Treating adult ADHD; bird flu update; avoiding heat illness: Upstate Medical University’s HealthLink on Air for Sunday, Aug. 18, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a nurse practitioner tells about Upstate's new program for adults with attention-deficit/hyperactivity disorder.

John Ringhisen, NP: ... It usually starts to manifest where people start really struggling professionally. That's where they usually see it first. They have difficulty at work completing tasks, or they have difficulty in the home. ...

Host Amber Smith: The director of the Global Health Institute discusses how concerned we should be about bird flu.

Stephen Thomas, MD: ... All sorts of birds can get infected with these viruses, and they can kill the birds. In July, the CDC had reported that over 9,500 different birds across the country had been infected. And it's everything from robins and sparrows and bald eagles and owls and crows. ...

Host Amber Smith: And an exercise physiologist shares some precautions about heat illness.

All that, and a visit from The Healing Muse, right after the news.

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

On this week's show, we'll learn what's important to know about bird flu. Then we'll hear some heat illness precautions. But first, a new program at Upstate is tailored to adults with ADHD.

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

Some people with ADHD are not diagnosed until adulthood, when they struggle with impulsiveness or restlessness or difficulty paying attention. Upstate now offers a program specifically for adults with ADHD. And today I am talking with the person who oversees that program, John Ringhisen. He's a nurse practitioner of psychiatry and behavioral sciences, and a member of the Pharmaceutical Subcommittee of the U.S. Guidelines Task Force for Adult ADHD through the American Professional Society of ADHD and Related Disorders.

Welcome back to "HealthLink on Air," Mr. Ringhisen.

John Ringhisen, NP: I appreciate the invitation. It's good to see you again, Amber.

Host Amber Smith: Let's start with a description of ADHD. Is this a mental health disorder or a physical disorder?

John Ringhisen, NP: It's a mental health disorder. Attention-deficit/hyperactivity disorder is a cluster of persistent behaviors that make completing tests difficult and generally fall into two broad categories.

You have either trouble remaining focused, or you have trouble remaining still.

Host Amber Smith: So how does it manifest in adults, compared with kids?

John Ringhisen, NP: In adults, it usually starts to manifest where people start really struggling professionally. That's where they usually see it first. They have difficulty at work completing tasks, or they have difficulty in the home, if the home is the profession, with staying on top of appointments or staying on time on a task in the home, to where simple tasks like laundry or cleaning dishes or taking care of children starts to pile up on people and starts to feel very overwhelming to people. The amount of time to get tasks done seems much longer than what it should be.

And that often starts impacting how they see themselves or how they see their performance.

Host Amber Smith: Do most adults who have ADHD, do they develop this as adults, or is this something that they probably had, and it went undiagnosed throughout childhood?

John Ringhisen, NP: There's a lot of research out there that's really trying to come to a succinct answer on that because the answer's probably somewhere in the middle. It's both. There are some individuals that possibly do start to exhibit symptoms later in life. And there are individuals that, because of either lack of resources or lack of being engaged with a mental health provider when they were younger, typically through the school system, they weren't picked up as ADHD when they were going to school, or maybe they left school early and for whatever reasons that they had to, and so they never been engaged with anybody in a capacity to be able to determine whether they have ADHD.

Host Amber Smith: What's the oldest age person that you've seen diagnosed with ADHD?

John Ringhisen, NP: The oldest in our clinic that came in diagnosis-free (had never been diagnosed) was a gentleman that was 57 years old, and we do have individuals that have been previously diagnosed, either in childhood or even in middle adulthood, that are continuing in our clinic, that are well into their 60s and retirement age.

Host Amber Smith: How likely is it if an adult who feels like they have trouble focusing actually has ADHD? Because it seems like maybe there's some symptoms that could be ADHD, but maybe they're not.

John Ringhisen, NP: Yeah, that's what makes an ADHD diagnosis very tricky. Things like depression, anxiety and other things that we struggle with in daily life. Trauma and some people's personalities can start to look like ADHD. For example, with anxiety, you just have to really dig into why you're so distracted, or what's the root cause of what pulls you away from being able to focus on things.

