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Professional

Commentary

Season 6 | Episode 5

 

 

Joe McIntyre (Host): Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. 

Listeria and foodborne illness have been prominent topics in the news lately, but what exactly are they and where do these risks come from? In this episode, we will define what a foodborne illness is and take a closer look at Listeria and listeriosis while sharing best practices for keeping you and your family safe.

I'm your host, Joe McIntyre. Our guest today is Doctor Larry M. Bush, an infectious disease specialist. Dr. Bush is an affiliate professor of medicine at Charles E. Schmidt College of Medicine at Florida Atlantic University and an affiliate associate professor of medicine at the University of Miami Miller School of Medicine.

He wrote a chapter on listeriosis that can be found on the Merck Manuals website. The link to that can be found in the episode description. Doctor Bush, thank you for joining us.

Dr. Larry M. Bush: Thank you for having me. 

Host: Let's first start off with educating our listeners about foodborne illness generally. Can you explain what that is?

Dr. Larry M. Bush: A foodborne illness or a disease resulting from the ingestion of a wide variety of foods that have either been contaminated by a pathogenic micro-organism, most commonly by a bacteria. It can be a parasite or a virus or bio-microbial toxin, which is a toxin that an organism produces either prior to eating it or after you've eaten it, and even by chemicals. 

Host: Now, what is the difference between a foodborne illness and a stomach bug?

Dr. Larry M. Bush: A stomach bug is sort of a lay term. A stomach bug, in essence, is the only organism that we really know that infects the stomach is Helicobacter pylori, or H. pylori, which is commonly seen in people who have ulcer disease and occasionally can cause cancer in the stomach. It's really not the stomach that gets infected, but it's the small intestine, and we call that enteritis, or the large intestine, and we call that colitis. Often, when people say I have a stomach bug, what they're referring to is a brief diarrhea disease, most commonly secondary to some of the viruses that we encounter all the time.

Host: What are some of the most common sources of foodborne illness in the United States?

Dr. Larry M. Bush: Well, it depends on the organism, but the majority of them either come from beef or pork or poultry. Additionally, fish, particularly shellfish and contaminated water. Some of these things come from sprouts or melons or plants that we eat. There's a whole range, but I think most people think of them with contaminated beef or pork, poultry, shellfish, other types of fish, and delicatessen meats. We know that Listeria is associated with various cheeses and unpasteurized milk.

Host: What are the other specific foods or handling practices that people often overlook which could pose or create some risk for foodborne illness?

Dr. Larry M. Bush: I think the major thing is undercooking and thinking things that can stay good in the refrigerator for a longer period than they're really meant to be, as well as keeping things outside the refrigerator. It's probably a common practice for people to defrost food outside of the refrigerator and within a few hours the surface becomes defrosted, and even though the center may still be icy, the surface can have organisms contaminated.

Other ones are not washing off your things, your plants and vegetables. Not washing any utensils and the devices that you're using to cut or store these things, putting them next to each other in the refrigerator. 

One common thing that goes unnoticed is raw chicken. People tend to wash raw chicken off in the sink before they use it. That can contaminate other things that are in their sink or other food products that are nearby. If you're going to fry, for instance, chicken breast, it goes directly into the pan and should not be washed off. Those are common issues that increase our risk of developing a foodborne illness.

Host: Does cooking food thoroughly kill all types of harmful bacteria? And to follow up what does cooking thoroughly even mean?

Dr. Larry M. Bush: Well, the CDC publishes documented data on how much the temperature has to reach for certain types of meat. For instance, for beef, veal, goat, and lamb, the recommendation is 145°, and the only way you would know that is not by the
temperature we set on our ovens, but by using a thermometer and I know most people probably do not do that. For chicken and turkey, it's recommended that these be 165°. 

For eggs, it's also 160° or cooking until the yolk and whites are firm. Ham has a lower temperature of 145°, and for leftovers, they should be reheated to 165°. It's variable depending on what type of food you're using, and again, it's really based on using a thermometer and not going by the temperature that's on the oven that we use because it's the inside of the product we're cooking that really counts the temperature measurement and not the outside.

Host: What is the reason that certain meats each have different temperatures to be cooked thoroughly? Why is poultry different from beef? 

Dr. Larry M. Bush: First, the type of microorganisms present in the food matters, as each is sensitive to specific temperatures. Proper cooking is needed to eliminate bacteria. Second, the thickness and density of the meat play a big role. If the meat is very thick, tightly packed, or uneven, the heat may not reach the center properly, leaving parts undercooked and potentially unsafe to eat.

Host: You also mentioned the safe temperature to cook eggs, and I'm sure some of us, myself included, have had a few cocktails with potentially raw eggs in it, or egg whites in them. Is that safe? Is there a significant danger to drinking those types of cocktails or consuming eggs that have not been fully set, either the whites or the yolks?

Dr. Larry M. Bush: Yes, although it's uncommon those may be contaminated with certain bacteria that are prone to be found in poultry or chickens. When you think about the vast majority of people who contract a foodborne illness, either asymptomatic, never get diagnosed or were fortunate in the food or stuff that they're eating just does not carry the bacteria or a sufficient quantity of the bacteria for many of these organisms. It's not just that the bacteria is present. It's also the quantity that has to be present to produce an illness that's symptomatic.

I'm not sure I said this at the beginning, but it's felt that there are about 48 million cases of foodborne disease in the United States every year, and that's hard to know because as you would expect, most people don't go and get examined or tested. Therefore, it's not reported it's a transient gastrointestinal symptomatic disease, but out of those 48 million, about 125,000 get hospitalized and about 3,000 deaths related to foodborne illnesses every year in this country.

Host: Is food poisoning always noticeable immediately after eating contaminated food? Basically, does it require a stomachache or diarrhea or some other symptom for you to know the food poisoning, or can you have it and not even know it?

Dr. Larry M. Bush: Most people probably have it and don't even know it, and they may have some indigestion or transient cyanosis or slight diarrhea. It also depends on which organism you ingest. As I said, the ones that form toxin outside the body and what you're actually eating is the toxin that's been placed in the food where the organism is living. That's very typical of Staphylococcus, as it produces several types of toxins. One of them may be produced in the mayonnaise or the salad that you're eating and the toxins present. In those particular instances, the person gets ill rather quickly, and the illness is a transient nauseous vomiting that may come on even six hours later and go away within 12 hours. That's the same thing we hear about reheated rice, where an organism called Bacillus cereus can live and that also can produce a toxin outside of the body and produce a quick onset of nausea and vomiting.

Other organisms have to percolate, so to speak, in our intestine. They invade the intestine, then they inflame the intestine, and that could take one to three days. Then they'll present with more systemic illnesses like fever, abdominal pain, severe diarrhea. And then Listeria. We'll talk about that some more. Listeria can invade the intestine and invade other organs that may not become evident until days and weeks later. That's why Listeria is so severe. The concern in pregnant women because they may be asymptomatic for quite some time. It does damage to the child, as they can be born with Listeria and it's a common cause of premature labor and stillbirth.

Host: How can someone avoid Listeria? For instance, if a mother doesn’t know she has it—or may not find out for weeks or even until birth—what steps can be taken to prevent it? Is it as simple as following dietary guidelines, or are there other ways to detect or educate yourself about having Listeria?

Dr Larry M. Bush: There are strict guidelines that I'm not sure if many obstetricians actually discuss or present to their pregnant patients about foods to avoid, and what you're really looking for are diseases that would be more severe in pregnant women. Pregnancy is an immunologic deficient state and the reason for that is because the woman is carrying another being almost like a transplant, and you don't want your immune system to attack it. When we think of some of these diseases, they're more severe in people at the extremes of age, very young or very old. Both extremes have either underdeveloped immune systems or immune systems that have waned. They are severe in people who are taking medications that are known to lower their immune system. We see a lot of these advertised on TV for diseases like psoriasis, Crohn's disease, inflammatory bowel disease, rheumatoid arthritis.

Obviously, people who are receiving medications because of transplants or even people with diseases that are common day now, such as HIV or AIDS, and those particular persons have to be very cognizant of what they're eating. For the normal person, eating Listeria bacteria may cause no symptoms, and pregnant women have a 10 to 17 to 27 times higher risk of having a severe disease. The interesting thing about Listeria is since the symptoms may come on so many days after exposure, it's very hard to do contact tracing to figure out who was around the same type of food at the same time because they present at different times.

Host: Is this a reason why pregnant women are often it's recommended to avoid lunch meats and sandwiches that have deli meats in them?

Dr Larry M. Bush: Absolutely, soft cheeses, certain fruits, certain melons, certain types of shellfish and other types of fish. Pregnant women may think that keeping the food in the refrigerator keeps it well, but Listeria likes to grow in cooler temperatures, so there's a whole list of foods that pregnant women are particularly warned against. I'm not sure how often that information is provided to them by their obstetrician, but certainly they could ask. 

Host: We often hear about the sniff test where if you smell something and it doesn't seem right, that means it probably isn't. Even if a certain food passes the sniff test. Can food that looks and smells fine still be contaminated?

Dr Larry M. Bush: Well, unless the quote sniff test has something to do with the odor of the food that's normally there. When we think of why somebody has bad breath or why their bowel movements may have a particular odor, sometimes people complain of odor in their urine. It's really the byproducts of bacteria or the bacteria themselves dying that produce odor; that's what gives us bad breath.

So if you have a quote “sniff test” and the food smells like it should not. The assumption would be that there is bacteria. It's heavily laden with bacteria that are produced by products or that are dying and not dying, and by-product production produces that odor. I would certainly avoid them. Not only dispose of it but clean the surface that they were on. If you stored them in a refrigerator, you need to make sure that you clean everything in that refrigerator. If you have food that's been sitting up against them, that should be discarded. It's important when you put food such as poultry and beef in the refrigerator. You separate it if it's open and not in the container for many of your other foods.

Host: You mentioned a few issues where you wish more doctors spoke to their patients about potential issues, especially for pregnant women. As an infectious disease specialist, are there any other tips that you would recommend that we haven't talked about so far for people to avoid eating certain foods based on their population, their gender, their whether they're pregnant or not? Are there any other recommendations that you have that we haven't talked about so far?

