Lung disease and countertop makers; a device that checks for stroke risk: Upstate Medical University’s HealthLink on Air for Sunday, July 21, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a pair of silicosis researchers sound the alarm about the lung disease risk for workers who make countertops of quartz and other engineered stone.

Jerrold Abraham, MD: ... The recognition of this terrible disease has come from places around the world where there's been this manufacture of these beautiful countertops that many people love to have in their kitchens, without knowing that the workers producing them have been exposed to unacceptable risk. ...

Host Amber Smith: And a nurse practitioner explains a device that helps some patients monitor their risk of stroke.

Stephanie Loveless, NP: ... The device that's implanted underneath the skin kind of communicates independently on its own with the device, either on your phone or at the bedside. ...

Host Amber Smith: All that, some positives about the terrible twos, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, a nurse practitioner tells about implantable loop recorders that monitor stroke risk.

But first, a pair of researchers explain the dangers of silicosis to coal miners, sandblasters and people who make engineered stone countertops.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

A lot of scientific research is incremental, with its importance becoming evident over the years. Sometimes scientists uncover information that needs to be shared more urgently, and that's the case with some research into silicosis at Upstate.

With me to talk about their findings are Drs. Jerry Abraham, MD, and Judith Crawford, PhD. Dr. Abraham is a professor of pathology and director of Upstate's environmental and occupational pathology. Dr. Crawford is a certified industrial hygienist and research associate at Upstate.

Welcome to "HealthLink on Air," both of you.

Judith Crawford, PhD: Thank you.

Jerrold Abraham, MD: Thank you.

Host Amber Smith: Let's start with a definition of silicosis. Dr. Abraham?

Jerrold Abraham, MD: Yes. Silicosis is one of the oldest recognized diseases related to exposure to something in somebody's job or environment. By definition, silicosis is the disease caused by inhalation of silica dust particles. It's usually a lung disease, resulting from inhaling, over periods of time, tiny particles of silica dust that injure the lung and cause a reaction, which can be different kinds, of different severity.

Host Amber Smith: So this isn't something that a person would be born with. It's an injury, it sounds like, or a disease that develops from breathing silica dust?

Jerrold Abraham, MD: That's correct.

Host Amber Smith: How long does silicosis take to develop? If you start breathing it, how long until you start having symptoms of silicosis?

Jerrold Abraham, MD: Well, like many diseases related to inhaling harmful materials, it depends on how high the concentrations are that you inhale. Classically, silicosis develops with a few decades of exposure to silica in various occupations like mining or milling, in the past. But there are other forms that we'll talk about where it can develop within months to years and in between those different timeframes.

Host Amber Smith: Is silica dust visible to the human eye, or does it have an odor? How would a person know they're breathing it in?

Jerrold Abraham, MD: Well, it doesn't have any odor. And if the concentrations in the air are high enough, the air looks dusty, especially when there's light shining through it. It's like a dust. Particles scatter the light, and you can see it look much more dusty that way. Just like in a foggy environment, if you shine your headlights through it, you can see the fog, but if you turn the headlights off, you won't see it so much, even though it's still there.

So silica dust can be inhaled without you knowing it. If you're in a very dusty environment, you probably are aware you're in a dusty environment, but you would have no way to know that it's silica dust unless you were informed about the hazards. And that's one of the primary responsibilities in occupational health, is to inform people. It's called the right to know. People should know what they're being exposed to, or prevent exposure to.

Host Amber Smith: Are there specific symptoms a person might experience if they've developed silicosis?

Jerrold Abraham, MD: Yes. As with most lung diseases, the main symptoms relate to breathing. So difficulty breathing or shortness of breath would be the most classical symptom someone would develop as they develop silicosis.

Host Amber Smith: Can you talk about how silicosis is diagnosed?

Jerrold Abraham, MD: Yes. One way it's diagnosed is with a chest X-ray that shows characteristic shadows, little round shadows in the lung, that are not 100% specific, but very suggestive for silicosis. And another way that it's diagnosed is not just based on an X-ray, but based on the physician taking a history of what the person was doing, how were they exposed to silica or other things, and to put it all together to see if that's a consistent picture before they make that diagnosis.

Host Amber Smith: Are there treatments available for this, and is there any way to reverse the damage once it's occurred?