Because if it's your anxiety getting the better of you because you have intrusive thoughts, possibly from trauma, or you're persistently worried about things that are overwhelming you in your daily life, the distraction is more a step to, or result of, being very anxious. And it presents like ADHD, but it's not truly related to being an ADHD diagnosis, and similar things can happen with depression as well.

Host Amber Smith: So let's talk about how an adult typically gets diagnosed, and the program that you oversee, do people come there already diagnosed, or do they come to you to potentially be diagnosed?

John Ringhisen, NP: Both. And we go through an extensive screening process, where there's a survey item, where it's a self-assessment. So that means that it's a document that we give the patient in the waiting room, and they fill it out, assessing themselves on a lot of the symptoms and some of the behaviors and some other questions that we ask that give us a sense of whether ADHD might be something that we would suspect in the individual.

We also encourage people to consider bringing a support person because a lot of times with adults, being able to assess themselves is difficult. And so having a spouse, a friend, a loved one who knows you well and that you would trust having present at your appointment is helpful in getting some of the collaborative, meaning the people around you's, opinions of kind of how you're presenting.

A real good example of this is one of the questions it asks is, "Do you often interrupt people, or do you often find yourself shifting topics quickly during conversation?"

If you do that as part of your natural conversation style, you might rate yourself very high. Or there's some people that underscore themselves, and then their wife kind of nudges them and says, "You interrupt me all the time."

And so it becomes, a bit of a laughing point and breaks the tension in the initial interview. But what we're trying to get at is what's happening around the individual, how is your environment reacting to your possibly having a true ADHD diagnosis. And how your environment reacts to you is very important in being able to accurately diagnose ADHD.

Host Amber Smith: So it sounds like it is challenging, or could be challenging, to diagnose this. There's not a blood test, there's not some medical test that would tell you whether someone has this or not.

John Ringhisen, NP: Correct. And there is what's called neuropsychological testing that a lot of people put a lot of faith in when it comes to "Can I go someplace and do a one-stop test that will tell me whether I have ADHD or not?"

And it's dubious because what neuropsychological testing really tells us is how severe are your symptoms, and do you have symptoms, and how much are your symptoms impacting your ability to function in your daily life?

It doesn't really get into causality, as to what's making those things happen and why you're struggling so much, and that's why it's very important to have conversation with a mental health professional and sit down and interpret those test results to see if an ADHD diagnosis is appropriate.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with John Ringhisen, a nurse practitioner of psychiatry and behavioral sciences at Upstate who oversees the new adult ADHD clinic.

What does treatment for adults generally consist of?

John Ringhisen, NP: In our clinic, treatment for adults consists of a multifaceted approach.

We encourage psychotherapy, which is talking to somebody in talk therapy, working through skills and coping strategies that will increase their ability to function. We offer supportive measures at school or work, if accommodations are appropriate, particularly in academic settings. We have a lot of adult learners that come to us where they want extra time on tests, or they want a different testing environment, so we can write supportive letters to provide those kind of accommodations.

We provide medication for ADHD through our clinic. We are a full prescribing and medication management clinic. And then, we're getting into and exploring coaching. You can kind of think of these as, when we talk about substance use, we talk about peer advocates, people that have kind of "been there, done that" and that have struggled with addiction before.

We're finding individuals in the community that are becoming coaches, where they struggle with ADHD themselves. And having somebody who has experienced and overcome the struggles associated with ADHD can sometimes be helpful and supportive to somebody, particularly an adult.

Host Amber Smith: Your program focuses on a nonstimulant-first approach?

John Ringhisen, NP: Correct.

Host Amber Smith: Can you describe what that is and why it's important?

John Ringhisen, NP: What we mean by a nonstimulant-forward approach is the medications that we prescribe for ADHD are kind of broadly broken into two categories. There's the stimulants, which is what everybody's probably more accustomed to associating with ADHD medication. That's Adderall, that's Ritalin, Vyvanse, Concerta. And then there's the nonstimulant medications, clonidine, guanfacine, Qelbree (viloxazine), atomoxetine.

