
Rheumatoid arthritis update; post-COVID syndrome; teen sexual health: Upstate Medical University's HealthLink on Air for Sunday, Sept. 8, 2024
Rheumatologist Patrick Riccardi, MD, tells how the outlook and treatment options for people with rheumatoid arthritis have improved. Physical therapist Kira Doll, DPT, discusses recovery from post-COVID syndrome. Pediatrician Aimee Steiniger, MD, talks about adolescent sexual health.
Transcript
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a rheumatologist tells how the outlook for rheumatoid arthritis is improving.
Patrick Riccardi, MD: ... For many patients, you'll hear expressions like, "I've got my life back," and they're back to work and doing activities (they did) before they had rheumatoid arthritis. It's been gratifying to witness. ... .
Host Amber Smith: A physical therapist discusses post-COVID syndrome.
Kira Doll, DPT: ... There really are not a lot of new cases of post-COVID syndrome, and they kind of think that that might have to do with more people being vaccinated. ...
Host Amber Smith: And a pediatrician talks about adolescent sexual health.
Aimee Steiniger, MD: ... There are some youth who really do seem to open up if I'm talking to them alone, and there are plenty that feel comfortable having those discussions with their parents in the room. ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, we'll learn about post-COVID syndrome and how it's changed since the pandemic began. Then, a pediatrician explains why adolescent sexual health is important. But first, the outlook for people with rheumatoid arthritis has improved.
From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."
Today we're learning about an autoimmune disorder called rheumatoid arthritis from Dr. Patrick Riccardi. He's an assistant professor of medicine specializing in rheumatology at Upstate.
Welcome to "HealthLink on Air," Dr. Riccardi.
Patrick Riccardi, MD: Thank you, Amber.
Host Amber Smith: Now, just to be clear, osteoarthritis when your joints are damaged by wear and tear, is not related to rheumatoid arthritis. Is that right?
Patrick Riccardi, MD: Yes. They're quite different conditions. Rheumatoid arthritis is associated with a lot of inflammation, as opposed to osteoarthritis, which is primarily a non-inflammatory degenerative process.
Host Amber Smith: Do people who have rheumatoid arthritis get osteoarthritis?
Patrick Riccardi, MD: They're more likely to get it, indeed. Anything that damages the surface cartilage can lead to secondary osteoarthritis, secondary degeneration. Our treatments are better today, but when I first started practice many years ago, it was one of the leading causes of joint replacement surgery. That's changed. But, anything that leads to damage to the surface cartilage, such as rheumatoid arthritis inflammation, could lead to secondary degenerative arthritis, yes.
Host Amber Smith: So how do people typically learn that they have developed rheumatoid arthritis?
Patrick Riccardi, MD: The symptoms typically, originally are pain and stiffness in the joints, multiple joints. The distribution of joint involvement tends to be the small joints, hands, feet, wrists, oftentimes elbows, shoulders, hips and knees are involved, in a bilateral, symmetrical -- which means both sides of the body -- type of involvement. Which is different than osteoarthritis, which tends to come on with age, usually after the age of 40, and involves fewer joints, and it's not as symmetric in location. It tends to dominate in the lower extremities, the hips, the knees, the low back, and the high usage joints of your hands, such as the base of your thumb, the distal interphalangeal joints, the small joints of your hands, giving you what looks like knobby knuckles in appearance.
Host Amber Smith: Is pain associated with this? And how do patients describe what it feels like?
Patrick Riccardi, MD: Pain is the prominent initial symptom, and stiffness, prolonged morning stiffness. Typically, a rheumatoid arthritis patient will have a stiffness that lasts at least a half an hour, and it can go on all morning long. Whereas an osteoarthritis patient, the stiffness is brief, usually lasts maybe five minutes, and once they move about, they're OK. However, with degenerative arthritis, when you've lost the surface cartilage, usage of that joint, such as weight-bearing activities, will aggravate the symptoms. And just the opposite is the case in rheumatoid arthritis, where the morning stiffness is usually alleviated by movement, and the patients feel better once they move about.
Host Amber Smith: Are there any tests that are done to determine for sure that it's rheumatoid arthritis?
Patrick Riccardi, MD: Yes. Both X-rays and laboratory tests are done. There's a couple types of antibodies that are typically present in over 80% of rheumatoid arthritis patients. One is called rheumatoid factor. Another one is called a (anti-cyclic citrullinated peptide) CCP (blood) test.
Furthermore, those patients typically will have elevated markers of inflammation in blood work. The sedimentation rate, the CRP (C-reactive protein) test are two measurements of inflammation. They should be up, whereas a typical degenerative arthritis patient, they're normal.
Host Amber Smith: Are there any body parts or body systems that may be involved beyond the joints?