Jerrold Abraham, MD: There's not really any good treatment. There can be treatment for complications. If you get damage to your lung and you get infections related to that, those can be treated. But the silica dust stays there and causes scarring in the lung, and it's not really possible at present to reverse that. That's the tragic part of it, and it's very simple. To prevent, if you don't inhale it, you aren't going to get that disease.

Host Amber Smith: So it is preventable?

Jerrold Abraham, MD: Yes. Maybe Dr. Crawford would want to talk about that a little bit.

Judith Crawford, PhD: Yes. It's 100% preventable. It absolutely is. And employers are required under the OSHA (Occupational Safety and Health Administration) Act, to provide a safe and healthful work environment to their employees, and to protect workers. And there are regulations specifically for silica control on the books. And so those, the types of things that can be done to prevent silicosis are things like training of workers. And we talked about dust. Control of dust is absolutely huge for preventing disease and protecting the workers. And that includes things like wet methods.

Wet methods are very, very important where you have, like, water delivery systems to your power tools that will directly go on a saw blade, for example, to keep the dust down, vacuum-type equipment that can also be attached to power tools, dust collection equipment. And so those controls are really important, as well as some you can control -- work time, the length or duration a worker can work.

The other types of things that can be used to protect workers are respiratory protection, and air testing is another type of activity that's really going to help document what type of exposures that workers might have. And then medical exams are also a part of it. So all those things need to be done when workers are exposed to silica.

Host Amber Smith: Now the type of workers who might be exposed, would that be construction workers and coal miners?

Judith Crawford, PhD: Those are two big groups, yes. I would say probably construction has more people potentially exposed. But there's also a lot of manufacturing industries that use silica. There's, for example, pottery, ceramics, brick, concrete manufacture, asphalt, jewelry -- silica is used in jewelry making -- and then the artificial stone -- we'll probably talk about later in this discussion -- but artificial stone countertops. But also sand is used, silica is used, in foundry work and hydraulic fracturing (fracking), and so it's across the board in different industries, not just construction and mining.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host Amber Smith. I'm talking about a lung disease called silicosis with Dr. Jerry Abraham, who's a professor of pathology and director of Upstate's environmental and occupational pathology, and Dr. Judith Crawford, who's a certified industrial hygienist and research associate at Upstate.

The two of you, and colleagues, have a paper in the American Journal of Industrial Medicine that says there's an increase of accelerated and acute silicosis, something called PMF, and autoimmune diseases among coal miners and silica-exposed countertop workers. How does accelerated and acute differ from regular silicosis?

Jerrold Abraham, MD: Well, as I mentioned earlier, the main, classic kind of silicosis takes usually decades of exposure, a few decades of exposure, to develop. The terms "accelerated" and "acute" are largely related to the time it takes for them to show up.

So acute silicosis is the most severe and rapidly developing, and it's not like an acute pneumonia or something like that. Acute for something like silicosis means developing after months to just a year or two of exposure. And accelerated means it's in between. Usually it means it's developing in less than 10 years of exposure.

So the heaviest exposures, for example, an occupation that has resulted in acute silicosis, is sandblasting, using silica.

So in the U.S., sandblasting with silica sand is still allowed. Whereas, recognizing the hazards of it, that practice was banned completely in Britain in the 1940s. And in many other countries around the world, they don't even allow that. But it's still allowed here in the U.S., and you can see people doing sandblasting, driving down the highway or seeing people sandblasting buildings if you're out and about in most parts of the country. So that's still an ongoing hazard.

The main problem now with what's called accelerated silicosis is that people are being heavily exposed and not recognizing that they're getting silicosis. The disease is developing in their lungs with scarring and inflammation, but not recognized by the clinicians as silicosis until it's further advanced. So there's a problem in reaching that diagnosis by clinical means, such as chest X-rays, for example. They often don't show it, even though the person may have pretty significant disease. You asked also about PMF. That's an abbreviation that stands for progressive massive fibrosis. So, just as it sounds, it means large areas of scarring in the lung. They show up as big opacifications, or whitish areas, on your chest X-ray. And those areas can be confused, for example, with lung cancers. So it requires the clinician getting the history of exposure and making sure they understand what the person has been going through, leading up to that point, to make that diagnosis.

Host Amber Smith: So there's an increase in this type of silicosis, this more aggressive type, because of the sandblasting, is that right?