The reason that we focus on the nonstimulant medications is because stimulant medications are controlled substances, meaning that there's a lot of rules and regulations from the Department of Drug Enforcement and federal regulation that govern how much we can give a person at a time.

We can only provide 30 days at a time. And the reason that these medications have extra restrictions around them is because they have been associated with misuse, building up tolerance and dependence. And so they have to be very closely monitored from a health standpoint and from an addiction standpoint.

So the reason that we use a nonstimulant-first approach in my practice is to try to reduce the reliance on stimulants in the population. There's also been, and it made national news, that there was a nationwide shortage of stimulant medication, which has also kind of prompted us to try to use more nonstimulants in our patients.

And there's also good evidence where if you are a significant responder, meaning that your symptoms get better on a nonstimulant medication, you can have as good of an outcome as you will with a stimulant. Now it does take a little bit longer for the medication to take hold; it takes a few weeks, versus days with a stimulant.

But the convenience of not having to worry about constantly finding a provider, the health implications of not being on a long-term stimulant, for your heart, for your overall health, is much better. And so it's what we offer first, and particularly patients who have never been on medication before, specifically for ADHD, we put that forward as the "try this first" option.

And then, of course, if they're not a good candidate for the medication, or if they just prefer to be on a stimulant, of course the patient's decision is going to be what ultimately decides the treatment that we prescribe, but we try to offer the nonstimulant as the first trial of medication for patients who have never been on medication before.

Host Amber Smith: Can you explain how a stimulant would help someone who's already hyperactive?

John Ringhisen, NP: It's actually the nonstimulants that work very well for people that are hyperactive. So if moving around and holding still is where you're really struggling, stimulants oftentimes can make that worse if it's truly a hyperactive presentation of ADHD.

Now, if the reason that you're moving around a lot is because you're easily distracted, you're getting up, and you're moving around because your focus is off, then that symptom will actually improve with the stimulants.

Host Amber Smith: So this, it sounds like, is a very individualized treatment plan for each person.

John Ringhisen, NP: Correct.

We take into consideration, as nurse practitioners, a holistic approach to care. And so we take into consideration what's their work schedule, what's their outside of work schedule, what's their personal schedule, when do they need to be performing at their peak performance, or their optimum levels, so that, that way we can time when the medication is at its best. Some people need to be early risers, very effective in the morning. Other people need it later at night. We try to time that and try to individualize and customize care as best we can.

Host Amber Smith: Are there coexisting conditions that you see typically in people with ADHD?

And how would you handle other conditions that this person might have?

John Ringhisen, NP: The other conditions that a lot of people have when they present with true ADHD is there's usually depression and anxiety alongside. You have to think that these are people that have constantly been measured by how they are not performing how we expect them to in society.

And there's a lot of judgment that enters into that, so you can see where somebody can very quickly become depressed and feel like they're not adequate or doing well, or what they should be doing, or as well as they should be doing, because they're struggling with ADHD. This can also cause people to suddenly feel very overwhelmed or anxious about doing what they need to do to care for the people around them or care for themselves.

And a lot of times we see people that have unfortunately tried to self-medicate using street stimulants, methamphetamine, cocaine, and so substance-use disorder is also very common with people with ADHD, but we don't see that as often anymore.

Host Amber Smith: If the ADHD symptoms improve, do you see the depression and anxiety improve, as well?

John Ringhisen, NP: Typically, it's more linked to how well their performance improves and whether the environment around them has a positive response to their ADHD symptoms getting better. So we do work comprehensively with the patient. We work with them on their mood. We prescribe antidepressants. We prescribe medication for anxiety alongside their ADHD medication if necessary. And we need to provide that support.

Host Amber Smith: I'd like to ask you about the risk factors for ADHD. Is there anything that people can do to reduce their risk of developing ADHD?

John Ringhisen, NP: It comes down to some of the theories of why do people get ADHD. We are finding that there is an increased incidence of ADHD, and we think it is coming from how we train our brains on a daily basis and how we interact with a lot of the technology out there.