Dr Larry M. Bush: The immunocompromised people that we talked about and a lot of people think, well, my immune system's fine, but if you're taking even a high dose of Prednisone, a common corticosteroid medication for various reasons. Once you've been on it for several weeks and we're only talking around 3 weeks, your immune system does become defective to some degree, and we don't necessarily measure that to say, well, how much is my immune system down? So I would recommend all those people. Be careful with some of these foods, undercooked food, food lying out, foods that are known to carry certain bacteria that you would not know because of the taste. Additionally, deli meats, shellfish, etcetera.

I don't know if you've ever noticed or your listeners have noticed that if you go into seafood restaurants, it tells you that if you have underlying immunosuppressive disorders or you have liver disease that should really avoid shellfish because shellfish can carry something called Vibrio vulnificus. People who have underlying diseases may have a really severe, complicated infection. Not just gastrointestinal, but infections that will cause what we call necrotizing fasciitis, which destroys the soft tissues on your arms and your legs. So those types of folks clearly have to be aware of what their immune system may or may not tolerate. And even though we like to dwell on eating certain foods, I would clearly avoid them.

Host: Are there any other myths that you find yourself busting or coming across, whether it's friends or colleagues or potential patients or those students you come across asking you these questions that you often find yourself busting often?

Dr. Larry M. Bush: I'll tell you one myth that's very interesting. People think if they eat in a so-called 5-star restaurant, the chance of getting ill from the food is very small. All foods are checked by the FDA and they go under their practices. But five-star restaurants, if you walk into the kitchen of a 5-star restaurant as opposed to, let's say, a fast-food restaurant like McDonald's or Burger King. The people preparing the food in a five-star restaurant, and you may notice this on these chef shows on TV, well they don't wear gloves. If they happen to be transmitting any organism asymptomatically in their stool, it's likely to get on our food. So, the highest rate of food illnesses, if they're related to a restaurant, usually are in high-end restaurants, so to speak.

Host: As we wrap it up here, I know we talked about a handful of foodborne illnesses. Can you tell us what is the most common? What is the most common that you come across? What is the one that you see most often here in the US?

Dr. Larry M. Bush: I don't come across it that much and partly because it's self-limited for most of the time. People tend to get better after an acute illness which would either be nauseousness, cramping or diarrhea. They don't get very ill; it doesn't spread to other parts of the body, so therefore, you don't get somebody with a gastrointestinal foodborne disease and now winds up with a brain or a spinal fluid infection like that could happen with Listeria. The other thing is it's very contagious and the answer is norovirus. Norovirus is the number one foodborne illness in United States. We always associate it with cruise ships and the reason for that is because it's so contagious and people are so contained and going to the same dining room over and over and over that a lot of people get ill.

Norovirus is transmitted in seafood is transmitted in salads. Therefore, you get to really wash off your lettuce when you're preparing your salad, etcetera. But that is the most common illness in the United States that people don't give much thought to. Because they say, “Well, I haven't been on a cruise.” You don't have to be on a cruise. The difference on a cruise is its very close contact with the other people on the ship with you.

Host: Are there any tips that you have to avoid it other than not going on a cruise?

Dr. Larry M. Bush: Well, one, it's who is preparing the food, so you don't have a lot of choice. But two is to carry hand sanitizer with you and use it, not sparingly, but use it quite a bit everywhere you go. It will eliminate the norovirus on your hand before you get it into your mouth.

Host: Well, Doctor Bush, thank you so much for joining us on the Merck Manuals Medical Myths podcast. If our listeners are looking for more information about listeriosis or maybe other foodborne illnesses, where should they go?

Dr. Larry M. Bush: The CDC website is always a good resource for information that deals with diseases, et cetera. This is both treatment diagnosis and prevention. I would recommend the Merck Manual. I'm not just saying that because I'm involved in writing some of the chapters in the Merck Manual, I'm saying that because I can tell you, I teach medical residents and training and intern. Medicine and every one of them has it on their phone and their computer desktop because it's a great resource. I know how often it's up to date and I know the people who are involved in writing it. It's the most used medical book, both professional and consumer in the world.

Medical knowledge is essential; it has changed the world, and it will continue to do so. It is up to us to acquire that knowledge.

Host: Well, thanks again, Doctor Bush. I will let you leave our listeners here with the final word.

Dr. Larry M. Bush: Medical knowledge is power, please pass it on to your friends and family.

PODCAST Foodborne Illness with Dr. Larry M. Bush

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Season 6 | Episode 3



 


 
Pediatric Myths



 
Dr. Alicia Pekarsky, MD: Parents don't have to be perfect. They have to be good. They have to be loving and attentive and they have to do their best.
 
Joe McIntyre (Host): Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. Today's episode will focus on the question that keeps many parents up at night. Why is my baby crying? 

I'm your host, Joe McIntyre, and to help us answer that question is Dr. Alicia Pekarsky, an Associate Professor of Pediatrics at SUNY Upstate Medical University, Upstate Golisano Children's Hospital, and she also serves as program director of Child Abuse Pediatrics Fellowship at Upstate Medical University, Golisano Children's Hospital. Dr. Pekarsky also specializes in general pediatrics, child abuse pediatrics, and neglect. She also has chapters about child neglect and abuse available for free on merckmanuals.com. 

Dr. Pekarsky, thanks for joining us on the podcast!
 
Dr. Alicia Pekarsky: Thanks so much for having me.
 
Host: Our first question for this episode is why do babies cry?
 
Dr. Pekarsky: There are so many reasons why babies cry. I think some of the more obvious reasons are things like hunger, baby is in a wet or dirty diaper, baby may be too hot or too cold, or even possibly developing a viral illness. On the other hand, there are other reasons that I think that many parents and caregivers overlook. Sometimes, the baby is overstimulated, just too much is going on in their environment, and sometimes they're bored. 

The other possibility, I think babies cry if they have an injury that just hasn't been recognized by the parent yet. And then another theory is that babies cry because they have an immature nervous system, and they're just unable to soothe themselves when they're frustrated.
 
Host: Let's move on to the question about colic. Can you explain what colic is and the symptoms it may present in infants?
 
Dr. Pekarsky: Colic is defined by frequent and long periods of crying that occur in young infants who are otherwise completely healthy and well. The crying typically begins in young infancy. In those first few weeks of life, it peaks between six to eight weeks of life and tends to resolve by three to four months of age. And then another feature of colic crying is that it typically occurs around the same time, in the late afternoon and early evening, but the child is otherwise completely healthy.
 
Host: I'm sure a lot of parents have questions like my child is crying for x number of minutes, maybe x number of hours. How long should a parent try to comfort a crying baby before deciding, hey, maybe this is an actual emergency and not just a baby who is frustrated or one of the other reasons you mentioned in the beginning?
 
Dr. Pekarsky: It’s going to be longer than minutes. I think you're right when you point out hours because babies with colic will cry for hours. I think that the most important thing to do before you chalk it up to colic is to look at your baby, check your baby, and feed your baby. But I think after a couple of hours, it should kind of quiet down. If your baby's crying from 6 pm to 9 pm, for example, most nights of the week, and then is otherwise well during the rest of the day, acting well, feeding well, and is engaged with their environment. It's not anything to worry about in terms of a medical emergency. Of course, it can cause a lot of frustration and anxiety in parents. 
 Host: I'm sure it can. I have a question here, which may be a little bit silly. When a baby is crying, that doesn't mean that the child is angry with the parent or does not like a parent or does not like someone else? It could mean a whole host of things, but probably not anger is my guess.
 Dr. Pekarsky: That's right because infants with colic are those young infants. They're not angry with the person who's caring for them. They just don't have that level of intentionality yet. And it's important; this is such a great question because the level of frustration that the parents feel towards themselves, their family, and the child just increases exponentially. I think it's important to remember that children cry for so many different reasons, as we mentioned before, and it really has to do with the child.
 Host: Is there a strategy or advice you give to parents to handle maybe the guilt, for lack of a better word, of not being able to stop your child from crying?
 Dr. Pekarsky: It really depends on the level of concern that the parents are having. If they're just having some mild feelings of guilt, one of the recommendations I will make, which may seem very simplistic, but it is effective, is just to put the baby down in a safe place and walk away, whether it's leaving the room, or it's taking a walk around your house or around the block. Interrupting that cycle and walking away may just brighten your mood. Other simple things that most people can access are turning on music or free apps that help with deep breathing, which are important. 

However, there are some parents who are really being pushed beyond guilt into postpartum depression or feeling angry towards the baby. I would recommend speaking with a pediatric medical professional. In addition to if you have a trusted friend or family member, it's important to engage our community resources when parenting because it's one of the most challenging things that people will ever do.
 Host: I'm sure plenty of parents have also held their baby trying to get them to fall asleep, finally, get them to fall asleep only for them to start crying again once they put their baby down. Can you tell us why that may be? And if there are any strategies or ways to kind of resolve that?
 
Dr. Pekarsky: Yeah, sure. Babies love to be in physical contact with their caregivers. I think, when we think about babies, not as little people, we really discourage that in pediatrics, but just as human beings, it makes sense that they want to be close to the people that they love and who love them. So, they don't have the same level of awareness as older children and adults do, but they recognize when they're being placed down, they're no longer next to their warm caregiver. And I think they respond to that because they're frustrated with crying, that's their way of communicating, they don't have a lot of other ways, especially in the first six months of life, to respond to their environment. They signal their distaste for being placed in their safe sleep space, while crying. And I know some parents there's a lot of different approaches to this. One approach is to put the baby down, walk away, close the door, and either listen to the crying because you have a monitor, or don't listen to the crying, and it will extinguish eventually, and you have several rough days when you're doing that. So that's one method of sleep training, and some people are able to tolerate that, I will say that it is really challenging for new parents, whether it's their first baby, second, third, or fourth, to listen to the baby cry a lot, and some people live in smaller homes that they really can't get away. I never recommend that if the parents are not ready to do that. 

Another technique is to put the baby to sleep, and then go back and reassure the baby that the parent is still there. And I think that has its pros and cons for the baby and the parents. It's sometimes sad if it satisfies the parents more than the baby, though, because the baby may be, like, partially asleep, and then the parent comes in to pat them or even comes into the room, and the baby wakes up again. It's based on parental preference and support and resources. I wouldn't recommend this for a parent who's parenting alone, necessarily, who has three other kids in the house and who's already really frustrated. I would, for that family, recommend lots of soothing, as much as possible, with walking with the baby, white noise, other things that may help the situation.
 