Jerrold Abraham, MD: Maybe Dr. Crawford, you'd want to reply to that one?

Judith Crawford, PhD: Well, I would say not necessarily. I think the increase in accelerated silicosis right now, across the world, is due to the artificial stone, silica-containing countertops. So that's really where that's coming from. And also, in coal mining, in more recent times, that's increased more because it's harder and harder to mine coal. There's less of it easy to get at. And so, coal mining involves the actually chewing up a lot of the earth to get to the coal they want, or in other mining as well to get to whatever the mineral element that they're looking for. And so that means for the worker there's a greater exposure.

So I think that those are kind of two of the factors. We've got the equipment to chew through the earth, and the quartz countertops have a high concentration of silica. They're up to, like, 90% silica, so they're a very, very concentrated source.

Host Amber Smith: So let's talk more about that type of silicosis, that's among the workers who manufacture the artificial stone and engineered stone. How did this risk come to light?

Judith Crawford, PhD: It really came to light with a lot of ill workers. That's how that came to light. And that's, unfortunately, the sad history of a lot of occupational disease. It's really not recognized until there's lots of sick, or dead, bodies involved. So that's how that's come to be known.

Host Amber Smith: And that's a risk for the people who are making these countertops. It's not a risk once they're installed in a home, is that right?

Judith Crawford, PhD: Correct. Once it's installed in the home, you're not going to easily be able to get any silica off that. It's really completely contained within the countertop. But the fabricating it, the cutting it and drilling it and sanding it and polishing it, that produces a tremendous amount of, almost, as I said, 90% silica dust. So it's very, very hazardous.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break. Please stay tuned for more about silicosis.

Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith, speaking with Dr. Jerry Abraham and Dr. Judith Crawford from Upstate about silicosis.

So, Dr. Abraham, can you tell us about the work you're doing here in Syracuse that's tied to California?

Jerrold Abraham, MD: Yes, as Dr. Crawford was just mentioning, the recognition of this terrible disease has come from places around the world where there's been this manufacture of these beautiful countertops that many people love to have in their kitchens, without knowing that the workers producing them have been exposed to unacceptable risk.

And in California alone, there's probably close to 100 patients who have been recognized as having severe disease. Some of them fatal, some of them so severe that the patients need lung transplants to survive. And these are young, young men, often immigrants working legally, in small shops where their conditions are just horrendously dusty. And some have developed this disease after five or 10 years. Some, I think, as little as three or four years, where they become so short of breath, and they go to the doctor, and the doctor who's examined them has said, "You have severe disease, and you need a lung transplant if you're going to survive." So it is that kind of severity.

And many of the people that need lung transplants can't get them because lung transplants are not readily available, and the whole procedure costs millions of dollars, probably, on the average, for a lung transplant with a long-term follow-up and maintenance clinically. So it's just tragic that this is happening with a disease that should be totally prevented.

How we got involved was that, as a pathologist who's been interested in silicosis and other occupational diseases for years, many years ago, actually starting in 1980, I began seeing sandblasters with silicosis from another epidemic that was in Texas, which is the subject of that paper that we recently published.

But because of that experience and expertise, I've also been asked to look at the lungs -- some from patients who have had lung transplant surgery in California, and some who have unfortunately died, and at autopsy I've been asked to look at their lungs to confirm the type of disease and the severity, and assist the families, basically, with filing claims for compensation. So my involvement has been through the claims of these families, and we're also conducting research on the type of silica and the amount of silica and other dusts in their lungs.

But we know, from all the experience we've had and others have had, that the silica is the main cause and could have been prevented if the exposure had not taken place.

I should mention that we haven't used the word quartz much, but silica and quartz are often used interchangeably. So quartz is one of the common types of silica. So people are more familiar with quartz. Some of those countertops are called quartz countertops. Other countertops that are not this artificial or engineered stone are granite, and those can also contain a high content of silica, but not in the 90% range that Dr. Crawford mentioned that occurs in these artificial stone materials.

Host Amber Smith: So we talked about the people in California, but this is a problem beyond the workers in California, is that right?

Jerrold Abraham, MD: Yeah, most definitely. It's a global problem. There's a huge epidemic in Australia that's been widely publicized to the point where Australia has taken the regulatory step to try to ban the use of these artificial stone products altogether. That has yet to happen in the U.S. But other countries that are able to do more rapid reaction to public health problems have looked into that. And there have been cases in many parts of Europe and China and Israel, and other parts of the U.S., not just California.