Flipping through the average length of a YouTube video when YouTube first came out was something like 15, 20 minutes. You're lucky to see a three- to five-minute YouTube video nowadays. That's kind of the average length of time. So training your brain to constantly flip through shorts, TikToks, Reels on Instagram, or the way that you digest your news if you never dive into and read through an article and really spend time focusing on a topic, you can start to train your brain to kind of behave like it has ADHD, even though you may not truly have ADHD.

Host Amber Smith: That's pretty frightening. But that's research that hasn't been proven yet?

John Ringhisen, NP: It's ongoing. We've got some preliminary studies that show particularly children and adolescents. We're trying to repeat a lot of these studies with adults to see if they behave in similar fashion, and the early results say that adults are similar to kids. If you train your brain to have a short attention span by constantly scrolling through things, you're going to start looking like you have ADHD because you've trained your brain to pay less and less time, and less and less depth of focus, on an individual task or an individual item.

Host Amber Smith: Well, before we wrap up, can you tell us about your role on the Pharmaceutical Subcommittee of the U.S. Guidelines Task Force for Adult ADHD?

John Ringhisen, NP: My role there is, we are putting together guidelines to try to help practitioners have kind of a playbook of how to diagnose, how to treat and how to prescribe and, and my specific role is on the prescribing subcommittee. So, medication and what things to look for and talk about and consider before, during and even after the symptoms of ADHD are present and diagnosis is what we're trying to provide.

People like me and other mental health and, especially, primary care, providers, because a lot of the primary care providers out there are the ones that see this first, and then it, lands in my schedule. So we're trying to give them some ideas, some thoughts and a little bit of a playbook on guiding their decisions in how they approach ADHD

Host Amber Smith: What is the best way, if someone's listening to this interview and they think, "I need to visit the adult ADHD clinic." Is there a way to do that, or do they need a referral through a primary care provider?

John Ringhisen, NP: No, it doesn't require any kind of referral. All you need to do is you need to call the office at 315-464-2689, or if that line is occupied, you can call 315-464-3265. Just specifically request an intake appointment with the ADHD clinic for adults, and we'll be happy to get you in our schedule.

Host Amber Smith: Well, Mr. Ringhisen, thank you so much for making time for this interview. It's been very informative.

John Ringhisen, NP: I appreciate you taking the time to speak with me.

Host Amber Smith: My guest has been John Ringhisen, a nurse practitioner of psychiatry and behavioral sciences at Upstate who oversees the adult ADHD clinic, and who's also a member of the Pharmaceutical Subcommittee of the U.S. Guidelines Task Force for Adult ADHD.

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

How concerned should you be about bird flu? Next on Upstate's "HealthLink on Air."

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

Just how concerned should we be about bird flu? I'm turning to Dr. Stephen Thomas, the director of the Upstate Global Health Institute. He's a professor of microbiology and immunology, and a doctor who specializes in infectious disease at Upstate.

Welcome back to "HealthLink on Air," Dr. Thomas.

Stephen Thomas, MD: It's good to be with you. Thank you.

Host Amber Smith: Bird flu keeps making headlines, especially in communities that have large poultry farms. Is this a potential threat to humans that we should be concerned about?

Stephen Thomas, MD: Well, I think the first part is that yes, this is something that can be a potential threat to humans because it's made people ill in the past; it's killed people, unfortunately, in the past. But the answer to the second part of the question is, I think, currently in the United States, the concern can be low to very low at this time.

But, obviously, we're paying very close attention to what's going on with poultry, what's going on with cattle, and what's going on with, the people who interface with those two populations.

Host Amber Smith: So we've heard about it in chickens, but does this affect -- is it possible to be in -- all birds?

Stephen Thomas, MD: Maybe taking a step back, there's a couple of different names that people have been using. They use avian flu, they use highly pathogenic avian influenza. Influenza viruses, they have two main components that we kind of use to name them. There's the H component, which is the hemagglutinin protein, on the virus. And then there's the N component, which is the neuraminidase component. And there are 16 different H components and nine different N components. And they can be mixed in all sorts of different ways, so when we think of seasonal flu, that's H3N2. When we had the novel influenza pandemic back in 2009, that was H1N1.