Patrick Riccardi, MD: Yes. You know, rheumatoid arthritis is an autoimmune disease. It's a systemic illness. And once your immune system, your body's defense system is activated, it can react against your own tissues -- not only the lining of the joints, which is the most predominant joint involved in rheumatoid arthritis, but also the lining of the heart and lungs. It can give you pericarditis and pleuritis. It can give you interstitial lung fibrosis, which causes stiff lungs and difficulty breathing. It can lead to chronic inflammation of your blood vessels, which predispose you to myocardial infarctions and congestive heart failure. It can irritate the lining of the eyes, the sclera, and lead to quite a bit of damage. And at times the skin and blood vessels are also involved as part of the autoimmune portion of rheumatoid arthritis.
Host Amber Smith: Do we know what causes this?
Patrick Riccardi, MD: We still don't have full knowledge of all the factors that cause rheumatoid arthritis, but we have learned that the initial steps likely involve environmental triggers in patients with genetic predisposition. And environmental triggers specifically at mucosal surfaces, such as exposure to cigarette smoke in our airways that lead to damaged proteins of the lining of the bronchial mucosa. Smokers have an up to a 20-fold increased risk of susceptibility to rheumatoid arthritis. People with periodontal disease, gingivitis, with altered gum mucosa will have an increased expression of rheumatoid arthritis versus the general population.
And also a big factor may be our gut microbiome.Our Western diets are pro-inflammatory, a lot of highly processed foods, a lot of sugar, can alter the gut mucosa and alter our gut microbiome. And it's thought that that certainly can affect expression of rheumatoid arthritis. Diets like the Mediterranean diet, for example, that help restore the healthy microbiome are associated with improvement in rheumatoid arthritis expression. So, we know that there is an environmental trigger involved in many, many patients.
There's also the risk factors of genetic predisposition. First-degree relatives of patients with rheumatoid arthritis have approximately three times increased incidence of rheumatoid arthritis. Even second-degree relatives -- grandparents, aunts and uncles -- have a two times increased incidence. So there's both genetic factors and there's environmental factors. An interesting statistic is that with identical twins, you have a concordance rate of rheumatoid arthritis in the other twin only 15% of the time. So if you have rheumatoid arthritis in your identical twin, your identical twin has a 15% chance of getting it. That means that there's something else involved here, not just genetic predisposition. And those environmental factors that we talked about are probably prominent.
Host Amber Smith: You mentioned, among the environmental factors, cigarette smoking. Does that apply to secondhand smoke inhalation as well?
Patrick Riccardi, MD: You know, I've not seen a study on that, but I'm sure it does. Knowing the increased risk that smoking conveys on developing rheumatoid arthritis, we have stressed to patients to stop smoking. We've been doing this for other reasons as well, obviously. But if we can successfully get them to stop smoking, the chances of them developing rheumatoid arthritis diminish with time. So, I'm sure secondary smoke and ongoing smoking are not good for you.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Patrick Riccardi, a rheumatologist at Upstate, about rheumatoid arthritis.
So let's talk about treatment. Is there any way to reverse the tissue damage?
Patrick Riccardi, MD: Unfortunately, the short answer is no. However, you can certainly improve the function of the patient with proper alternative therapies, physical therapy, occupational therapy, but once the damage has occurred, it tends to be permanent. The key to successfully treating rheumatoid arthritis is to diagnose it early, and in most patients, they will have progressive joint damage and disability if they're untreated.
So we nowadays treat quickly with immunosuppressive medication, what we call disease-modifying anti-rheumatic drugs. Methotrexate has become the mainstay of therapy. Weekly methotrexate is typically the first immunosuppressive drug we use.And in about 40% of patients, it will be, by itself alone, able to reduce the rheumatoid inflammation to either a low level or a full remission. The other 60%, we typically have to add additional immunosuppressive medications.
Thankfully, in the last 20 so or so years, we have developed more targeted therapies called biologics, which have really been a game changer. I started way back in 1981. We had lousy drugs. We had gold and penicillamine, and they were very ineffective. They might work for mild rheumatoid arthritis, but for moderate or severe rheumatoid, they were very poor therapeutics.
About in the late 1990s, the first group of biologics came out: Enbrel, Humira, Remicade, the anti-TNF (tissue necrosis factor), more targeted drugs against... TNF is, a protein, a cytokine that's produced in excess in rheumatoid arthritis. Anyway, it quickly changed the outcome of the majority of patients. And we've now developed other targeted therapies, other biologics, which have also really changed the outcome of these patients.
Host Amber Smith: Are there complications for rheumatoid arthritis that treatment can help prevent?