Host Amber Smith: Is the industry looking at newer ways to manufacture countertops that don't put workers at such risk for silicosis, and other diseases?

Judith Crawford, PhD: I think that's happening. What I've heard is that the attempt is to try to reduce the quantity of silica in the countertop, and so that it's not going to be as hazardous. And I don't know where that actually stands, but it seems like a very good idea so that it could be used without being so hazardous.

Host Amber Smith: You're listening to Upstate's "HealthLink on Air" with your host Amber Smith. I'm talking about a lung disease called silicosis with Dr. Jerry Abraham, who's a professor of pathology and director of Upstate's environmental and occupational pathology, and Dr. Judith Crawford, who's a certified industrial hygienist and research associate at Upstate.

OK. Back to the original people who got silicosis, the coal miners, are they still being exposed on the job? Dr. Abraham?

Jerrold Abraham, MD: I'm not directly involved in the regulations and enforcement, but I know disease in coal miners has increased, and a lot of it has been reportedly related to lax enforcement of respiratory protection and ventilation. As the industry shrinks, it's maybe cutting corners. There's a lot of expertise on that that I don't have. But certainly it's possible to protect coal miners. There are standards for exposures in coal mines, to coal dust and to general dust, as well as to silica. And it's obvious, one of the conclusions that come out of studies that are going on of coal miners' lungs is that they're getting silicosis. So obviously the protection has been inadequate.

Whether it can be perfect is unlikely, but it certainly can be better, because what the studies with the National Institute for Occupational Safety and Health, or NIOSH, have shown is that the severity of disease in coal miners dipped chronologically as regulations were put into place after the 1970s. And then in the last decade or two, there's been an increase in severity of disease in coal miners. Again, some for the reasons that Dr. Crawford mentioned with changing mining technology and more rock exposure as they mine thinner seams of coal. So instead of 90% coal and 10% rock, they might be mining 10% coal and 90% rock because they're able to separate the coal, which is what they want. And the miners have consequently had greater exposures.

Host Amber Smith: Well, let me ask you, the lung tissue of the sandblasters from Texas, from the 1980s and 1990s, does that look like the lung tissue from the people in California that have developed this, working on artificial stone?

Jerrold Abraham, MD: There's a lot of overlap. Some look a little bit different because the sandblasters exposure was a little bit different than some of the countertop workers. But in the end, some of the sandblasters have died from severe silicosis, and some of the countertop workers have died or needed transplants from the severe silicosis, and that at that point the pathology -- what a pathologist would see when they examine the lungs after surgery or autopsy -- and in the microscope would often be indistinguishable. They would look like severe, fatal, unsurvivable silicosis.

One of the things, though, that's important is that the pathology examination has been able to show that there's an earlier stage where it can be diagnosed by the pathologist before it shows up on the chest X-ray as the little round nodules classical for silicosis. And it's hoped that from the studies that we did from the people years ago with the sandblasting and what we're doing now with the people working on artificial stone, that it'll enhance awareness among physicians to look harder for this disease, where, as I mentioned, it can't be seen when it's so early, sometimes, on a chest X-ray, but can be seen with different methods such as a high-resolution CT (computerized tomography) scan, for example. That can show the disease even when the chest X-ray may not show it yet.

So that's a way, if it's identified earlier, at least those people can be removed from the workplace before they have further exposure. But it won't be reversible, at present.

Host Amber Smith: Well, it sounds like a health crisis in real time. So, what is your message to physicians and public health providers?

Jerrold Abraham, MD: Well, the main thing is for the clinicians to spend the time needed to get a good occupational history: What does your patient do? What have they done? They might have done something for 10 years and now have a desk job. So you have to go back and get a full occupational history. And as physicians get busier and busier and use more electronic methods, that history is less and less often adequately taken. So that's a lesson to patients to tell their physicians what they've been exposed to or what their family members have been exposed to, and to the physicians to keep in mind that the person with pretty much any disease, but especially lung diseases, may have an environmental or occupational contributing cause.

Host Amber Smith: And Dr. Crawford, what is important for the workers? Someone who has a job that might expose them to silica or quartz, what do they need to know?