These are being, some of them, are being confirmed as H5N1, and those combinations may just seem like a word salad. But they're really important, because each of these viruses have different characteristics, and they have different tropisms, if you will, or different types of cells and different animals and animal species and humans for where they like to infect. And then that can change their ability to be transmitted from animals to humans or to make people sick and these kinds of things, so that's kind of the background to the whole thing.

But to get to your question, all sorts of birds can get infected with these viruses, and they can kill the birds. In July, the CDC had reported that over 9,500 different birds across the country had been infected. And it's everything from robins and sparrows and bald eagles and owls and crows. And the list goes on and on.

Host Amber Smith: Does the bird flu kill the birds? Do they die from this?

Stephen Thomas, MD: They can. Yes. Many of the reports that the CDC (Centers for Disease Control and Prevention) and departments of health list are based on the equivalent of autopsies, basically, investigating why the bird died.

Host Amber Smith: Now, you mentioned cattle. Does this spreadfrom birds to cattle? Does it spread to other animals as well?

Stephen Thomas, MD: This has been in the news recently because I think the count now is about 157 dairy herds across the country that have been affected, meaning they've had cows that have tested positive for the influenza virus. And poultry, which is where we started. I mean, the count there isalmost a hundred million affected.

The concern is that humans obviously engage with these animals. Some people have poultry in their backyard, right? And we've had backyard herds, if you will, that have been infected. And there's the commercial (poultry farms), where they've had lots of, flu. And now in commercial dairy we've seen these infections, and people who work closely with them, either as part of the commercial enterprise or in terms of outbreak investigations or culling of animals, we've seen humans get infected. Fortunately, not a lot. I think the total number since 2022 has been nine, four following exposure to dairy cows and five following exposure to poultry.

But the concern is that that's going to become more and more common and people are going to become much sicker than what we've seen.

Host Amber Smith: Now when you say exposure to poultry or birds, does a human have to touch the animal, or are they breathing the air that the animal's breathing? How does it spread to the person?

Stephen Thomas, MD: Back to the earlier conversation about these H and N proteins based upon the proteins and the combination of proteins, these viruses can preferentially infect certain types of cells, and it can get into secretions, so from the respiratory system, but it can also get into excretions from, like, the gastrointestinal tract. And so, you can have urine and feces, and these things can dry out, and they become powdery, and then you have wind blowing them up and people breathing them in. And so folks can get infected that way.

With the cows, they have found high levels of infectious virus in the milk. That's why they're saying, "Don't drink raw cow milk." Those are some ways that you can get exposed.

Host Amber Smith: So what about eating chicken? If the chicken was infected with bird flu and gets packaged and sent to the grocery store, could a person catch it from eating that chicken?

Stephen Thomas, MD: I am not familiar with any reports of that occurring. My guess is that, similar to milk, where a pasteurization process makes the milk safe, my guess is that the process of slaughtering the chickens and cleaning the chickens and packaging the chickens and then ultimately cooking the chickens, that that would make the chicken non-infectious. But I'm not sure. I have not seen any reports about human infections resulting from eating infected chickens.

Host Amber Smith: Now, once a human is infected, can they spread it to other humans?

Stephen Thomas, MD: With highly pathogenic avian influenza, we have not seen that yet, which is a good thing. But that's always been the concern. If you want to go way back, before COVID, say 20 years ago, and you talk to a bunch of infectious disease people and epidemiologists and people that think about pandemic preparedness, if you had asked them, "Well, what do you think the next pandemic is going to be?" people would've said it would be a strain of influenza. And the doomsday scenario would be a strain of influenza that is as contagious as what we see with seasonal influenza, but that it would be as pathogenic -- meaning ability to cause severe disease in people -- it would be as pathogenic as these highly pathogenic avian influenzas. So that combo of highly transmissible and making people very, very sick, that would be kind of the pandemic doomsday scenario that everyone was very worried about. And then COVID came along, different virus, similar concerns. But now we're back on the highly pathogenic avian influenza bandwagon again in terms of what we're concerned about.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Stephen Thomas about bird flu.