Patrick Riccardi, MD: Absolutely. We talked about joint damage. When I started, I'm going to guess, joint replacement therapy was occurring in rheumatoid arthritis patients equally with that of degenerative arthritis. That ratio has flipped with the advent of the new medications. So joint damage and disability is markedly reduced with effective immunosuppressive medications, but also the complications of cardiovascular disease. Until the newer medications became widely available, it was the leading cause of premature death in rheumatoid patients from causing plaque-like formation in the blood vessels leading to stroke, heart attack, congestive heart failure.
That's all much improved with our newer medications. Plus, a knowledge that this is a risk factor for rheumatoid patients, and we pay more attention to their cholesterol levels and treatment of their blood pressure and those types of things.
The fibrotic changes of interstitial lung disease, which occurs now up to 10% of rheumatoid patients, that also is diminished with effective immunosuppressive therapy.
Scleritis, which can be terrible, I've seen some awful cases, where we've actually hadperforation of the outer layers of the eye. That has also improved and is much less frequent with these newer medications. Really all the organs that are involved with rheumatoid arthritis are much improved with our newer medications.
Host Amber Smith: Well, with these new medications, what is life like for someone with RA? How debilitating can this be?
Patrick Riccardi, MD: It can be severely disabling. It used to be one of the leading causes of disability. With effective treatment -- in high-income countries like United States where we can afford to use biologic medications -- probably 90% of the joint destruction can be avoided if we can get the patient on the right medication. But not everybody. There's something called difficult-to-treat rheumatoid arthritis that still occurs in 10% to 15% of rheumatoid patients. Those patients will have ups and downs in their disease activity. And they can do very poorly without taking the proper medications or if they happen to be in that 10% who don't respond to the current medications.
Host Amber Smith: All of these different medications, do they leave people with RA immune suppressed?
Patrick Riccardi, MD: Absolutely. That's always been the big concern. Are we going to cause more harm than good? Fortunately, the infectious risk for most patient is less than 1% for serious infection. However, we carefully choose which patients go on them. If the patient has a tendency for infection, if they have COPD (chronic obstructive pulmonary disease) with emphysema, recurrent bronchial infections, if they have cellulitis with recurrent bacterial infections of their legs, if they're a diabetic, all those patients we are very careful to use them. A lot of times we don't use them at all. There are specific groups that you can't use certain biologics with. If somebody has a history of lymphoma or melanoma, we can't use the Enbrel, Humira, anti-TNF category safely. Each of them have their own risk, but they have been game changers. And for many patients you'll hear expressions like, "I've got my life back," and they're back to work and doing activities (they did) before they had rheumatoid arthritis. It's been gratifying to witness.
Host Amber Smith: Are there activities that people with RA are advised not to partake in?
Patrick Riccardi, MD: Well, I'll answer it this way. I, and most rheumatologists, encourage our patients to exercise. There are certain types, if you have bad hips and bad knees or bad ankles and feet, high impact weight-bearing exercises are not going to be well tolerated. But, they can get on an exercise bike. They certainly can swim. I'm a big fan of getting patients to go to their local pool and put on a flotation belt around their waist to go to the deep end and raise their arms and feet in the deep end, where there's no impact ... walking ... all these things dowonders for the patient in terms of balance, strength. The most common cause of hospitalization in patients over the age of 75 is falls. They do a great job in helping restore strength and balance, and the physical therapists are key to developing an individualized program that will work for them.
Patrick Riccardi, MD: Is there any sort of diet or specific foods that you recommend people with RA eat? I think the most common diet that is recommended by rheumatologists is the Mediterranean diet: high in fruits, vegetables, nuts, fish, lean meats, low in sugar and processed foods.
Highly processed foods are probably pro-inflammatory and not good for you. There have been studies that show less joint symptoms in patients who have been treated with the Mediterranean diet.
Host Amber Smith: So today, what are the options for someone who is diagnosed with rheumatoid arthritis?
Patrick Riccardi, MD: It's better than it ever has been. And like I said, up to 90%, if we can get them early and get them on those medications, the biologics, I would say 90% of the patients can expect to get control in their life back so that they can resume work, prevent end-stage damage in joint replacement therapy.
Back in 1950, the year I was born, Philip (Showalter) Hench from the Mayo Clinic won a Nobel Prize in medicine because they had discovered cortisone. And they thought they had the cure for rheumatoid arthritis. Six months later it became a very ignominious award because the patients who were on chronic steroids were gaining weight, fracturing bones because of osteoporosis. There are all kinds of side effects, including infection. So now we treat steroids sparingly. We may use them early because they're quick to work, but we try to get the patients off them as soon as possible. It took until 1990s before the biologics came about. But we've made remarkable progress, and it's no longer something that people should lose sleep about when they have the diagnosis because there's plenty of good treatments available.
Host Amber Smith: Do you ever see children with RA?