Judith Crawford, PhD: If someone's exposed on their job, to silica, as I said before, they need to know that it's the employer's responsibility to protect them, and they should be seeing things in their workplace, they should have heard about this. They should be seeing things like control measures for the silica, respiratory protection, written control plans, people testing the air, medical exams, things like that may be appropriate. And if they're absent, they need to be asking about that and saying, "Am I at risk?"

And if the employer doesn't do that, then they should be calling OSHA, osha.gov. Call them. Talk to them about it. They can help.

Host Amber Smith: Will most of these workers need to be wearing masks to be safe?

Judith Crawford, PhD: Not necessarily. Not necessarily. Depends on, again, these other controls that we have, the local controls on power equipment. And depending on how well those work, they may not need respiratory protection at all. Or if there's a short length of time that they use this equipment, again, with controls, then they may not need respiratory equipment. But some of the jobs, for example, sandblasters, they really always need respiratory protection.

Host Amber Smith: Isn't sandblasting done outdoors, though?

Judith Crawford, PhD: It can be definitely outdoors, but they can still be exposed. They can still be overexposed. So yes. Other sandblasting can be done in an enclosed cabinet, indoors too. But even outdoors, they require respiratory protection.

Host Amber Smith: Well, that's really good to know.

I thank you both for making time for this interview.

Judith Crawford, PhD: Thanks for having us.

Jerrold Abraham, MD: Thank you for having us.

Host Amber Smith: My guests have been Dr. Jerry Abraham, he's a professor of pathology and director of Upstate's environmental and occupational pathology, and Dr. Judith Crawford, a certified industrial hygienist and research associate at Upstate.

I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," some patients benefit from a device that monitors stroke risk.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Implantable loop recorders are sometimes used in medicine for patients who are having palpitations or are fainting, or whose hearts sometimes beat in unusual ways. They can also be useful in detecting heart rhythms that may cause strokes. That's what we'll be focusing on today with my guest, Stephanie Loveless. She's a nurse practitioner at Upstate working in neurology.

Welcome to "HealthLink on Air," Ms. Loveless.

Stephanie Loveless, NP: Thank you for having me, Amber.

Host Amber Smith: You care mostly for patients with neurological issues, including stroke. We think of strokes as a neurological disease, but how might the heart be involved in some types of stroke?

Stephanie Loveless, NP: That's actually a great question. If we think back to our anatomy lessons in high school, growing up, the heart is directly connected to the brain by providing it its blood supply. There are essentially four vessels that go from the heart up into the brain to supply the blood. So if there is an irregular heartbeat causing clots to form within the heart, they can then travel up those pipes, causing stroke in the brain.

Host Amber Smith: Now what about, I've heard of atrial fibrillation being a risk factor for stroke. Is that what that is?

Stephanie Loveless, NP: Yes. Atrial fibrillation is an irregular heartbeat that 95% of the population can be in and out of without even knowing that we are in and out of that rhythm. So it's a very reckless, reclusive type of a rhythm that we need to be aware of.

For every decade of life we age, we have an increased risk of about 10% of getting or running into atrial fibrillation and / or being symptomatic with that rhythm. The strokes that we find from a rhythm in atrial fibrillation tend to be the ones that leave our patients with the biggest deficits.

Host Amber Smith: You used the term "reclusive." Can you explain what you mean by that?

Stephanie Loveless, NP: Reclusive meaning sinister or very hard to pin down, inconsistent. Just because we know that the patient may have had this irregular heartbeat, it may not be back within the next day or two. The heart is very automatistic. Each cell has the ability to kind of take over the rhythm, and some of them do a better job than others.

Host Amber Smith: So if a person has atrial fibrillation, do they need an implantable loop recorder?

Stephanie Loveless, NP: A lot of our patients that come in with stroke present with symptoms that would have us look into the etiology, or reason for which they've had that stroke. One of those etiologies, or reasons, for having a stroke could be atrial fibrillation. They could still be in the atrial fibrillation on arrival, or they could not be. So it's a process by which we follow protocols to do a series of testing to determine whether or notadditional workup should be done for that patient depending upon the findings of those tests.

Host Amber Smith: So let's talk about who would qualify for an implantable loop recorder. Are there age restrictions or other diseases the person might have that would prevent them from getting one?