So are all farmers with chickens at risk, potentially?

Stephen Thomas, MD: Well, according to the CDC, 48 states have outbreaks in their poultry. So that's pretty much all of them. And so I think the potential is there.

My understanding is that testing has not been as widespread and pervasive and aggressive as, certainly, the people who care about pandemics would hope. And I can understand there's another perspective on that, the perspective of the farmer, and this is their livelihood. And so I can understand the concern with that. So I would say that yes, if you have a poultry farm in the United States, then you should be concerned. You should be observant. If you're seeing die-off of birds, or you're seeing employees getting ill with flu-like illnesses -- and we could talk about what that looks like -- then fast testing and isolation and potentially culling of animals would be the best thing that you can do, both for bird health and human health. But it's a very complex issue that involves discussion, and more than just the viruses.

Host Amber Smith: What about those people, though, with the backyard chickens? I mean, this would be a concern for them too, right?

Stephen Thomas, MD: Both commercial flocks and backyard flocks have been impacted. To the people that have backyard flocks, I have the same advice to them as the folks who have commercial flocks, which is you just need to be informed, stay informed, be observant, be vigilant that if something doesn't look right, or your birds aren't healthy or something like that, call your local department of health, and they can help facilitate getting some testing done.

Host Amber Smith: There's not any sort of vaccine available or any preventive steps people can take to make sure their birds stay healthy?

Stephen Thomas, MD: They have licensed a couple of human vaccines, and there are a number that are in development. They have not been widely deployed. They were kind of made and then not stockpiled, per se, but put up on the shelf, and I think they're now dusting those off and breaking them out and offering them. I think we just saw that the government has issued a very, very large award to one of the messenger RNA vaccine manufacturers to develop an H5N1 vaccine.

So, they're out there, for humans. For animals, not that I'm aware of. Certainly not for poultry, that I'm aware of.

Host Amber Smith: And it sounds like we're not there yet in terms of needing to be worried about it. But a lot of people keep bird feeders, and naturally, there's a lot of birds around. But we don't really need to be concerned about that at this point?

Stephen Thomas, MD: Yeah, it seems predominantly, in these high-density, large-population commercial flocks, primarily. Again, there have been home flocks, domestic backyard flocks, impacted as well. But I think the main concern are these very, very large numbers. We're concerned about the animals for lots of different reasons, some of which are commercial in nature, food source, things of that nature.

But the concern from the infectious disease standpoint is just like the virus that causes COVID, every time a living being gets infected with this virus, that virus is going to go through millions of replication cycles in its normal course of infection. And every time it does one of those cycles, there's the potential that a mutation can occur. And we know they do occur, and they often occur, and usually it doesn't amount to anything. But if the planets align and the virus gets lucky, it can mutate into something that can reflect that doomsday scenario I was talking about, right? Where something that can easily jump from an animal to a human, and then the worst-case scenario, from human to human.

So this is another reason why we want to kind of isolate these infections and stamp them out as quickly as possible. We're trying to not give the virus any more evolutionary advantage than it already has.

Host Amber Smith: How does bird flu compare with seasonal flu?

Stephen Thomas, MD: So highly pathogenic avian influenza, the mortality rate can be quite high in people who get sick. Fortunately, what we've seen so far, since 2022 when we started to track these cases, in the poultry and in the dairy, the people who have been infected, they have had flu-like symptoms, and so they have had fever, and they've had some cough and some chills, and they may have had kind of a sore throat or a runny nose. They've also had, interestingly, conjunctivitis and eye tearing. Conjunctivitis is what people would say is red eye, pink eye, that kind of thing. That's interesting because the types of receptors that these viruses like to attach to, so they can infect the cells, the receptors in the eye are similar to some of the receptors in the respiratory tree. So it's plausible, and it's not unexpected, but it's been interestingly consistent with these workers who have been infected.