Patrick Riccardi, MD: Oh, yes. And,there's three pediatric rheumatologists at Upstate who are quite busy. And, juvenile rheumatoid arthritis remains alive and well. We use the same medications, primarily, to treat them, and they do much better, and they handle the immunosuppressive drugs better than most adults, I should say.
But yes, that's a common problem.
Host Amber Smith: Are people who are diagnosed with rheumatoid arthritis, are they followed by rheumatologists, or do you see some people that are treated just with their primary care provider
Patrick Riccardi, MD: If they're on an immunosuppressive drug, typically they're followed by the rheumatologist, in conjunction with their primary care. We still need the primary care doctor to stay involved. Unfortunately, there's manpower shortage of rheumatologists nationwide, including Syracuse, where there's a backup to get a patient in in a timely fashion. But if they're on immunosuppressive medication because of the complexities involved in proper management, a rheumatologist should be involved.
Host Amber Smith: Dr. Riccardi, thank you so much for making time to tell us about rheumatoid arthritis.
Patrick Riccardi, MD: My pleasure.
Host Amber Smith: My guest has been Dr. Patrick Riccardi, an assistant professor of medicine at Upstate, specializing in rheumatology. I'm Amber Smith for Upstate's "HealthLink on Air."
Today's post-COVID syndrome is different than at the start of the pandemic -- next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Brain fog and extreme fatigue are two common symptoms of long COVID, but there are many others. Physical therapy has emerged as a crucial aspect of managing patients with long COVID, and today I am talking with Doctor of Physical Therapy Kira Doll about what this involves.
She's from Upstate's department of physical medicine and rehabilitation.
Welcome to "HealthLink on Air," Dr. Doll.
Kira Doll, DPT: Thank you, Amber. It's great to be here.
Host Amber Smith: Now, to be clear about what long COVID is, this is when symptoms linger after a person is no longer contagious with COVID. Is this weeks or months? How long is long COVID?
Kira Doll, DPT: It depends on what you read, and it depends on who you're listening to, but generally it's accepted to be about 12 weeks after your original infection with COVID.
If you're still having symptoms about three months later, you start to be classified as a person with long COVID, which currently the words are being used as post-COVID syndrome, as opposed to long COVID.
Host Amber Smith: Post-COVID syndrome.
Kira Doll, DPT: Post-COVID syndrome.
Host Amber Smith: Do we know what percentage of people who are infected with COVID end up with post-COVID syndrome?
Kira Doll, DPT: According to the CDC (Centers for Disease Control and Prevention) from 2022, it was about 7%. I definitely think that that number has changed at this point, and there are sources that say anything from 3% to, I've read, 80%, which seems unreasonable. But the numbers are changing constantly. Everything is changing about post-COVID syndrome. So the CDC currently says 7%, but I don't think that's completely accurate anymore.
Host Amber Smith: Well, what about those with post-COVID syndrome?
Is it more male or female? Older, younger, those who were vaccinated, those who were not? Is there any characterization you can give us?
Kira Doll, DPT: Again, depending on what you read, it's kind of all over the board, but it is pretty consistently accepted to be more prevalent in females.
Most sources do say the older population. However, the CDC's website does say, I can't remember the exact range, but it's like 35- to 49-year-olds. But pretty much every other source says it is more prevalent in geriatric patients, anybody over 65.
Definitely the unvaccinated population originally was showing more post-COVID syndrome.
There aren't that many people anymore who aren't vaccinated, and there really are not a lot of new cases of post-COVID syndrome, and they kind of think that that might have to do with more people being vaccinated.
Host Amber Smith: So among the patients that you and your colleagues care for, what are the most prevalent symptoms?
We mentioned fatigue and brain fog. Is that the No. 1?
Kira Doll, DPT: I'm going to say it again: It depends. Post-COVID syndrome is so broad, it's such a broad spectrum, it doesn't even have a good definition. Basically, it's just symptoms that you have that you did not have pre-COVID. It can be cardiovascular symptoms, it can be pulmonary symptoms, it can be psychiatric symptoms, it can be dermatological symptoms.
It is truly all over the board. I personally work with the pulmonary group here at Upstate, which is where we started to get referrals for post-COVID syndrome, because initially people were coming in with respiratory issues or lung issues following their hospitalization or their bout of COVID.
That has decreased significantly, and so now when we're getting referrals for post-COVID syndrome, they are primarily people with the brain fog, the fatigue, sometimes POTS (postural orthostatic tachycardia syndrome), which is like an orthostatic issue where people get dizzy; they're not able to tolerate exercise or even upright positions sometimes. We get a lot of referrals for those, but again, truly, we're not seeing the numbers of referrals that we originally were.