Stephanie Loveless, NP: There's not any age restrictions and / or disease that would prevent them from getting an implantable loop recorder. It depends on, again, the location of the stroke, whether it's in a cortical or top of the brain area coming off of a major artery, the left middle cerebral artery or the right middle cerebral artery, for example.

They will benefit patients long term for monitoring for this rhythm. So yes, we've had implantable loop recorders placed in 40-year-old patients up until 85 years young. It kind of depends on the patient, how many other medical issues they have. We are living longer in society, so it's all specific and case-by-case dependent.

Host Amber Smith: How do you describe implantable loop recorders to patients when they're considering one?

Stephanie Loveless, NP: A lot of times, my colleague and I both have the opportunity to sit down and show them a pamphlet that we've got from the device company that we use.We also have the demo of the device itself, showing them the size of it, the weight of it, and how teeny tiny it is. So they're kind of put at ease as far as it's a teeny, tiny device. It's gotten smaller as years gone by. The first device, I did a little research, and it was, I think back in 1990 it said, was the first implantable loop recorder, but it was much bigger. So as technology has changed and come along, they've gotten a lot smaller.

But we have a talk about the benefit of wearing it, the duration of wearing it. And it's really a bedside procedure, that if you're inpatient and carry the diagnosis of cryptogenic stroke -- which that etiology really means we don't know why you had the stroke -- then you are benefited to have this implanted prior to discharge from the hospital.

Host Amber Smith: Where does it get implanted?

Stephanie Loveless, NP: The anatomical position of where the device is implanted, if you're looking at yourself in the mirror and you know where your clavicle is on your chest, we count down four spaces in between the ribs on the left side of your sternum, which is the bone in the middle of your chest, and then we numb that area with lidocaine.

Once we numb that area with lidocaine, we wait a minute or two and then when thatlittle incision device we use just shows that the skin is firm and like a little pressure but not pain, then we make an incision and place the device underneath the skin.

Host Amber Smith: Are there any wires or cords that come out of the device?

Stephanie Loveless, NP: Luckily not. It's beautiful what technology can do these days. It's a wireless device. It sits right underneath the skin and communicates between either an app that the reps can put on the phone to show their rhythm over time, or a device that the patient takes home and puts within 10 feet of where they sleep at night. So if somebody has to sleep in a recliner chair in their living room for one reason or another, that device can sit on a table right by the chair or in their bedside.

The device that's implanted underneath the skin kind of communicates independently on its own with the device, either on your phone or at the bedside. During the overnight hours when you're sleeping -- so it's nothing you'll be responsible for -- it communicates and then transmits to the cardiologist who is actually monitoring that device remotely.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with nurse practitioner Stephanie Loveless, who specializes in neurology at Upstate, and we're talking about implantable loop recorders.

So once it's in place, can the patient feel it with their fingers below the skin, or can they hear it?

Stephanie Loveless, NP: They can certainly feel it. Yes. It will be noticeable underneath the skin, but not by any way impeding or limiting their activities of daily living or life. Patients ask if they can fly. Yes, you can. They ask if they can swim. Yes, they can. My biggest take home is you can always have an MRI. Don't be told that you can't. A lot of patients will go to the emergency room, and some emergency rooms will say, "Well, we couldn't do an MRI, which is a scan of the brain, because the patient has an implantable loop recorder." That's not true. So that's one important take-home we like to get across for patient education.

Host Amber Smith: Are there batteries in it that would need to be changed in the future?

Stephanie Loveless, NP: No. The lifetime of the battery that's in the device is up to three and a half to four years. So once it's implanted under the skin, as that implantation process is completed, the rep is with us at the bedside, so it's showing and ensuring that we have the proper signal that will show the proper picture to the cardiologist for the three and a half to four years of the device's battery life.

Now, when the battery life is dead at that three and a half to four year mark, the patient can have a conversation with the cardiologist to make a determination whether they would want that removed or not.

Host Amber Smith: So they may, it may be time to take it out, maybe they don't need it anymore, or maybe they need a replacement?

Stephanie Loveless, NP: The research that I'm aware of so far, we aren't replacing them after the timeframe of the battery life. That's not to say that with all the research being done on a daily basis out in the world, that that may not change tomorrow or down the road.

They can be what they call explanted or removed by the providers that place them, but they don't have to be. They can be with you for the duration. They won't interfere with the rest of things of life.