Host: Yeah, so there's no right or wrong way to handle situations like this. Which I'm sure in some ways is probably good for parents to hear and in some ways, it may be frustrating, because there is no one way. It's basically whatever feels right for the parent in some ways? 
 
Dr. Pekarsky: I think in medicine, and especially in pediatric medicine, which I practice. It's shared decision-making. In shared decision-making, even about parenting practices, the parents have the final say in everything. And if a parent comes to me and says, “What would you do?”, then I tell them what I would do and what I did do with my children when they were young. And sometimes, families just want to hear that, and I'm happy to talk to them through my professional and personal experience.
 
Host: It feels like parents can be understandably very judgmental of themselves and want to be the best parent that they possibly can be. But as you said, asking a doctor like yourself, asking a friend or someone, a family member you're close with how they handled it can be reassuring to know that hey, whatever you do, whatever you decide to do, is probably going to be right for you and your child.

Dr. Pekarsky: I think as long as they're being safe, the things to avoid are in my opinion, endorsed by the American Academy of Pediatrics, not sharing the sleep surface. If you're getting to a point where the only way you can get your child or your baby to sleep is by sleeping in the same bed with them, then we have to revisit that approach. And then the other issue that will come up, of course, no one would condone this as someone who's become so frustrated that they pick up and hurt the baby. So in those scenarios, the latter, the advice is always put the baby down in the crib, walk away. Doesn't matter if the baby's crying, the crying is not going to hurt them. It's more piercing to our ears and our hearts as parents. 

I think parents need to know that because you're right, there's so much judgment of parents, especially these days with social media, and all the resources that are online. And I think you said it best: parents don't have to be perfect, or you were kind of going there; parents don't have to be perfect; they've got to be good. They've got to be loving and attentive, and they have to do their best.
 Host: Yeah, just to maybe reiterate, it is true that if you leave your baby in the crib or in their bassinet, whatever it is, and then check on them periodically, they will eventually go to sleep, the crying will eventually stop to tell parents that hey, this won't last forever.
 
Dr. Pekarsky: It won't last forever, but for anyone who's parented or has provided care to a young infant, it feels like it's going to last forever. But I can guarantee you it won't. Particularly if you look at the length of time that this occurs during the baby's life, it is a period of time when most babies are starting to soothe a little bit better by three months of age. But it is an incredibly long period of time when you listen for hours on end to the baby’s cry. I should also mention that sometimes colic just presents as a baby who must be soothed the entire time, so that's also a baby who has colic. It's just that you can soothe them, but you must hold them the entire time, or you have to rock them the entire time, which is exhausting as well.
 
Host: What are some tips or best practices you have? You mentioned rocking, consoling kind of constantly. But some best practices for parents to console their baby who may be crying a lot.
 
Dr. Pekarsky: I’m going to share a personal tidbit because my youngest child had colic. And some of the things that worked best for her were holding her and walking around with her, which we mentioned. Another thing that I eventually figured out when she was a little bit bigger, I think probably around the one-month age, maybe six weeks, was putting her in an infant carrier that was strapped to my chest, because she needed that contact, and she was fine. If I had her against my chest, she would have been fine. That allowed me to move about my home, do chores, do the other work, and take care of her twin brothers, who were toddlers at the time. 

Some other things that help babies would be swaddling, and it's not super-duper hard to swaddle an infant, you can get help from a pediatrician or a nurse in a pediatric practice or another pediatric professional. Maybe your parents and extended family may know how to do it as well. It's just important that it's not so tight that the baby can’t obviously breathe. You must make sure that the blanket is below the collarbone of the baby so nothing comes up above their face. But they do like that sensation, it kind of mimics them being in utero when they were growing and kind of being compressed by the uterus. 

I'd say another technique is to use white noise and this makes sense again, other people, adults use white noise, kids use white noise to sleep. Sometimes that sound, whether it's a white noise machine or something as simple as putting your phone on with some white noise or the vacuum like people used to do. Those are very effective at soothing babies. It's not going to work every time, but that's a great technique as well.
 
Host: Dr. Pekarsky, there's a myth, or maybe it's not a myth, out there that sometimes crying for an infant child is their form of exercise. It's their way of moving their body, moving their muscles a little bit. Is that the truth? What's the reality there?
 
Dr. Pekarsky: That's an interesting question. I don't think I've been asked that, or anyone's shared that myth with me, but I can see it. And it kind of makes sense because if we think about crying as a way of expending energy, I think babies who are overstimulated do cry. And that's their way of getting off some of that steam that they have built up. Older children and adults could use, hopefully, their words to express themselves and other modalities, but infants have nothing else besides the sounds that they make.
 
Host: It's very interesting. We all have our own ways, I'm sure, of expending energy, whatever it is that we're looking to get out of our bodies and babies are limited, so that's interesting. Dr. Pekarsky, you're also an expert in child abuse pediatrics. Can you talk to us about Shaken Baby Syndrome or shaken baby? How does that come to be? What are some of the effects of that? And obviously, why is it so important for parents to avoid that?
 
Dr. Pekarsky: As a child abuse pediatrician, I see many victims of abusive head trauma. And while it is gratifying to make that diagnosis, to help the child and family moving forward, I think prevention is the key in terms of avoiding this because it does often lead to lifelong permanent disabilities for children. So many times, babies start crying between three and four weeks, and they peak at about two months of age. And that is the time when we start to see more cases of abusive head trauma. The peak in crying coincides with the peak in the diagnosis of abusive head trauma. 

The message I'd like to share is to normalize that for parents and caregivers, that baby is crying, it's normal, it's probably healthy for the baby, even though it doesn't feel like it to us as parents and caregivers. And the baby is fine. And you're doing a fine job as a parent. As a medical professional and as a general pediatrician, I always share with families at their child's two- and four-week visit, as part of my anticipatory guidance, that your baby is likely to start crying a lot more over the next couple of weeks. 

If we can share that with families in advance, normalize it, and say it more than just once, during a time period when they're exhausted and tired and taking care of lots of other things. Hopefully, they will internalize that and be less frustrated when their baby does start to cry more. We want to avoid parents and caregivers shaking because most times when parents and caregivers do that, they're not doing it with the intention to hurt their child or they're not waking up in the morning and thinking I want to shake my child because I want them hurt. They're doing it because they're frustrated. And their threshold for frustration and acting out on that has been crossed. Because babies are frustrated when they cry. We need to normalize crying and we need to tell parents and caregivers that they're doing a great job and be supportive of them. And hopefully, we're going to decrease the incidence of abusive head trauma over time with that and other measures.
 
Host: Finally, Dr. Pekarsky, if our listeners are looking for more information about general pediatrics, colic, crying children or just have questions about parenting, where should they go for that?
 
Dr. Pekarsky: I would reference the chapter on colic at merckmanuals.com and another great resource is healthychildren.org which is produced by the American Academy of Pediatrics. There are several pages on colic, crying and what to do for your baby there.
 
Host: Dr. Pekarsky, thank you so much for joining us on this episode of the Merck Manuals Medical Myths Podcast. As we close it out, I'll let you leave our listeners with a final word.
 
Dr. Pekarsky: I want to thank you for having me. It's been a pleasure. Medical knowledge is power. Pass it on.
 
Host: Thank you so much.



PODCAST Pediatric Myths with Dr. Alicia Pekarsky

podcast-pediatric-myths-with-dr-alicia-pekarsky

Season 6 | Episode 3Pediatric MythsDr. Alicia Pekarsky, MD: Parents don't have to be perfect. They have to be good. They have to be loving and attentive and they have to do their best.Joe McIntyre...

Season 6 | Episode 2



 

Snoring Podcast
 
 
(Joe McIntyre) Host: Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. I'm your host, Joe McIntyre. This is part two of our two-part series with Dr. Richard Schwab, a professor at the University of Pennsylvania Perelman School of Medicine in Philadelphia, where he is the chief of the Division of Sleep Medicine. On our first episode of this series, we discussed the topic of insomnia; why it happens, how it affects us and what we can do to prevent it. If you haven't listened to that one yet, please check it out. In this episode, we will dive into another issue with bedtime, sleep apnea and snoring. Now Dr. Schwab, let's switch gears a little bit and get away from insomnia and to a couple other sleeping issues: snoring and sleep apnea. So, something I'm sure many people face, either they have or maybe their partner experiences one or the other. Why do some people snore?
 
Richard J. Schwab, MD: So, snoring is really common. 15% of women and 25% of men are chronic snorers, in terms of intermittent snoring, it goes up into the 40-45% range. And then alcohol, just as it was bad for insomnia is also bad for snoring. So you can take someone who normally doesn't snore, you give them alcohol and they'll start to snore. Or you can take someone who snores, and you give them alcohol; their snoring will get worse, and they may develop sleep apnea. Or if you have a patient with sleep apnea, and then you give them alcohol, they even get worse. But to answer your question, snoring is abnormal; it's typically a vibration of the uvula or the soft palate, that is the thing that hangs down in the back of your throat. So, it vibrates. And that's what causes the sound of the snoring. So, if your airway’s narrow, obesity is the primary risk factor for sleep apnea. But and so many people who snore have sleep apnea. But if you have an abnormal airway, in particular, a large tongue, big tonsils, big uvula, small jaw, or your jaw’s back, they will put you at risk for snoring. So it's really common, but it means there's something wrong with your airway. It's not normal to snore.
 
Host: Those nose strips that people may see in the pharmacy or on TV commercials, whether they have magnets in them or whatever they are just maybe some metal, do they actually stop you from snoring?
 
Dr. Richard J. Schwab: No. So snoring is a problem in the back of your pharynx where the uvula is. So, what these Breath Right strips do is they open up your nasal valve. So, for the audience, everybody take a breath through your nose. Okay, now push your nose up and take another breath. It should be easier to breathe with your nose up. So that's a nasal valve. So, if you have a nasal valve problem, these Breath Right strips or whatever you want to call them, will help that. But it won't help apnea at all. So, they're not expensive, it's not going to hurt you, but it doesn't help apnea.
 