There have been no fatalities among these nine that I'm aware of in the U.S. so far. But with seasonal influenza we have -- just because of the numbers -- we have 20,000 to 30,000 people a year who die of seasonal influenza in the United States. We have about a million people who end up in the hospital because of it. So hopefully we don't get into those numbers with this highly pathogenic avian influenza that we're seeing right now.

Host Amber Smith: Is there a blood test to test and say, "Yes, you have bird flu," or is it based on the symptoms?

Stephen Thomas, MD: You know, I was always taught that clinicians make diagnoses, not tests, right? Tests are designed to support a clinical diagnosis. So if somebody were to come in with flu-like symptoms in July of 2024, these clinicians should be asking very specific questions about not just the symptoms, but where have you been? What have you been doing? Have you had contact with any animals?

Because what do we have? What's going to happen in a couple of weeks? We're going to have a big, huge state fair. There might be poultry. There might be cattle there. Might be pigs, right? Pigs are also great for influenza viruses. So we have lots of agricultural activities here, farmers, et cetera.

So you just have to take a good, detailed history to say, OK, are they sick? Could this represent influenza? And do they have an exposure history that could be consistent with someone who's at risk for avian influenza?

You should test them for the routine sorts of things, right? But I think the only places you can get definitive H5N1 tests -- so tests for highly pathogenic avian flu -- is at certain departments of health. And so I would immediately be on the phone with (New York State Department of Health) Wadsworth (Center, the laboratory investigations unit) and say, "I have a respiratory sample that I would like to have tested." And then care for that person accordingly, and isolate them accordingly.

People with flu, it's so common, we don't think so much about it. But people with influenza really should be isolating themselves routinely from other people because they can pass it. So I would treat them the same way if I thought it was seasonal flu or avian flu.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more about bird flu.

Welcome back to Upstate's "HealthLink on Air". I'm your host, Amber Smith. My guest is Dr. Stephen Thomas, the director of Upstate's Global Health Institute, and we're talking about how concerned people need to be about bird flu.

Well, I wanted to ask you about the spread of bird flu with the changing climate. Does that impact how respiratory viruses like the bird flu spread, either from animal to animal or animal to people?

Stephen Thomas, MD: So, infectious diseases that are typically within certain animal populations, and if those animal populations have migratory patterns where they impact the density of animals coming together, moving together, that kind of thing, I guess that changes in ecology in general, changes in temperature, could potentially impact that, for diseases, human diseases that are transmitted person to person, which this one we have not seen yet.

Temperature changes how people behave, right? And obviously being outside in the sun with lots of ventilation and everything reduces risk, for person-to-person transmission. But I'm not sure specifically about any climate/highly pathogenic avian influenza correlation, just yet -- with the caveat that they're actually investigating a poultry culling event where a couple of people were infected. And they think it's because, or what could be contributing, is that it was so hot, and there were fans going, and people were in personal protective gear, and they were sweating, and they think it could have potentially reduced the effectiveness of the personal protective gear. So that's an indirect way of how climate may have interestingly impacted a recent cluster of cases of people who went there to cull animals to try and stop the spread. So an indirect way the climate might've impacted.

Host Amber Smith: Well, before we wrap up, I wanted to ask you if you can let us know about some of the projects the Upstate Global Health Institute has underway that are tied to respiratory viruses, because I know you're sometimes looking for people to volunteer to help with those studies.

Stephen Thomas, MD: We're involved in a number of influenza studies. We're involved with great partners at the University of Maryland and the NIH (National Institutes of Health) in a universal influenza vaccine development project that's been going on for a couple of years now. And we'll have a study that's coming up relatively soon, so spring of next year.

And then we have other projects that we're involved in with combination COVID-influenza vaccines. We're involved in vaccine projects of people just trying to make better flu vaccines, vaccines that perform better by being a little more specific to the viruses that are circulating at the time.