Host Amber Smith: Now, you mentioned a rep. Is that a representative from the company that makes the device? So they're there helping on the insertion?

Stephanie Loveless, NP: They'll bring the device to bedside, and they will talk to the patient and / or family member after the procedure's completed, showing them whether they help them upload the app on the phone, or it's the device that goes home with them.

They will talk to them about where to put it up in the house once they're there. They will tell them just the little idiosyncrasies that come and go with a new device. But there's a supportive 800 number that they provide to patients. They reach out. They're just as involved as we are from the word "go," which is nice.

Host Amber Smith: Now, are there any risks that patients should be aware of? I know you said it doesn't curtail their activities, but are there any precautions that they need? Can they go near a microwave, for instance?

Stephanie Loveless, NP: We have been told there are really no restrictions from the ins and outs of daily life, which is nice. So I would say there are no restrictions. Now, if somebody comes across one, you let me know, and then we'll share that.

Host Amber Smith: Now, do I understand correctly, it's cardiologists, the doctors who specialize in the heart, who were the first to implant loop recorders, right?

Stephanie Loveless, NP: That is correct. Cardiology is a phenomenal bunch of providers that work very closely with us. We've had the privilege here at Upstate to work with Dr. Avneet Singh and Dr. Andrew Weinberg. In moving this process to what it is today, Dr. Weinberg assisted credentialing myself, Taylor Weber, the other nurse practitioner, along with Dr. Hesham Masoud and Dr. Aravind Reddy.

So the four of us are neurological stroke providers that do have that ability to cross the boundary into cardiology, within reason, to assist giving our patients all that they need to have the best opportunity of not having another stroke from a central source.

Host Amber Smith: Is it common for nurse practitioners to do these procedures?

Stephanie Loveless, NP: I think as a whole, there are some advanced practice providers within the cardiology world that are doing the devices. And we've just been able to expand it out of that discipline to include neurology. So it's a procedure that's beneficial to our patients that in years past we've had trouble getting in a timely matter that didn't delay discharge or hold up a patient. So giving more resources to us to be able to provide that care to the patient gives them the best possible outcomes moving forward, going out into the community. There is an external monitor that patients can wear, but it's not as sophisticated. It's not as sensitive. It's not as forthcoming for providing what we're looking for over the long term.

Host Amber Smith: How do you tell patients to prepare for the procedure? Is there any blood work ahead of time, or any other testing they have to do, or?

Stephanie Loveless, NP: Nope. Nope. A lot of times we have a patient, I actually placed one yesterday. It was a matter of going in and explaining the procedure to the patient, essentially walking them through step by step what we would be doing. They signed consent, so permission for us to make that little incision and then put the device underneath the skin. Sometimes it requires a suture or two thereafter, and then some glue to keep the skin.

And then we'll come in with the heart and vascular team, is very helpful. Ashley Hunter is one of the main nurses down there that comes to bedside with us with every procedure and helps us do what we do best. So it's definitely a multidisciplinary and team dedicated process.

Host Amber Smith: Does it start working right away?

Stephanie Loveless, NP: It starts working right away. As I understand it, for example, if you have the implant done and then they go home and then you connect the device then the communications begin.

So that device will be letting the office know the next day if there's any alerts, if there's any arrhythmias. And then they would contact the patient and / or myself or somebody within the neurology team that took care of that patient to ensure their medical management changes.

Host Amber Smith: So if the machine does detect an arrhythmia, or a problematic heart rhythm, will the patient know that? Is there an alarm that they hear?

Stephanie Loveless, NP: Not that I was told. It's a great question. Maybe in the upcoming models there will be. But they do get, typically, a phone call from, like I said, the device team's area. They will let them know that there was atrial fibrillation detected. And then cardiology or ourselves would then change the medical management, typically off of the antiplatelet agents that they were discharged home on to an anticoagulant.

Host Amber Smith: So how much of an emergency might that be? If the patient has alerted that there's been an arrhythmia detected, is that something that has to be dealt with immediately, or do they make an appointment to come in, like, the next day?