Host Amber Smith: So why do you think that is? Are people getting better on their own?
Kira Doll, DPT: There are a lot of different theories about this. When we do get referrals currently, this is anecdotal, this is just what I'm seeing, those patients had COVID in 2020, 2021, maybe 2022. I don't know if it has to do with the current strains of COVID, but we're not seeing any referrals for actual post-COVID syndrome from anyone who had COVID in 2023 or 2024.
Host Amber Smith: So those that came for help rebuilding their fitness or their stamina, were you able to work with them and see improvement? Does physical therapy actually help those people?
Kira Doll, DPT: It depends on what their symptoms are and whether or not they have true post-exertional malaise symptoms, which we can probably talk about in a little bit.
But the post-exertional malaise that is most frequently seen with chronic fatigue syndrome is a common symptom found with post-COVID patients as well. And those patients are handled slightly differently because it's not just deconditioning. They're not just out of shape. It's not just that their fitness is decreased. It is truly a physiological change in their ability to tolerate exercise, activity, even, like, daily life.
So those patients we treat with education, primarily. We're teaching them activity modification techniques and energy conservation techniques and really just teaching them to live with their new symptoms, because if we're basing what we know on what we know about chronic fatigue syndrome, those patients are unlikely to improve. So those patients we're treating with education.
All of the other patients that we get referrals for, we treat what they're coming for. So if they do have pulmonary issues, we put them through a course of pulmonary PT (physical therapy), and they absolutely improve. if they're coming with dizziness, we'll often refer them to like vestibular therapy or possibly for an eye exam. We also do a lot of referring to occupational therapy for things like brain fog, difficulty concentrating.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host Amber Smith. I'm talking with Doctor of Physical Therapy Kira Doll from Upstate about recovery from post-COVID syndrome.
I heard about research published earlier this year where scientists in the Netherlands took biopsies or samples of muscle tissue from post-COVID syndrome patients before and after exercising. This was published in the journal Nature Communications. Can you discuss what they found?
Kira Doll, DPT: It's got a pretty small sample size. I think they looked at, like, 25 patients with post-COVID syndrome, but it is very interesting. They found basically that the patients were actually having issues with their skeletal muscle, that the problems that they were having with the fatigue was not actually coming from a more centralized, like a cardiac issue or a lung issue, it truly was a problem with the skeletal muscle itself, which is really interesting.
And what I would actually be interested in seeing is that compared to patients with chronic fatigue syndrome because that article in that study was specifically looking at patients who get that post-exertional malaise, which again is traditionally seen in chronic fatigue.
So I'd be interested to see if those muscle biopsies were similar or the same.
Host Amber Smith: So is this like muscle fatigue after you do a big workout, or you are very active in the yardwork one day, and your muscles are really sore the next day? Is it like that or is it something different?
Kira Doll, DPT: No, it's completely different. It is an actual physiological change in their ability to do exercise, and it's interestingly not that well understood for how long it's been studied in the chronic fatigue population.
It essentially means when people have post-exertional malaise, they one day can do exercise, they will get tired, but then they crash. Not they get kind of tired, and they can still go about their day, and they can go to work, and they get kind of sore: Their body just crashes. And I mean, it can last up to weeks. It's usually days longer than a traditional person who just overexercises, which will recover within three days or so. These people will be kind of down for the count, not able to do anything for days and days and days, up to three weeks.
It's something completely different.
Host Amber Smith: So what is recommended in terms of physical activity for people who have lingering COVID symptoms?
Kira Doll, DPT: It depends on the symptoms. Recently, the referrals that we do get seem to be more for what's called deconditioning, as opposed to post-exertional malaise, which is not treated with exercise. Exercise is contraindicated (not recommended) for that.
People who have deconditioning are basically out of shape a little bit or just like lower than they normally are, from being sick, from being in the hospital, from inactivity. And those patients do tend to respond very well to just a pretty basic exercise program with vitals (pulse, temperature, blood pressure, etc.) monitored. We monitor their vitals, make sure everything's going OK with their heart and their lungs, but generally those patients do very well.
Host Amber Smith: Someone who has recovered from COVID at home, at what point would they consider seeing a physical therapist?
Kira Doll, DPT: Generally, that is recommended by their physician. Unless they have some kind of history with physical therapy, people with post-COVID syndrome are generally not seeking it out anymore.
In 2022, when post-COVID syndrome was much more frequent and also less studied, not as well understood as it currently is, people were scared and people were not listened to a lot of the time. People felt very alone and lost, so they were seeking out care on their own. A lot of the referrals came from people who found internet sites and different Facebook groups that would recommend trying therapy.
So what I would say for somebody recovering at home is, if you are not continuing to improve, so if you're just under the weather, you get better, but you're not 100%, and you're able to kind of every day feel a little bit better, you're probably fine to stay not coming to physical therapy.