Host: Good to know. One question that I'm sure a lot of listeners have in their head is how in the world do I stop my partner, or the person I'm sleeping with, or my sibling that I'm in the same room with from snoring? How is that possible? Is there a way to do it?
 
Dr. Richard J. Schwab: So there's no simple way. You can do a lot of things, though, to wake them up. So, you can wake them up, and they'll stop snoring. You can move to another bedroom so that the snoring won't bother you; you can try to move them. So, maybe they're on their back and you move them to their side. Typically snoring is worse in the supine position when you're sleeping on your back. So, if you move to your side that will help. But most of it involves somehow knocking your partner from a deeper stage of sleep to a lighter stage of sleep or waking them up. Hopefully, they'll go back to sleep. But what typically will then happen is they will begin to snore again or have apnea again. So, there's no simple way of getting rid of that outside of waking them up.
 
Host: You just mentioned that moving them from a deeper sleep to a lighter sleep, is there a certain cycle, sleep cycle, where snoring is more likely to occur?
 
Dr. Richard J. Schwab: Yeah, typically in your deeper stages of sleep, but even in stage two sleep, you can see loud snoring; stage three is deeper REM sleep. Apnea is typically worse in stage three, in REM. Snoring can be anywhere, pretty much across all those different sleep stages. You can figure out when somebody falls asleep because they often will start to snore. But you can't really fix that either. There's no way to modify that, so you’re kind of stuck with it.
 
Host: Now, if you snore really, really loud, does that mean you have sleep apnea? Essentially what is the difference between snoring and sleep apnea.
 
Dr. Richard J. Schwab: Almost everyone who has sleep apnea snores, but not everyone who snores, has sleep apnea. So, snoring may just be that your airway is narrowing a little bit and, again, fluttering your soft palate. Sleep apnea is where your airway narrows enough that you either reduce your airflow and drop your oxygen or you have complete apnea; apnea means the sensation of flow. So, you're not getting any air through and that's associated with a lot of cardiovascular diseases. But it's basically snoring, which is the first sign that you are potentially at risk of apnea. But then as your airway gets more crowded, maybe you gain more weight, or you start a sleeping pill or something else because those actually increase your risk for sleep apnea, then you develop apnea, but it's a progression. Snoring is a sign of sleep apnea. Again, you can snore and not have apnea, but almost everyone who has apnea snores.
 
Host: Okay. Why is sleep apnea such a concern? What are the risks associated with it? What happens if you have it? Take us through that a little bit.
 
Dr. Richard J. Schwab: So you can think about it, all of a sudden, you’re snoring, and then you have apnea, and you have sleep fragmentation. You're not even getting into deeper stages of sleep. So you're going up and down, your oxygen is dropping. There's sort of sleep fragmentation and arousals and changes in blood pressure as you're going off to sleep. And you wake up the next morning, you know, although you may have slept for seven or eight or nine hours, you feel like you didn't sleep at all because you never got into deeper stages of sleep. Because every time you go into a deeper stage of sleep, your oxygen drops and your body says, “I don't like that,” so they're going to wake you up. You have sleep fragmentation. There are the sleepiness effects of sleep apnea, and then obviously you worry about people driving, right? So they fall asleep driving, they are falling asleep at a red light, or they're falling asleep in movies, or they're falling asleep in face-to-face conversations. So there's a sleepiness effect, which can be important, especially if you're driving. And then there's a lot of cardiovascular effects because every time you have an apnea, it's like it's a sympathetic surge, or it's a surge of adrenaline. So all of a sudden, your blood pressure goes up. And then, so now you have high blood pressure, you're developing higher blood pressure, you can have heart attacks, or you can have strokes or different cardiac arrhythmias because your oxygen is dropping in atrial fibrillation. So, there are all these cardiovascular effects, and there are sleepiness effects. So, with treating sleep apnea, when we treat it, a lot of people feel like they've had a brain transplant. They go, “Oh my God, I can think again,” “I'm not falling asleep,” “I don't have to read a paragraph four times,” or “I'm not falling asleep or red lights.” And all of a sudden, their blood pressure gets better, they feel better and they're at less risk for heart attacks and strokes. So lots of reasons to treat it.
 
Host: Is sleep apnea only a concern for older adults or can it affect younger folks or even children?
 
Dr. Richard J. Schwab: Everybody. So, there are different anatomical reasons. Typically, it's an anatomic disease, and you have different structures in the back of your throat that put you at risk. Kids usually have big tonsils or big adenoids. So, you can take them out, and they'll get better. But the primary risk factor in adults is obesity. That makes your tongue larger, and you have more fat in your tongue, a bigger soft palate, and more fat in the soft palate. So, obesity is the primary risk. And then, as you get older, you can see it in those patients, too. A lot of times their apnea isn't necessarily as based on obesity anymore, but just as you get older, your apnea gets a little bit worse. So, all age ranges, but the most common is 30 or 40-year-old, overweight gentlemen with high blood pressure, or typically menopause makes sleep apnea worse. So typically, a woman in their 40s may not have sleep apnea, but a woman in their 50s will. Again, typically menopause creates some weight gain, and that's part of it. But almost any age range will have sleep apnea.
 
Host: Should you always see a doctor if you snore at all, or if you snore regularly, just to make sure that it's not a sign of a serious issue? When should you decide hey, I should probably see someone about this. 
 
Dr. Richard J. Schwab: Yeah, I think if you're snoring chronically, I would do it. If you snore only when you're drinking alcohol, your intermittent or nasal allergies or something like that, probably don't have to worry about it. But if you're snoring on a regular basis, and especially if you're sleepy during the daytime, you have high blood pressure, your bed partner starts to notice you stopped breathing at night. Go see your general doctor and I would get a sleep study. It's easy. You can do sleep studies at home; it's relatively easy. Sometimes, you do them in the lab, in the sleep lab, but a sleep study is not risky. And you can make sure you don't have apnea and like I said, if you have it and you treat it, you're going to feel better.
 
Host: If you have sleep apnea, is the only treatment today wearing a mask or breathing machine when you sleep? Is that the only solution now or has that changed in the past few years?
 
Dr. Richard J. Schwab: So it's changed. First of all, the masks are much better than they used to be. They're much more comfortable, a lot of them fit under your nose. CPAP stands for continuous positive airway pressure, which is the machine you're talking about. They are good in the sense that we can at least track your use. We know how many hours people use it, how many days, if it's working or not, there's a measure of efficacy and if they have mask leak. So that technology has improved, and in time, I think you're going to see personalized masks that even make it better. But it is a nuisance, and probably 30 to 50% of patients can't use CPAP. There are other options; there's oral appliances, which are appliances that fit in your mouth to pull your lower jaw forward. So, your tongue, the part you can't feel inserts into your chin. So if you move your jaw forward, it's going to pull your tongue forward, the base of the tongue, and that's going to help apnea. There are a lot of different oral appliances there; they can be a little pricey, but they work pretty well. And then there's a lot of surgeries, especially if you have big tonsils, you can take them out, that works. The newest surgical procedure is something called hypoglossal nerve stimulation, which is basically a pacemaker for your tongue. So it's a device that is inside your body and inside the right side of your chest. And then there's a lead that goes to the hypoglossal nerve, which is under your chin, and it stimulates that nerve to push your tongue toward your lips. And what's cool about that surgery is that it works about three-quarters of the time, which is better than almost any other surgery. It's reversible. It's expensive, but if insurance covers, you can take it out. But you know, if you take out your gallbladder, you can't put it back in. This you can take out and so from that standpoint, it's kind of nice, it's reversible. So if you hate it, you can take it away.
 
Host: Are there any other misconceptions or myths about snoring or sleep apnea that we haven't talked about yet that you want to address here?
 
Dr. Richard J. Schwab: So, couple points again, one with alcohol, alcohol makes sleep apnea worse, snoring worse. So be careful. And one of the things I kind of make fun of is, you know, if you drink alcohol at lunchtime, you're good to go. So the martini lunches, no problem. But if you're drinking at dinner, and you're going to be sleeping the next four to six hours, not a good idea. The other thing that's going to change, that is already here, are these GLP-1 agonists for weight loss. They're going to be a game changer, we believe, in terms of not only treating hypertension and obesity but sleep apnea and in people who are heavy. These medications do a really good job of suppressing your appetite and can absolutely help sleep apnea. So, I think that's something that people listening to this should think about and talk to your general doctor about these GLP-1's, there's a bunch of different types, and there's going to be newer ones coming out. But I think that's something people should pay attention to, at least in the treatment realm for sleep apnea.
 
Host: So Dr. Schwab one final question, at least from me, before we close out. I actually just purchased this book, “Why We Sleep” by Dr. Matthew Walker, that gets into some of the background, historical aspects of why mammals sleep in general. But in your perspective, why do humans, why do we need to sleep?

Dr. Richard J. Schwab: I would say that's a million-dollar question. It's probably a Nobel Prize kind of answer. If I knew the answer. If you think about it, from a Darwinian standpoint, survival of the fittest, sleeping is a bad thing. If you're an animal and you're sleeping, somebody can come gobble you up, right? I mean, that doesn't sound good. And so there's nothing really beneficial from a survival standpoint in sleeping. So, it must have a huge impact. It has an important effect. And as far as we know, every mammal sleeps, even fish, part of the brain shuts down in dolphins etc. So, it is clearly important. The why though, whether it's important because of memory, whether it's important for cleaning sort of waste in your brain. I mean, there's been lots of theories, but I don't think we know. But I think it's fair to say that it's really important and that you need, everyone needs to sleep and obviously if you get a good night's sleep, you have a better day at work, you can function better, think better and the whole nine yards. But to answer your question, I don't think we really know why it is, but someone will win a Nobel Prize if they figure it out. 
 
Host: Someday soon, hopefully. Final question. Dr. Schwab. If our listeners are looking for more information or have questions about snoring, sleep apnea, insomnia, where should they go?
 
Dr. Richard J. Schwab: Well, absolutely go to the Merck Manual, or merckmanual.com. There's lots of information there. You're going to not only see these podcasts, but there's information on all these different sleep disorders. So pay attention to that. That's where I would go first.
 
Host: Dr. Schwab, thank you so much for joining us on this podcast. Great conversation busting some of the myths surrounding insomnia, snoring and sleep apnea.
 
Dr. Richard J. Schwab: Thanks Joe, it was fun as usual.
 