We're working with the county, Onondaga County, on a respiratory virus project, which we hope to launch at the start of this season, so September, October of 2024. And, I will disclose, I've made a couple calls to folks who are doing H5N1 work to say, "You know, we would be great partners because we like to work on things that impact our community, and we have a lot of agricultural and dairy enterprises up here in Upstate and Central New York. And so we'd like to work on projects which can help our community directly. So, we're not doing any H5N1 work right now, but I'm hoping that, just like with COVID, we'll be called upon to participate in these trials.

And COVID projects continue. We have a couple that are queuing up right now. I think that we have been successful in the work that we do. And a primary reason we're successful is that we have a very supportive community, and we have people who are interested in wanting to volunteer for these studies and to participate. I think they realize that nothing is going to get on a shelf, nothing's going to get in your doctor's office, nothing's going to get into your urgent care center or hospital or clinic, it's just not going to happen unless these studies are done. And these studies are not going to be done unless people are willing to volunteer. So we have an incredible amount of gratitude for Central New York and the people who participate in these studies.

Host Amber Smith: And people that might be interested in that can learn more if they go to upstate.edu/globalhealth, online. They can kind of stay apprised of some of the projects you've got underway.

But in the meantime, they don't really need to fret too much or worry too much about bird flu?

Stephen Thomas, MD: I think that that's true. And I think just like everything, people just have to be, they have to be informed by listening to programs like this. They have to be observant. They have to be aware. And then if something seems out of the ordinary, then they need to call their trusted clinician and express their concerns.

Again, it's people who are sick with an influenza-like illness and have had exposure to birds or other types of animals, those are the people that we would be concerned about and want to evaluate aggressively.

Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Thomas.

Stephen Thomas, MD: Oh, it's a pleasure. Thank you.

Host Amber Smith: My guest has been Dr. Stephen Thomas, an infectious disease specialist, professor of microbiology and immunology, and the director of the Upstate Global Health Institute. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Carol Sames from Upstate Medical University. What's important to know about heat illnesses?

Carol Sames, PhD: 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.

Know 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. 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.

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. 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.

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.

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.

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: You've been listening to exercise physiologist Carol Sames 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: One of medicine's tenets is for physicians to commit themselves to lifelong learning. Joan Roger, a poet and emergency physician, provides us with a striking example in her poem "Blind." She completed her emergency residency at Bellevue Hospital in New York City, from which this poem emerged, she begins blind with an epigram from James Baldwin:

"-- Not everything that is faced can be changed,

but nothing can be changed until it is faced."

Blind, sedated, in a body bag,

shackles around his ankles,

he is chained to an iron ball

and brought to Bellevue Hospital

by six armed guards from Rikers prison.

The dead-weight of him is hoisted

by the grunting guards, and dumped

with a thud onto a gurney.

I watch as they wheel him

like a shopping cart, to room five.

I am an intern in pale blue scrubs,

new to New York. Algorithms

whirl inside my skull. A stethoscope

drapes around my neck. My brown eyes

have seen little outside of books and classrooms.

They unzip the body bag

and the man's tattooed arms, wider than my thighs,

fall limp over the stretcher.

It is important to see that this is a black man.

It is important to see that I am a white woman.

Together we live in this city of eight million souls.

We breathe the same air.

We are nearly the same age.

His chart says: patient gouged own eyes.

The guards say: he was in solitary.

The tranquilizers shot in his thigh

ensure that he says nothing.

My job: to examine the red mounds

of his sockets. I inch to the bedside.

My hands are shaking.

I have been told

that this is a dangerous man.

I wonder if he is sedated enough.

I lean forward, less than the width

of two fingers between our lips.

His breath mixes with mine.

I fear he will awaken to crush my throat

with hands that fractured a guard's leg,

or so they say. My two eyes are intact

in my head and I am the one leaning over him.

He is the one who was injured,

this man who was once a child with eyes open.

I will never know all that he has seen.

I can only lift his swollen lids

and witness the wreckage --

collapsed casings, lenses dark, distorted

with blood and pus from days in the dark --

a brokenness that cannot be mended

and for a moment the veil

between us lifts and I fall through

his hollow chambers, no longer blind

to what he can no longer see.

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 Dungeons and Dragons is helping teens in therapy.

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.