But if you don't find that you're improving over time, or if you're getting worse, I would talk to your doctor and then maybe even just come in for a consult. We do a lot of those.
Host Amber Smith: Well, Dr. Doll, thank you so much for making time to talk about post-COVID syndrome. I appreciate it.
Kira Doll, DPT: Oh, thank you so much for having me.
Host Amber Smith: My guest has been Kira Doll, a doctor of physical therapy at Upstate, working in physical medicine and rehabilitation. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," adolescent sexual health, from a pediatrician.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Adolescence is a time of major transition for kids physically, emotionally and socially. This is also when many are exploring their sexuality. Pediatricians can be a resource during this time, and I'm talking about that today with Dr. Aimee Steiniger. She's an assistant professor of pediatrics at Upstate.
Welcome to "HealthLink on Air," Dr. Steiniger.
Aimee Steiniger, MD: Hi. Thank you so much for having me.
Host Amber Smith: Before we get into this, can you tell me, what are the years of adolescence?
Aimee Steiniger, MD: I think it depends on where you're looking, but at the American Academy of Pediatrics, we're usually looking around ages 10 or 11, up until 21.
Host Amber Smith: So is that the age when kids start seeing a pediatrician confidentially, like 10 or 11, without their parents being in the room?
Aimee Steiniger, MD: Yes. I'd say it is likely provider-dependent, but I think a lot of us like to start that process early, to gain trust with the family and make it an understanding that teenagers and young adults are going to start taking control of their own health care and being involved in it.
Host Amber Smith: Do you find that kids are universally more comfortable talking about sex without a parent in the room?
Aimee Steiniger, MD: I think that really depends on the family and the young adult. I think there are some youth who really do seem to open up if I'm talking to them alone, and there are plenty that feel comfortable having those discussions with their parents in the room. It's kind of part of my job to figure out where we are in that space and which way I can help the adolescent the best.
Host Amber Smith: Now, when do you recommend that a girl start seeing a gynecologist?
Aimee Steiniger, MD: So that I think is pretty pediatrician- or provider-dependent as well. I think, we have moved the guideline for Pap smears to age 21, and so since then, and with all of the testing that we've had over the past few years, we're able to do a lot more without doing an invasive pelvic exam.
There are certainly some young women who may want to have a relationship with a gynecologist earlier in life, and I think that that's great and is a great thing to do, but this may be something that you would like to talk to your pediatrician about and see when would be a good time for you to see that specialist.
Host Amber Smith: And let's talk about what is important, from a pediatrician's point of view, when a kid turns 10? What are you looking for? Is there any preventive care on your mind?
Aimee Steiniger, MD: Yes, certainly. I think, when I look at adolescents between ages about 10 and 11 up to 21, there are different topics of things that I'm looking at to keep that young person well, and they're really similar topics, but they change throughout the development of the adolescent.
So for instance, starting at age 10 or 11, pediatricians are assessing puberty, seeing how puberty's progressing, we're checking growth, height, weight in relationship to pubertal changes. We're often looking at risk factors for cardiac disease and diabetes for the future. So things like obesity, trying to establish healthy eating, daily exercise, really healthy habits for youth and young adults moving through life, as well as blood pressure checks, cholesterol screenings and things of that nature.
One of the big things that starts to come at this age are sports clearances, trying to screen and reduce risk of any type of sudden cardiac death, which is rare, but is very scary in the young adult age.
And then we start talking about a lot of anticipatory guidance, and that's a lot of the well-child check for an adolescent or young adult.
And these have, again, similar topics and the content just kind of changes throughout those years. So a lot of times as adolescents are getting older, trying to gain independence, they may have different risk-taking behaviors. And so we like to talk about things like safety: helmet safety, seat belt safety and things of that nature.
It's important to open the discussion about substance use and substance abuse because this is something that young adults and adolescents are often coming into contact with in their daily life, through their peers and through other ways. We talk about sleep, school performance. We're looking at family life, interactions among the family, interactions among their peers.
And, starting at this age, we'll start to do depression screening and really paying attention to the mental health of youth.
We also talk about sexuality and sexual health, which is a really important topic that needs to be addressed during these ages.
Social media has become a really big part of adolescent and young adult life, and so making sure that our young adults have the best ways to interact with social media and technology is very important.
Lastly, we're giving immunizations like human papillomavirus, Tdap -- which is tetanus, diphtheria and pertussis -- and meningococcal, or meningitis, vaccines.
And then a really big topic that I like to bring up throughout adolescence is starting to educate youth on how to manage their own health care. So starting when they're younger with little things, maybe engaging in their MyChart (their online medical information), starting to take a little bit of ownership for some of their own health care, and then increasing that as we move through adolescence so that when they turn 18, or they turn 21, and they're all of a sudden an adult, they have all this experience behind them and really know how to manage that health care.