Host: As we close out, I’ll let Dr. Schwab leave our listeners with the final word.
 
Dr. Richard J. Schwab: Medical knowledge is power. Pass it on.


PODCAST Snoring Myths with Dr. Richard Schwab

podcast-snoring-myths-with-dr-richard-schwab

Season 6 | Episode 2Snoring Podcast (Joe McIntyre) Host: Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked...

Season 6 | Episode 1



 

Insomnia Podcast


Joe McIntyre (Host): Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. Today, we're taking a closer look at sleeping disorders, specifically the common ones that most of us are familiar with but may be misinformed about: insomnia and sleep apnea. I'm your host Joe McIntyre, and I'm joined by Dr. Richard Schwab. Dr. Schwab is a professor at the University of Pennsylvania Perelman School of Medicine in Philadelphia, where he is the chief of the Division of Sleep Medicine. If that name sounds familiar, Dr. Schwab did a two-part series on sleep and dream myths last season. If you haven't listened to it, please be sure to check it out. Dr. Schwab, thanks for joining us on the podcast.
Dr. Richard J. Schwab: Thanks, Joe. Glad to be back.
 Host: Oh, we're glad to have you. So let's start off with the topic of insomnia. Can you tell our listeners what exactly insomnia is and how it is different from occasional sleeplessness?
 Dr. Richard J. Schwab: So insomnia is a perception of inadequate sleep. And all of us have insomnia some of the time, right? You don't sleep well one night and the next night, you sleep better, and you wake up fine. Typically, what happens in somebody who has chronic insomnia or prolonged insomnia, it's multiple nights where you have trouble sleeping,
 
Host: Does having insomnia mean not getting enough sleep? Or does it mean not getting any sleep? Is there a scale there? How does that work?
 
Dr. Richard J. Schwab: Yeah, it's hard because you're not measuring sleep in patients at home, at least we don't do that on a clinical basis. You could do it on a research basis. And again, it's this perception that you're not getting enough sleep, you may have actually had a lot of sleep, but you've perceived that you don't. And so we don't really know the answer that question. But you're getting some sleep. It's not as if you're getting no sleep, you get some sleep, but you just don't get enough sleep and you feel awake, you wake up and you just don't feel refreshed. You don't feel like you're yourself, you feel like you didn't get a good night's sleep. But it's more of this perception. So it's not so quantifiable.
 
Host: Does insomnia affect people in different ways? Meaning if someone gets, let's say, for example, five hours of sleep that may constitute insomnia versus if someone gets four hours of sleep, that may be okay, there may be enough sleep for them. How does that work? 
 
Dr. Richard J. Schwab: Yeah, it really depends on how much sleep you need. And everybody's a little different. People need, in general, seven and a half to eight and a half hours of sleep. But it's really hard to figure that out. The only way you can sort of determine how much sleep you get is when you go on a vacation for two weeks and the first week and just kind of recover from all the sleep deprivation because we are all sleep deprived. That's why we all drink coffee. We're all sleep-deprived. But if you take a week off, and then you don't drink alcohol, and you don't exercise differently, you might be able to figure out what the normal amount of sleep you require. But most people don't know that most people get more sleep on the weekends because we're overworked during the week, but in general, seven and a half to eight and a half hours. But there are people on both ends of that. So there are people who need or can get by with five hours of sleep and other people who get by with 10 or 11 hours of sleep. But the insomnia piece of this is, well, if I normally get seven half hours of sleep and now, for whatever reason, I'm getting six hours asleep, or at least that's what I'm perceiving, then I'll feel like I have insomnia.
 
Host: Now let's dig into some of the myths surrounding insomnia. Is it true that a person can really live on no sleep at all?
 
Dr. Richard J. Schwab: No, everybody needs to sleep and pretty much every mammal that we know of needs to sleep. How much sleep... a little more debatable, but everyone needs to sleep.
 
Host: There's a common thought that some over-the-counter products, such as melatonin, are the be-all and end-all to any person troubled with this disorder. Is there any merit to that?
 
Dr. Richard J. Schwab: There is. First of all, we can get into this, alcohol is really bad. So, one of the things people will say is you know what, I have problems with insomnia. Let's try alcohol. Alcohol causes sleep fragmentation. It may get you to go to sleep but alcohol is a really bad choice. In terms of other over the counter products of the group, melatonin is the safest. One of the problems with melatonin though, is that we don't know what the right dosage is. It's not a medication, it's just a brand, and if you buy something that says one milligram of melatonin, you may not be getting one milligram, you may be getting less, you may be getting more. In general, you don't want to take any more than 10 milligrams, but it is a naturally occurring hormone. It's not generally dangerous, but if you take too much, it will be a problem. And there was a recent report about kids taking too much and opening up the bottle. So you really need to protect it from younger people. Most of the Benadryl-type agents are like Tylenol PM, anything with PM in it. There's really very little data to know if any of those products are any good. They have a long half-life. So, if you take Benadryl, you may sleep well into the next morning; they have anticholinergic effects, so they are not good for men who have large prostates. We don't really recommend the Benadryl agents very much. And I don't think anybody should really be taking advantage of like medication unless they have an allergy or skin rash or some other reason why they're taking Benadryl, but I'd be cautious of all the PMs and of the over-the-counter, melatonin is the best, but again, very little data to support its use.
 
Host: Good to know. Now let's get into some of the differences in age for a minute here. I've heard insomnia is just a normal part of aging. As you get older, you're probably going to experience insomnia. Is that true? Is that the reality?
 
 
Dr. Richard J. Schwab: No, I don't think that's true. I do think that menopause in women causes a lot of sleep fragmentation and hot flashes. It is not uncommon for women going through their menopause to have problems with insomnia. But I see plenty of patients who are 30 years old who have insomnia which is probably more genetic than anything else. As you get older, your sleep will be reduced; you often lose what we call delta sleep and you will get less sleep. But insomnia doesn't have to be a part of aging.
 
Host: I assume most people are aware that exercise is an important part of getting a healthy night's sleep. It's an important part of a healthy life. But how does diet affect our ability to sleep either positively or negatively?
 
Dr. Richard J. Schwab: Well, first, I want to say that exercise is really good for insomnia because, first of all, it relaxes you, calms down some of the anxiety, and makes you sleepier. So exercise is a great idea. In terms of diet, eating close to bedtime is a bad idea. Probably a lot of carbohydrates close to bedtime, a bad idea. And there are certain foods that make you sleepy, that's why Thanksgiving, the turkey or the tryptophan, maybe would help but there's again, no real good studies on these different dietary manipulations for insomnia.
 
Host: Now, many self-diagnosed insomniacs may say how their body has adjusted to the lack of sleep or poor quality of their sleep. Is the human body actually capable of adjusting itself to fewer hours of sleep over a long-term period?
 
Dr. Richard J. Schwab: Not really; I mean, if you start doing it, you're going to get sleep-deprived. I mean, there's plenty of studies out there that if you reduce your sleep to four hours a night, over time, you're going to be sleep deprived, and you're not going to function as well, from a mental standpoint, physical standpoint. So, I don't think your body can adjust. Now there's a sleep debt, and you can recover that sleep debt. That's sort of what we do on the weekends, right, we recover our sleep on the weekends. And that's common because again, as I described earlier, most of our entire society is sleep deprived The other thing that I would say is not so much that it's related to your body, but patients who have insomnia, people with insomnia typically focus on their insomnia. The more you focus on it, the worse it becomes. It's kind of like breathing; if you start focusing on your breathing, your breathing becomes really weird. It's like, I don't even know how to breathe anymore. So, the more you focus on insomnia, the worse it becomes, it's very hard not to do that. But I try to tell all my patients, listen, try not to focus on this; the more you focus on it, the worse it's going to become. Don't worry about your insomnia; it's going to get better.
 
 
Host: Now, I think we can probably guess that one of the effects of insomnia is you’re tired, but what are some of the other effects of insomnia on our health, either short or long-term?
 
Dr. Richard J. Schwab: So first of all, in terms of the tired piece, a lot of that's mental, and you think you're tired, but maybe you're not really so tired, you can probably do all the things you want to do. And in fact, it may take you a little longer because you're not quite as quick, mentally, but you can do all the things you're supposed to do as long as you don't let it affect you. That's one of the reasons why we actually think coffee is not a bad idea for someone who has insomnia. You don't want to have coffee close to bedtime because it will disturb your sleep, and obviously, you probably won't want to have any coffee after lunchtime, but in the morning, it's probably a good idea. But to answer your question, insomnia, at least associated with short sleepers has been associated with heart disease. So heart attacks, high blood pressure, heart failure. So, there is some cardiovascular risk. These are in epidemiologic studies. These aren't typically one person type, you're absolutely going to get that but if you look over big populations, short sleep with insomnia is a cardiovascular risk factor.
 
Host: Now, what are some best practices our listeners can implement to prevent insomnia? Let's say it's not totally a chronic problem. At this point. Maybe it's been a week or a few nights. What are some practices that they can do to prevent insomnia?
 
Dr. Richard J. Schwab: So, as I've kind of described, exercise is really good. And it's more cardiovascular exercise, not so much core training or weight training but cardiovascular exercise. Obviously, not drinking alcohol because alcohol causes sleep fragmentation and makes things worse, and then going to bed at the same time each night. So, one of the things that you don't want to do and it's very hard if you're a shift worker and you're in that becomes even more difficult, but if you're not a shift worker is to go to bed at the same time, get up at the same time. Maybe on the weekend, you sleep a little bit longer, maybe an hour, but you don't oversleep. So, the more your body absolutely gets used to going to bed at the same time, getting up at the same time.
 
Host: How much should we avoid our phones? Is there a time before bed we should avoid our phones? I think we've all heard about the importance of avoiding them as we get closer to bedtime.
 
Dr. Richard J. Schwab: Absolutely. The bed should be used for sleeping. It shouldn't be used for working, it shouldn't be used or looking at your phone, paying the bills, watching television, any of that. In terms of the phone, yes, especially blue light affects you and makes you less likely to be able to fall asleep. You do not want to use your phone within an hour or two before bedtime if possible, and absolutely not within the bed. And the bed needs to be used for sleeping, nothing else.
 