Stephanie Loveless, NP: Thankfully, atrial fibrillation could be a rhythm that could cause patients symptoms, including, but not limited to, acutely being short of breath and inability to catch their breath, a rapid heart rate that's irregular. But it's not one of those medical 911 emergencies where you're running to the emergency department, per se, unless you, with that abnormal breathing, you really had a tough time. But traditionally it's not anything more than a phone call and a change in medications that then work on the blood to keep it thin to prevent another clot from forming and then traveling to the brain, causing another stroke.

Host Amber Smith: What has been the feedback from your patients who've had these implanted so far?

Stephanie Loveless, NP: So far, so good. You know, we've been very fortunate to work collaboratively with Dr. Weinberg and Justin Kurtz, who's his nurse practitioner out in the community, who sees our patients for the two-week wound check. So they look at the insertion site and make sure everything is healing nicely. And so far, so good. We haven't had any poor responses, so it's just, it gives us another level of security that we're doing what's best for the patients, given they're unfortunate at having a stroke, but hopefully that first stroke was something that they'll recover nicely from and not be living with a deficit and thereby moving forward, preventing them from an additional deficit from this persnickety rhythm that we may have.

Host Amber Smith: That's really encouraging and good to know that there's a way, potentially, to prevent a future stroke. So I really appreciate you making time to tell us about this.

Stephanie Loveless, NP: Thank you for your time, and thank you for letting me educate the community because that's very important.

Host Amber Smith: My guest has been Upstate nurse practitioner Stephanie Loveless. She specializes in caring for neurology patients at Upstate.

I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from pediatrician Dr. Jenica O'Malley from Upstate Medical University. What are some positives about the so-called "terrible twos"?

Jenica O'Malley, DO: There's lots of them. So, I think a lot of what gets labeled as the terrible twos is really a lot of that cognitive and problem-solving development that you see. So they're starting to figure out the ways that they can sort of manipulate the world around them. And I don't mean, like, manipulate the way I behave, but just the way that they know their action causes a reaction., And they're really starting to come to terms with that.

At the same time, you start to see that their language is emerging, but it's not fully there. So there's a lot of big feelings they're starting to develop. So they're starting to show this wide range of frustration and anger and sadness and silliness and loveliness and all of these different things, but they don't always have the language to kind of say, "I feel really angry right now," or "I feel really sad." So it comes out the only ways that they know how, which is outbursts or tantrums that we call those things. And those things are not necessarily problem behaviors. They're just the ways that children are kind of trying to figure out how to cope with what's going on around them.

And you see just, that is such an age of social development. So, learning how to play together. So up until really around 2 years of age, you see kids playing together, but they don't do a lot of interacting together. They do a lot of playing side by side. They do a lot of taking this toy from someone because they want to use it. They don't do so much of that back and forth of "I'm pretending to be grandma, and you're the child." After the age of 2 and going into 3 and 4, they have this huge bloom in their imaginative skills. And that's a developmental milestone really, is starting to have that really strong, imaginative play, where they can just carry on a whole scenario without, really, any toys and go back and forth with other kids. I think that's one of the most wonderful things about that "terrible" time of their toddlerhood.

Host Amber Smith: You've been listening to pediatrician Jenica O'Malley 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: Gaetan Sgro describes himself as an internal medicine doctor, girl dad and assistant professor of medicine at the University of Pittsburgh School of Medicine. His poem "Things I've Dreamed" explores things seen and unseen.

When I was twenty-one and dressed as a patient

My temple prepped and poised

To reveal that mass of milky Jell-O

That conjuress both heaven and hell

The howling craniotome and stench

Of sizzling collagen curdled my sleep.

Besides a few jags of bone that click and catch

On humid days it's hard to say how I've changed.

I've always passed my idle time

Imagining catastrophes, but who isn't

Always bracing? Whenever I drive on highways

I understand the world as a windscreen

Myself a juicy insect hurtling. One spring

I spent a day in lush Savannah

And afterwards itched for weeks even though

My skin was clear and I'd never had allergies.

One-third of patients with Hodgkin's disease experience

Itching. I'm an internist. Of course I was worried.

Everyone knows where there's smoke there's fire

But at that point isn't it always too late?

In my sixth summer ...

I dreamt, looking back over my father's shoulder

At our living room in flames.

In my seventh summer ...

I awoke, looking back over my father's shoulder

At our living room in flames.

I've spent my whole life dissecting that sequence

Trying not to believe in things I've dreamed.

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," how patients benefit when primary care integrates with behavioral health.

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.