And that transition doesn't come in just one day.
Host Amber Smith: I like how you say "anticipatory guidance," because that's looking ahead at what may come or what is to come, but it seems like it also involves the parents. It kind of gives the parents a heads-up along with the patient.
Aimee Steiniger, MD: Absolutely, and I think a lot of the pediatrician's role is to guide those discussions between the young adult and the parent.
So I know we talk about confidentiality, and we talk about talking to the youth alone, but know that your pediatrician is really trying to help engage the youth and the parent together and really foster that relationship between them so that they can tackle these challenges that come along throughout life together.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Upstate pediatrician Aimee Steiniger about adolescent sexual health.
So what is included in sexual health for adolescents?
Aimee Steiniger, MD: I like to include a lot of things in sexual health. Obviously sexually transmitted infections, birth control or contraception is very important. Healthy relationships are really important, so allowing adolescents to recognize healthy relationships or what may not be a healthy relationship. And then things like gender identity and sexual orientation are things that youth are really navigating through and trying to figure out very early in life, but especially through this time.
Host Amber Smith: Do girls and boys have questions about contraception, or is that something that you generally bring up?
Aimee Steiniger, MD: I think that really depends on the adolescent. I think some of them just don't know that we're kind of an open door to have that discussion. And so when I open the door, I really get a lot of questions, a lot of very great questions, that show me that that person has really been thinking about these things but perhaps doesn't know where to go or who's a good person to talk to about that.
And then I have others that I really have to ask a lot of questions to, and that's OK, too, as long as the information is getting across, and as long as at the end of the visit that teen knows that we're a good source of information, and we're an open door where we can come and talk about these difficult topics.
Host Amber Smith: Is there a method of contraception that you recommend for young people over other types of contraception?
Aimee Steiniger, MD: So for me, I think that's very individualized and dependent on the adolescent and what they think is most important to them. What. I would say is long-acting reversible contraception, like intrauterine devices or implants, are extremely effective at preventing pregnancy, if that's our top priority, and very safe for adolescents of all ages.
And I think this has really been shown in the research and is a really important part of contraceptive care.
Host Amber Smith: You mentioned that you bring up what a healthy relationship is, and that clearly is really important. How do you describe a healthy relationship, or do you have red flags that you share for a potentially unhealthy one?
Aimee Steiniger, MD: I think some signs of a healthy relationship are partners that have open communication, especially in the setting of problems or issues that they may have. It's really important for your partner to give you space and time to spend with your friends or family or other people. And your partner would really show support and respect you for who you are.
I'd say some red flags can be if your partner's trying to stop you from seeing others, like family or friends, people that are very important to you, someone who might threaten you, someone who could hit, slap, push you. And then things like calling you derogatory names or criticizing you or even humiliating you in front of others or alone. Those are all red flags that we want to look for.
There's a really great website called Futures Without Violence that has really great information for parents to open up this discussion and for signs for parents to look for in their youth if they're worried about unhealthy relationships.
Host Amber Smith: What are the sexually transmitted infections of most concern in adolescents?
Aimee Steiniger, MD: I'd say over the past couple of years, we've definitely been concerned with an increase in sexually transmitted infections among this age range, probably for a lot of reasons.A lot of these infections do not have any symptoms, and people may not be aware of that or aware that they're having the infection. And so it's really important to be screening sexually active young people to make sure that we're really helping them stay healthy.
I'd say chlamydia is the most reported sexually transmitted infection in New York state, and 47% of those diagnoses are among people younger than 26 years of age. So there's a really important infection that we want to make sure we're screening for and checking for.
Gonorrhea is also really important that we're checking. In New York state among males in 2022, the highest gonorrhea rates were among those age 20 to 24, and among females, the rates were highest among those age 15 to 24, meaning there's a really important infection that we need to make sure we're paying attention to in our young adults.
Syphilis cases nationwide are increasing, and it's really important that we're thinking about screening for syphilis because I think it's not always something that we're thinking about.
HIV as well, is so important that we're educating youth about. We now have something called pre-exposure prophylaxis (known as PrEP), which is taking a medication every day to prevent HIV. It reduces your risk of getting HIV from sexual intercourse by 99%, which is phenomenal and is very safe medication to be using.
When I think about STDs, I'm always thinking about the treatments and things of that nature. So chlamydia and gonorrhea, we have treatments and cures for, as well as syphilis. Syphilis's treatment is penicillin, so it's a pretty easy treatment for an STD that we really need to make sure we're watching out for.