Host: Now, let's say we've had a bit of a chronic problem or an ongoing problem with sleeplessness. When should someone consult a doctor like yourself or someone else when they feel it's become a problem? Or how should they know that it is a problem?
 
Dr. Richard J. Schwab: That's a really good question. And there's probably not a great answer for that. But I think if you start having consistent problems, and especially if there are family members who have had the same problem because maybe genetic or something's changed. Typically, insomnia can happen after a terrible event, right? Somebody dies and then it gets better. But if it doesn't get better over three months, I would think about being evaluated in the sleep center. One of the things that sleep centers can provide independent of medications is something called cognitive behavioral therapy. And that's counseling. It does a lot of different things. It teaches you sleep hygiene techniques; it tells you what to do if you can't fall asleep in bed; it teaches you what to do and how to think about insomnia in terms of not overly manifesting in ways that you might think are terrible but really aren't. What they do more than anything else is make your sleep more efficient; they actually reduce your amount of sleep and then slowly increase it. So cognitive behavioral therapy is the best treatment for insomnia if you have chronic insomnia, much better than medications, or at least as good as medications and no downside, no side effects. And so if you really do have a persistent problem with insomnia, over again, about a three month period, I would see someone in the sleep center.
 
Host: Yeah. My next question was about, quote, unquote, sleeping pills. And whether they are a safe remedy or not, what is your perception there?
 Dr. Richard J. Schwab: Yeah, the sleeping pills are interesting. They’ve all been designed for short-term use. So, six weeks, but my experience is once you get put on a sleeping pill, they are not stopped, you are on them for a long time. And they have real risks; they affect your memory, especially as you're getting older, and there are fall risks. So, you get up to go to the bathroom in the middle of the night, and you've got a sleeping pill on board, and you trip on the carpet, and you hit your head, and you break your hip. I mean, you can die from these things. So, we don't love to give out sleeping pills; sometimes, it's necessary. But they're not better than cognitive behavioral therapy. That's clear. There are real side effects. We don't really know what's the best medication; there are very few head-to-head trials, and there's some expense to this. In general, we like to do cognitive behavioral therapy. That being said, you can't get that for everybody. And again, a lot of people will try over-the-counter melatonin, which I think is fine. And you can try different sleeping pills. But that wouldn't be my first treatment.
 
Host: But there any other myths regarding insomnia that you want to clear up for our listeners or questions you’ve gotten from patients or even from students that you want to clarify here?
 
Dr. Richard J. Schwab: Sure. So again, just reiterate the fact that alcohol is a really bad choice. And then cannabis or cannabis-like products. It's not clear they help insomnia. They're very good for people with chronic pain. And they, I think, help people who have chronic pain sleep. But the one thing about cannabis in any of its forms, if you take it regularly, the one data point that I think is relevant is that when you stop it, you come off it, you are going to have very bad insomnia. So if you start a cannabis-like agent and you have insomnia, and you come off it, that's going to be a problem. Because that's the one feature of cannabis that's been shown over and over again, you stop it, you're going to have problems with insomnia. So, I'd be very cautious before I started anything like that. On the other hand, if you have chronic pain, I think kind of cannabis and the products are good for people with insomnia with chronic pain.
 
Host: Dr. Schwab, thank you so much for your time. For now, let's stop there, and on the next episode of the Merck Manuals Medical Myths Podcast, we can focus on the topic of sleep apnea; for our listeners looking for more information about insomnia, please head over to merckmanuals.com. Until next time, I'm Joe McIntyre, thanks for listening.


PODCAST Insomnia Myths with Dr. Richard Schwab

podcast-insomnia-myths-with-dr-richard-schwab

Season 6 | Episode 1Insomnia PodcastJoe McIntyre (Host): Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked...

Season 5 | Bonus Episode



 


 
A Veterinary Journey: Dr. Laurie Hess on Avian Medicine, Exotic Pets, and the Merck Veterinary Manual 
 
Transcript
 
Joe McIntyre (Host): Welcome to the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. I'm your host, Joe McIntyre, and we're taking a brief break from medical myths for a minute to introduce Laurie Hess, Doctor of Veterinary Medicine and the new Editor in Chief of the Merck Veterinary Manual. After graduating with a B.A. in Biology from Yale University, Dr. Hess earned her veterinary degree at Tufts University, she then completed an internship and a two-year residency in avian and exotic animal medicine and surgery at Schwarzman Animal Medical Center in New York City. Dr Hess co-lead the Avian and Exotic Pet Service at the Schwarzman Animal Medical Center for nearly a decade, and she subsequently established the Veterinary Center for Birds and Exotics in Westchester County, New York, in 2010. Dr. Hess is also the author of the book, “Unlikely Companions: The Adventures of an Exotic Animal Doctor, (or What Friends Feathered, Furred and Scaled Have Taught Me About Life and Love)”. The book highlights her unique experiences as an exotic animal expert, with Dr. Hess, often on the front lines with pets and sometimes their demanding owners. 

On our last episode, we talked to Dr. Hess about the signs and symptoms of avian flu. If you're new to the Merck Manuals Medical Myths Podcast, be sure to check out that episode and any others on your favorite podcast platform. On this episode, we will talk to Dr. Hess about her background, lessons learned during her illustrious career and expectations as the new Editor-in-Chief of the Merck Veterinary Manual. Dr. Hess, welcome to the podcast.
 
Dr. Laurie Hess: Hi. Thanks so much for having me.
 
Host: It's great to have you. So, I want to have you talk for a little bit. Tell us more about your background. What got you interested in veterinary medicine in the first place?
 
Dr. Hess: Well, like many of my friends and colleagues, I wanted to be a vet my whole life, ever since I was 15 years old. I grew up in New York City, so I started working as a volunteer in my local small animal hospital. I didn't really know that I wanted to work with birds and exotic animals until much later in my career, but I had a crazy family. I had a mom and dad and brother. We lived in an apartment on the eighth floor of a high-rise apartment with all kinds of animals, birds and cats and dogs and fish, and we were a little crazy, but my family is very supportive of me becoming a veterinarian.
 
Host: I'm sure they're all very proud. So, during your career, you've experienced, I'm sure, a number of situations, some wilder than others, and I believe a number of valuable lessons learned. Have there been any that have stuck with you during your career?
 
Dr. Hess: Actually, there's one story that I like to share with people, because it really did shape who I am as a veterinarian. It was something that happened to me just a couple of weeks out of graduating from veterinary school. I was working during my internship, as you mentioned, and I was the night doctor, basically, the one doctor who was on all night long, running what was the largest animal hospital in the United States at the time. It maybe still is now. But in the middle of New York City, the only doctor taking care of 100 plus pets who are already in that hospital and then anything that came in the door that night. So it was a hot July night, and I walked in very nervously as a new vet into an exam room and saw that there was a man standing there with two bags, one containing a very, very large cat, not like a lion or tiger, but something definitely larger than a house cat, and then another little gym bag. And he was wildly screaming in a language I couldn't understand, but he was really, really disturbed. And I looked at him, and I looked at the cat, and I said, “it's okay, calm down. The cat looks okay”. And he said, “No, no, no”. And he took the gym bag, put it up on the table, tore it open, and in the bag was a little monkey who was unconscious. The monkey had an IV-line dripping fluids into one arm, and then the other arm was missing its hand. It was just kind of a bloody mess from about the elbow down, and he proceeded to explain to me that the cat had bitten the monkey's arm off, and he wanted me to take the arm out of the cat and put it back onto the monkey. Now, having been a veterinarian for just a couple weeks, I was not prepared for this situation, and I immediately began to freak out. It was about two or three o'clock in the morning. I politely stepped out and I called my supervisor, who was very understanding. She said, just take precautions because we know that many primates can have illnesses that are transmittable to people. And so I suited up, like in the movie Outbreak, with the whole thing on and walk back in. A little disturbing to the to the gentleman, but I took the cat, I did an x-ray, and I did see the monkey's hand. It was very tiny. It was passing through. It was almost at the other end of the cat. And I explained to him, the cat was going to be fine, and really there was no way to salvage the monkey's hand. But what I realized from this experience was this was one of the most unusual and probably the most unprepared I'd ever be for a situation, for something like this. And I realized that if I could retain my composure, and help the animals, which I did, and unfortunately, the monkey ended up having a serious illness and passing away. But we tried to help the monkey, and the cat was fine. And I got the man some peace of mind. If I could get through that at the start of my veterinary career, I could really get through anything. And so I've never had anything quite that crazy, but it was an interesting way to start my career.
 
Host: Yeah, it sounds like a TV show. I guess there's no bigger challenge to make sure you can handle the stress test early on than that. So maybe over the past few years, things have been a little less crazy than that, but I'm sure there's still plenty of wild stories you have to tell.
 
Dr. Hess: That's why I have a book. 
 
Host: Exactly right. Exactly right. We'll get to that in a minute. You are only one of about 100 board-certified avian specialists in the world. Is that correct?
 
Dr. Hess: That's correct. Yes.
 
Host: Now, can you tell our audience, what does that exactly entail? What does it mean to be a board-certified avian specialist for your winged patients and those who care for them?
 
Dr. Hess: Sure. So not many people really know this, but to be a specialist in any field of Veterinary Medicine it is not like it is in human medicine. In human medicine, it's expected that you go to medical school, you do an internship, and a residency, and often a fellowship, and then you tend to specialize. Even if you're a family practitioner, you go through additional training. In veterinary medicine, it's a little different. There are not enough internships or even residencies for people to become specialists all around the world. It's very competitive. You can theoretically just graduate from veterinary school and go out into practice. It's very hard to do that because usually you don't know enough. You go from book learning to real life, and it's very hard. So I was fortunate enough to achieve a one-year residency, as you mentioned, and then a two-year residency in avian and exotic animal medicine, and so to become a specialist, typically, you have to do some sort of residency. There are ways to do it through years and years of practice. But after that, as an avian specialist, you have to write some publications. They have to be accepted. Once you pass that stage, you have to take a test, and the test involves knowing birds all the way, from the tiniest of hummingbirds to the largest of birds like ostriches and emus and everything in between and passing that test, and then every 10 years, I have to recertify that specialty. So I'm actually doing that now, and fortunately, I don't have to take the test again. I have to show that I've kept up with my knowledge and continued education, etc. But because it's such a long haul, and it's such a rigorous process. Not many people choose to do it, and that's why there are so few of us. What it means for my avian patients is that I have a certain level of knowledge about birds and an understanding of their disease and their anatomy so that I can provide that additional care to them. And other veterinarians who are great may not have that. They may do the initial steps and then refer to me for more specialized care.
 
