced what it's like to burn. And I want to make sure that my clothing is appropriate.
I always tend to like, if I'm going to do something that's a little bit more strenuous, to do a loop type of activity so that I know I'm coming back to civilization. Just in case, because you never know what can happen until you experience something like heat cramps, where you know you're in trouble. It's always nice to be closer to civilization.
It's also good to practice with this, to not just go out the first time and go, "I'm going to take chews, or I'm going to take all this water, and I'm going to be fine," because some people, it takes an adjustment for their stomach to kind of get used to food or water slashing around when you're doing an activity. For some people that's not comfortable. So it's best to practice that.
And I think, you know, it comes down to what's common sense. And in Central New York, our weather changes quite rapidly. Something else: In the summer, it's not unusual potentially to have a storm coming. So, all those want to take into account, especially if you're going to be out for more than, like, 20, 30 minutes.
Host Amber Smith: Are you able to make your own sports drinks or chews, to save money? I mean, those can kind of add up.
Carol Sames, PhD: Yeah, they are.
I have seen people use cornstarch. There are recipes out there where you can put a flavor into cornstarch, and it will solidify. It's very fast-acting glucose, and certainly, that would work.
And there are some things that you can, like, sprinkle into (water), so I know that Gatorade has a powder format that you can throw into a drink, so its cost per unit is cheaper, so you still are getting those electrolytes, again, if you're going to be out for a while, or it's really kind of warm and humid. So there certainly are options for that.
I'm speaking from experience because, yes, I have crashed before. It's a terrible feeling. I've experienced heat cramps before. It's just not a good feeling that you want to get yourself into.
Host Amber Smith: When it is super hot, is swimming or rowing, is that a safer activity because you're on water or not necessarily?
Carol Sames, PhD: It certainly can be.
The thing with swimming is, if you're going to be swimming, depending on what kind of suit you have, if you're a guy or a girl, you can burn on your back. Sometimes people are thinking, "I'm under the water, I'm not going to burn." It's a little bit different than if you have a whole shirt on.
So it's just something to think about. But, yes, swimmers do sweat. They still evaporate heat in the water. Sometimes people are, like, "They don't sweat." Yes, they do. You just can't quite see it because they're already wet.
Rowing also can be wonderful, but again, make sure that sunscreen is on.
And some days there's just not any wind current out on a water source. Wind is always really helpful when it's hot, because at least it helps with evaporation.
Host Amber Smith: I know especially runners and bicyclists, they like to kind of train on their own. When conditions are severe, in terms of heat, would you recommend to have someone nearby or at least let someone know where they're headed?
Carol Sames, PhD: Personally, I think that's a great idea. And I would also say if somebody is not highly trained, it might just be a day where you say, can I do something at home? Do I have any equipment at home, or am I a member at a (gym) facility? Like, maybe today is not the day.
I think, probably, if I look back on my bad experiences, I had plenty of signs to tell me, but I ignored them all. And the problem is, you ignore these signs, and then you end up in difficulty. And so, if I had an older adult, and they were saying, "It's hot and humid, I really want to get my walk in," can I go to the mall? Can I go somewhere, do I have the ability to do that? And if not, can I do something at home? So, can I go up and down the stairs in my house? Can I set up a little high-intensity interval training workout in my home? Because it might just be a safer option for me. It's just always great to be proactive. Retroactive is not always the best way to go. You can run into some serious dehydration quickly.
Host Amber Smith: Dr. Sames, thank you so much for sharing this advice.
Carol Sames, PhD: My pleasure. Thanks so much for inviting me, Amber.
Host Amber Smith: My guest has been Upstate exercise physiologist Dr. Carol Sames. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from ophthalmologist, Dr. Mark Reno from Upstate Medical University. Does eating carrots keep eyes healthy?
Mark Breazzano, MD: Carrots can help keep eyes healthy. However, it is in moderation, like many other vegetables that are part of a nutritious and balanced diet. Some of it has been overhyped, a little bit. And some of the history of that actually dates back to World War II, where the British Air Force actually had radar technology that was helpful against the German Air Force. And unbeknownst to the Germans, they were actually able to fight them off and keep Britain safe. And, as part of this effort in keeping the morale high for the Allies, they attributed it to the "cat-eye vision" that the British pilots had -- and they had easy access to carrots and planting carrots. So instead of eating things like ice cream and of that sort, they were actually eating lots of carrots and putting carrots, frozen carrots, even, in pies. And they were relatively easier to grow.
And so there was sort of this -- for lack of a better term -- a propaganda type of effort to increase the amount of carrot production and consumption. And so that translated into this myth of getting ultra vision from carrots.
But in reality, carrots produce beta carotene, and beta carotene is a provitamin carotenoid, basically a molecule that needs to be converted to vitamin A that our body can use. The bio availability, as the term is called, or the ability to do that conversion, actually lowers the more that you eat. And so you can eat as much as you want, but it's not going to help produce any more visual success for your eye. So as long as you're getting enough of the daily recommended allotment of vitamin A, and you have been doing that for a while, and you have no issues with your gastrointestinal tract that you're aware of over time, you should be more than fine with a few carrots a day and not overthinking it too much.
Host Amber Smith: You've been listening to ophthalmologist Dr. Mark Breazzano from 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: Terry E. Hill is a geriatrician in Oakland, California. He gave us a poem from his early days as a medical student, "I Wish I Had Let Her Know." It lets us see how profoundly connected a student and patient can be as life ebbs.
"I Wish I Had Let Her Know"
At 5:00 am it fell to me to phone the wife and say he died,
and by the way, ask her for an autopsy.
Right, it's July, I'm a student. The call went well enough,
she was kind, but I didn't think to say I was there,
I was there when he died, my hand on his in a dark room,
attending to his breath, irregular, rough, the only sound,
and to my breath, easy and slow, the prayer of my breath filling
and emptying, thinning into pause before filling again but
his breath mostly thinning, thinning, pause and more pause
and then I'm breathing a pause immeasurable in a silent room,
sitting by his side, my hand on his. To this day, I remember wife,
husband, the soft silent dark, the pause generous and kind.
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," diagnosis and treatment of melanoma.
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.