HIV still has no cure, but I think PrEP is really an important thing that young people and all people know about, so that if they are engaging in higher-risk behaviors where they may have an increased risk of HIV acquisition, that they can ask their doctor about it and consider whether it's right for them.
Host Amber Smith: Any advice for parents about how and when to talk to their kids about sex?
Aimee Steiniger, MD: Absolutely. So I think what's really important about this is talking to your kids or teenagers about sex shouldn't just be one big talk and then it be over. It's really something that should be a process that, over time, teens and young adults can learn about, and that there's an open door of communication between parents and their young people.
That kind of relationship can really help teens know that they can come to parents when they're wondering about how their body might be changing when they're younger or maybe about sex when they're older. I think whenever your teen comes to you with a question about sex, it's important to answer it in a developmentally appropriate way.
One of the ways that can open a door is when teens come across this information, either on social media or on the television or through music, it's really important that you can use those opportunities as a way to open the door and talk about sex and healthy relationships. It's a good chance to talk to them about what they saw on the TV or heard in the song and ask them what they think about it.
You'd be surprised how much they can tell you about what they think and what they know. It's really important to listen more than you talk, and that can really give you a lot of insight into what your teen or youth is thinking.
Another piece that I think is great is to not always have the word "don't," so: "Don't do this. Don't get pregnant. Don't get a sexually transmitted infection."
It's good to educate them about the ways to protect themselves against those, but you could make sure in your discussion you have more "do's," like what can they do to be sexually healthy with a partner that they do care about? How can they address pressure to have sex when they don't feel like they're ready? And then who can they come to talk to about sex when they're ready to have that discussion? These are really important, and I think what also can be really important for parents is acknowledging sexuality is not necessarily the same as condoning or giving your youth permission to have sex. So it's important to share your values and your thoughts about these things in a non-condescending way, and then give your youth an opportunity to share with you what they think and what they feel.
So I think having this long conversation over all the adolescent years and really being a place that your teens can come forward and feel comfortable talking to you about these things is really the best way to talk to them about sex.
Host Amber Smith: Well, Dr. Steiniger, thank you so much for making time for this interview.
Aimee Steiniger, MD: Of course. You're very welcome. Thanks for having me.
Host Amber Smith: My guest has been Dr. Aimee Steiniger, an assistant professor of pediatrics at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from nurse practitioner Thomas Ringwood from Upstate Medical University. What can a person do if they believe they have an anxiety disorder?
Thomas Ringwood, NP: My main feeling is this: I want people to know that having anxiety is like having a pulse. It's a normal human experience. It's an indication that you're alive.
I worry about a tendency to pathologize normal human experience. And, you know, that's why I think language is so important. So I get frustrated when I see stuff in the news or in the paper about a crisis of anxiety.
Anxiety is normal. If you're feeling completely overwhelmed and like you can't function, that is the time to seek treatment. And I would just encourage a curiosity about what it might mean.
The other thing I want to really send the message is that anxiety is a function, and our current mental health crisis, as it's labeled, is a function of a power arrangement in our society and that it is normal to feel anxious about everything that's going on. And we also live in a time where it's like you can't even seem to get away from it. It's in your face all the time, and, sure, it's normal to feel helpless. COVID, of course, highlighted this, but this was going on before COVID.
So, are we just in the middle of some epidemic? Or are we noticing that lots of people in our society are feeling anxious and what might the reason be for that? That's what I would hope to send the message. So if you're feeling totally overwhelmed, it's normal to feel overwhelmed. If you need help with it, the right thing to do is to call and talk to somebody about it and get the help.
Host Amber Smith: You've been listening to nurse practitioner Thomas Ringwood 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: Barbara Crooker is a master poet whose nine previous books of poetry record all aspects of life, love and loss. The poem she gave us, "The Dailiness of Grief," strips away the drama and suspense to reveal the desolation that accompanies the surviving spouse every minute of every day.
"The Dailiness of Grief"
You wake up alone in a bed
that now seems huge, a vast
Atlantic of flannel. No one
has a pot of espresso hissing
on the stove. The lonely
butter, the pot of jam,
the demi-baguette. Halved,
that's what's happened
to everything. No one's
reading out loud articles
from the newspaper I've
already read. No one
interrupts me at my workspace,
saying I need a hug. Later,
there's no one to talk to
at the end of the day. To walk
with after dinner around
the neighborhood, getting
those steps in. Dinner --
what's the point
of cooking for one? But I do,
and light a candle, put on a CD,
jazz or the blues, pour a glass
of wine. Because it goes on,
this ordinary life, day after
captive day. Because somehow,
the love we shared still exists:
a scent, a memory, a photograph,
the breeze that comes out of
nowhere, caressing my arm.
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," premenstrual dysphoric disorder.
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"produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.