Host: So do you get patients, and obviously those who care for them from all over the country who come to you as a specialist and say, “Hey, I have this exotic bird that’s sick or needs some help,” and you can kind of help them out. Is that how that works? 
 
Dr. Hess: That’s how it works. I mean, we had to limit it. My animal hospital is in New York, so we try to take local patients, New York, New Jersey, Connecticut, Massachusetts, Pennsylvania. I was at one point getting emergency calls from Puerto Rico and other countries. But really, to help most animals, I have to see them. So I really try to explain, you know, I refer to my specialist friends, and the Association of Avian Veterinarians has a great network to do that, but yeah, we do get quite a few calls, and it's hard because you really do want to help everyone, but you can't.
 
Host: Yeah, for sure. Now let's switch gears just a little bit and talk about your new role as the Editor-in-Chief of the Merck Veterinary Manual. When was the first time you heard about the Merck Veterinary Manual? 
 
Dr. Hess: I heard about the Merck Veterinary Manual years ago when I was in vet school. In fact, it played a pivotal role in my passing my New York state board exams. It used to be that the New York State Board exam was an in-person exam. I think they stopped doing that, and maybe my class was one of the last ones, which was many years ago. I think it was too expensive for them to do that. But it used to be that you finished school, and then when you studied for your boards for about a month, and then in New York State, they brought you to basically a big room, a big gym. I think it was actually at the University of Pennsylvania, where they held the test, or it may have been at Cornell. They brought in animals over three days, and there were hundreds of people there, and you were brought in in small groups of like eight to ten people at a time to be asked questions, and then you'd sit around and wait for the next question. And I remember very distinctly being very, very nervous and sitting in this big gym, waiting, waiting, waiting. And someone said they brought in pigeons. So we all had our Merck Manuals with us and were frantically flipping through our Merck Manuals to read the pigeon section. And so the Merck Manual is always there with me. The Merck Veterinary Manual is a great resource, and it has been my whole career. Now, it's a website and an app which is great, and it's right at our fingertips and right on my phone, and it's a great resource for everybody, but it's been a big part of my life all the way from even before I finished veterinary school.
 
Host: I'm sure many of our listeners are not vets; they're not doctors. They're mainly consumers. Would it be valuable, or is there any ability for a consumer to read the Merck Veterinary Manual, or should they always turn to professionals like yourself instead of trying to care for their pets by themselves? 
 
Dr. Hess: That’s a great question. The first part of the answer is that yes, there's some great information. It's in the pet owner section of the Merck Veterinary Manual, again, available online and in the app, and it is a great, trusted source. Because, unlike other sources that you could find on the internet, if you Google something, we know that all the information on the Merck Veterinary site is written by veterinarians and reviewed by veterinarians. So it's reliable. It's not just something that someone picked up from a website, and it's not unreliable, and it is kept current. Certainly, if you have a sick animal, you should always go to your veterinarian and never try to treat the animal yourself. But if you're just trying to get some general information and learn about disease or care of a pet, the Merck Vet Manual is a great resource. 
 
Host: Great. Now, you're also obviously the new Editor-in-Chief of the Merck Veterinary Manual, which is exciting, but what gets you excited the most about this new role?
 
Dr. Hess: Well, as I mentioned, the Merck Vet Manual has been something that's been a big part of my career as a resource my whole life, and I'm really excited now to give back to my profession by contributing to the education of new vets, younger vets, even vets who've been out for a while, who want to brush up on some diseases or learn about new things. We try to stay current, so we're constantly rewriting the veterinary content of the chapters in there. So, you know, veterinarians can turn to that information and remind themselves of things they may have learned years and years ago. We do cover large animals and small animals, and exotic animals and zoo animals. So, there's a really huge breadth of knowledge. And I'm just really excited in this part of my career to be able to give that education back to people who are learning as my legacy to veterinary medicine.
 
Host: Now, we mentioned this at the onset of our conversation, but you are also an author of a book talking about your career and your adventures as an exotic animal doctor. Tell us about why you decided to write that book, what sorts of stories maybe are in it, about your personal and professional life. And lastly, where anyone interested in reading it can find it.
 
Dr. Hess: Sure, it was kind of something I never planned to do. I had one of my clients whose pet I was treating said, “You know, you have such interesting stories and I write books.” We started to talk. And it turned out she ended up not being the most honest of people, but I found out as I looked into this, there were people who were really interested in all the stories I had. These were all like cocktail party conversations, like my monkey story. And as I began to write them, and I was working with another author who helped me write the book. She's fabulous. I had a lot of stories, and my career has always been very intertwined with my family life. I have two now-grown sons. In the book they're young, but they're in their 20s now, and they're both interested in medicine, not veterinary medicine, unfortunately for me, but human medicine and nuclear medicine, but they were a big part of my career in supporting me as a veterinarian. And we all love animals. We always had lots of pets. So it's a fun, light read for someone who loves animals, loves interesting and funny, silly, sometimes touching and emotional stories. And it's also a little bit of a look into my life as a mom. So it's a lot of fun, and if you're interested, it's available on Amazon.
 
Host: Dr. Hess, thank you so much for joining us on this podcast. It was a pleasure learning more about you, your new role as the Editor in Chief of the Merck Veterinary Manual, and also about avian flu. As we close out, I'll let you leave our listeners with a final word. 
 
Dr. Hess: Medical knowledge is power, so pass it on.

PODCAST Bonus Episode with Dr. Laurie Hess

podcast-bonus-episode-with-dr-laurie-hess

Season 5 | Bonus EpisodeA Veterinary Journey: Dr. Laurie Hess on Avian Medicine, Exotic Pets, and the Merck Veterinary Manual TranscriptJoe McIntyre (Host): Welcome to the Merck Manuals Medical...


Listen Now - Season 5 of Merck Manuals Medical Myths Podcast 
Season 5 of the Merck Manuals Medical Myths podcast continues with a closer look at some of the most common misunderstandings around some of today’s most pressing medical topics. Hear from Merck Manuals authors separating fact from fiction on topics including osteoporosis, strabismus, ear infections, rosacea and dandruff, multiple sclerosis and more. Tune in today!
Heart Attack vs Cardiac Arrest 
Dr. Ranya N. Sweis, an Associate Professor of Cardiology at Northwestern University Feinberg School of Medicine, unravels the distinctions between heart attack and cardiac arrest.
Halitosis 
Dr. Bernard J. Hennessy, DDS, from Texas A&M University School of Dentistry, unveils the truth about halitosis, commonly known as bad breath, and dispels common misconceptions about mouthwashes, breath mints and the effectiveness of brushing teeth in reducing bad breath.
RSV 
Dr. Brenda Tesini from the University of Rochester Medical Center sheds light on the respiratory syncytial virus (RSV) and what distinguishes it from COVID-19, flu and other respiratory illnesses. 
Osteoporosis Myths
Dr. Marcy Bolster, Professor of Medicine at Harvard Medical School, separates fact from fiction when it comes to osteoporosis and how our bones change as we get older.
Strabismus Myths
Dr. Leila M. Khazaeni, Associate Professor of Ophthalmology at Loma Linda University School of Medicine, breaks down what parents and patients need to know about strabismus and misalignment of the eyes, from the impact of screentime to the idea that it will go away on its own. 
Ear Infection Myths
Dr. Bradley Kesser, MD, Professor and Vice Chair, Department of Otolaryngology and Head and Neck Surgery at University of Virginia School of Medicine, talks ear infections and myths associated with ear care, including cotton swaps and candling. 
Debunking Skin Myths: Rosacea and Dandruff 
Dr. Jonette Keri, Professor of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, shares common myths and misconceptions around rosacea, including its causes and treatments. She also tackles the most pressing myths around dandruff. 
Multiple Sclerosis
Dr. Michael C. Levin, MD, College of Medicine, University of Saskatchewan, talks multiple sclerosis and the most common myths surrounding it, including what we know about its causes and the impact of a diagnosis in the short- and long-term. 
 
You can listen to the Merck Manual Podcast here 
 



PODCAST SEASON 5

podcast-season-5

Listen Now - Season 5 of Merck Manuals Medical Myths Podcast Season 5 of the Merck Manuals Medical Myths podcast continues with a closer look at some of the most common misunderstandings around...

Season 5 | Episode 8



 
Joe McIntyre (Host): Welcome to the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. On this episode, we're taking a closer look at multiple sclerosis, also known as MS. I'm your host, Joe McIntyre and I'm joined today by Dr. Michael Levin. Dr. Levin is a professor of medicine at the University of Saskatchewan in Saskatoon, Canada, where he is the inaugural Saskatchewan multiple sclerosis clinical research chair. Today, we will explore MS and the myths and misconceptions surrounding the disease. Dr. Levin. Thanks for joining us.
 
Dr. Levin: It's a pleasure to be here. Thanks for having me.
 
Host: Of course. So first off, can you tell our listeners, who may not be familiar with MS, what exactly it is, how this disease works, maybe how it comes to be? - just kind of an overview.
 
Dr. Levin: Sure. So, it's a neurologic disease and it affects fairly young people, it's most commonly diagnosed in people in their 20s to 40s. It has three components, and we will talk about them throughout the session. The first one is that it's inflammatory, or autoimmune, and that means inflammation or our immune system that's there to protect us instead (and there's the brain and the spinal cord) begins to damage it. So that's the inflammatory part, it damages the brain and spinal cord in two ways. First, it damages the myelin. And myelin is a coating on nerve cells, very similar to the coating or the insulation on copper wire. And so the myelin is important so that the nerve cells work well together. And so you may have heard the term demyelinating. And so the inflammatory cells damage the myelin. And then, of course, underneath that myelin is the nerve cell itself. And the nerve cells also become damaged.
 
But really, so those are the three pieces. But what does it look like in people? It's a relapsing-remitting disease. And that means people have acute attacks of neurologic dysfunction. So, one of the most common attacks, also known as a relapse, that people come to the doctor for, is loss of vision in one eye. That's called optic neuritis - it's inflammation behind the eye. And people lose vision over the day. And that's separates from stroke, where you would lose vision in one eye in a matter of seconds, or maybe a minute in MS it’s much more slower than that. And because it can affect anywhere in the brain or spinal cord, then you can get symptoms all over your body and that's why it's so variable in people. So, we've talked about optic neuritis, loss of vision in one eye. If you had inflammation in your spinal cord, then both your legs might become weak or even numb. So those are two common ways people develop MS. But I also want to emphasize its relapsing and remitting, and the remission part is that after an acute attack, which may last a couple of days, or even a couple of weeks, then people can come back to normal earlier in the disease. So, it's a bumpy road. And these relapses occur randomly throughout someone's life.
 
Host: Dr. Levin, do you know how many people worldwide or even in North America are diagnosed or have an MS diagnosis? 
 
Dr. Levin: There are almost 3 million people worldwide and about a million in North America. I think it's about maybe 900,000 in the US and about 100,000 in Canada. Again, the prevalence rate is one in 3,000 worldwide, one in 1,000 in the US and one in 300 in Canada and other parts of the Northern Hemisphere. 
 
Host: How might someone know if they have MS, what should they be looking out for, if anything, how often should they go to the doctor? Who should they see - anything there?
 
Dr. Levin: Yeah, I mean it can be tricky early on, because again, as symptoms get better on their own, and so patients and people tell me or will say, “My left arm became numb for a week or two but it slowly got better and so I didn't have it looked at,” or, “By the time I got into see a doctor, either a primary care doctor or a neurologist, those symptoms were gone”. And so that makes it tricky to diagnose. But the things to look out for, as we've talked about one already - loss of vision over the day, that doesn't get better on its own that lasts anywhere from a couple of days to a couple of weeks - that needs immediate attention. You should probably go to the emergency room for that. And then if both legs get a little bit numb or tingly, or feet get numb or tingly and then after that your arm or hand goes numb and tingly. We talked about MS being relapsing and remitting, so symptoms come and go. So again, loss of vision, numbness in one part of your body, weakness in one part of your body, or numbness and weakness in both legs are really, really common. 
 
The next step is to see a health care provider as quickly as you can because we can diagnose people really early now. The physician or healthcare provider will take a very close history and do a physical exam. But the most sensitive test to diagnose MS is MRI scan. If you could choose one, I would recommend an MRI scan of the brain. But typically, we would do an MRI scan of the brain and the spinal cord, because MS affects both. And we can now diagnose people very early. So, you go through those episodes, and you get to the doctor and you're normal, you feel well and that has resolved, we can still see those areas of damage on the MRI scan. We've talked about the damage in myelin and the damage of nerve cells. Those areas in the brain and spinal cord are called plaques, it's its own thing. A lot of things in the human body are called plaques. But this is an MS plaque that we can see it on MRI scan, we can see it very early in disease. And we can see it even when people no longer have symptoms.
 
Host: Now, this is a podcast where we discuss myths quite often. So, let's get maybe a big question out of the way. I think there's a lot of fear with MS. At least there certainly was many years ago, but is an MS diagnosis fatal or death sentence? How treatable is it maybe now compared to years ago or just in general?
 
Dr. Levin: So it's rarely fatal, especially early in its course. I think the biggest myth I want to dispel is that MS is some type of guarantee of a lifetime of disability. That was true, it's no longer true. There are more than 20 medications on the market, your health care provider will find one that fits your lifestyle and how you want to take the medications. And in the last five years, we've invented what we call high efficacy medications, medications that work really well. And if caught early enough, these medications can really nip a disease in the bud. And so, one myth I want to dispel is that there's no guarantee that this is going to be a lifetime of disability - quite the contrary. If captured early enough, most of my MS patients live full and active lives.
 
Host: Relief for a lot of people I'm very sure, that's great. I mean, I think you kind of dispelled it there. Certainly, not everyone with MS ends up in a wheelchair, with a cane, or some sort of support for a disability. But I guess if that were to be the case, would that be mostly because it would be diagnosed too late in life? Is there any correlation there?
 
Dr. Levin: The later you get on medication, the less effective they are. And this kind of opens up a little bit of the types of MS in that we've talked about relapse and remitting MS. Eventually, those relapses go away. But people still slowly get worse, what I call ‘the dwindles’ - trouble walking as quickly, maybe can’t keep up with your golf game, trouble with urine control and that kind of thing. And that happens after the relapsing phase, where people slowly get worse without those relapses. It happens secondarily. And so that's called Secondary Progressive MS. No great meds for that yet. And then there's Primary Progressive MS. The third kind of MS, where people slowly go downhill usually have trouble walking early, they never get that attack phase. And there's no medications for Primary Progressive MS yet. 
 
So, to get back to your question, and people who are already in a wheelchair, or might be headed in that direction, sometimes those patients have gotten to the health care provider or their health care system too late. So, the lesson is, get diagnosed early and get treated early. There is the rare patient that has such an aggressive form of MS early on that it's very, very difficult to treat. That's the vast minority, but it still happens.
 
Host: Does MS occur more in women than men? Is that the case?
 
Dr. Levin: It does, about two to one. And so yeah, all autoimmune diseases from lupus and thyroid disease occur more common in women. And MS is autoimmune. And so, women are at twice the risk of men.
 
Host: Is MS an inheritable disease?
 
Dr. Levin:  A small amount. And so, if you look at risk, the risk worldwide for MS is about one in 3000. The risk in the US is one in 1,000. The risk in Canada is one in 300. And if you have a first degree relative with MS, your risk is about one in 50. So, it does increase your risk, there's still a high probability that you won't get it, but it can go from as high as one in 3,000 to one in 50. And that's a mixture of genes. It's not one gene, we don't understand all the genetic predispositions. So, it has a mild but definite inheritable risk.
 
Host: Now, you mentioned that there are a number of different treatments for this, what do those treatments range from? Is it just medication? Is it some sort of physical therapy? What does that also include? 
 
Dr. Levin: I think first, again we talked about MS being inflammatory and autoimmune, so all the medications suppress the immune system to some degree. The idea being that if you can prevent the immune system or inflammatory cells from entering the brain, or if they're in the brain already, if you can get them to quiet down and suppress them, you'll help MS. 
 
So, they're all in that category of what we call immunosuppressive where they dampen the immune system, or immunomodulatory or immunomodulation, where it shifts the immune system from attack mode to rest mode. Okay, so they all fit into that category. 
 
That being said, a healthy lifestyle is important. We know from a lot of really good studies that smoking can make your MS worse. Obesity and being overweight can make your MS worse. And what I like to tell my patients is that if they're struggling a little bit, the minute they're struggling, they should make a long-term relationship with a physical therapist, because there's no doubt that physical therapy plays a critical role in maintaining people's health and maintaining their activity for as long as possible.
 
Host: So, you mentioned the importance of living a healthy lifestyle, I assume that means if you have MS, you are not prohibited in any way from exercising, from walking, from doing the things typically, especially if it's diagnosed when you're younger, that you used to do in your pre-diagnosis life.
 
Dr. Levin: I mean, actually, quite the contrary, there are studies to say that exercise helps MS. In fact, in our animal models of MS, exercise when we look at it, we can give mice a disease that mimics MS. When we put them on treadmills and we exercise mice, they actually get better. And so, there are actually clinical trials looking like that. The only thing you have to be concerned about with MS is safety. And so, if you're having an issue with balance, you know, I'm not sure the balance beam would be the best exercise for you. So as long as you take safety into account, there are no limitations to someone exercising. And quite the contrary, it will not make your MS worse, it'll keep it stable. It might even make it better.
 
Host: Got it. Now, you mentioned also earlier that it seems to be a different disease for individual people. I'm sure there are big ranges from one person to the other in how it affects them. What are those ranges? I assume not everybody with MS has the same effects. But how does that really go about happening?
 
Dr. Levin: It's very variable. So, we talked about how it's a disease of the brain and spinal cord, which affects almost everything we do. Depending on where those plaques are and depending on where those areas of damage are, is why people's symptoms are so variable. That's number one. Number two is there are some risk factors for people progressing quickly. Men tend to progress a little more quickly. And by progress, I mean, get worse over a shorter period of time, making it worse more quickly. The more attacks you have earlier in your disease puts you at risk of getting worse, as well. And it's really highly variable. I see people that it may only attack their vision and so vision is a big issue but everything else is okay. And then I see people where it really attacks the spinal cord. You know, all the information from our limbs goes through our spinal cord, so a small plaque, an area of damage in the spinal cord, can cause trouble with walking and balance and coordination of the hands and legs. And part of neurology, I always say, is like real estate: location, location, location - it's not only the number of plaques you have in your brain and spinal cord, but where they are. Because a lot of what we do, as humans, is actually in our subconscious or unconscious. And if MS affects that part of the brain, you may not be very aware of it. But you can imagine a plaque in the middle of your spinal cord could make both your legs weak. And so that's why it's so variable. It's really location, as much as it is number or quantity of plaques in the brain or spinal cord.
 
Host: For a woman, obviously, you said they're about almost twice as likely to be diagnosed as men. Does it affect their ability to get pregnant if they have MS.
 
Dr. Levin: You know, yes and no. MS does not put you at risk for not getting pregnant, doesn't put you at risk for having a miscarriage or none of those things. We work with women all the time, with family planning and trying to plan their pregnancies, usually they're put on an MS drug to try to make the disease quiet and then most people have to be taken off that drug during their pregnancy. And then as soon as the pregnancy is over, we put them back on those MS medications. Now there's some exceptions. There are some medications we can actually give during pregnancy. And the nice thing about pregnancy in MS, it's actually protective. So, the relapse rate goes down during pregnancy. And then after you deliver the baby, then your baseline comes back so you need to see your healthcare provider. 
 
So, my recommendation is, I tell women, if you want to go make babies,  if that's what you want to do, we will help you through it. We'll talk to your obstetrician; we will play with your meds, and we will get you through it. And so again, my goal is to have people with full and healthy lives, and if having a family is part of that it just needs to be planned a little bit more carefully. But there's no reason women cannot have children.
 
Host: Let's say you have a friend or a family member who was diagnosed with MS or has MS. Is there something or anything that you can do or should do as a friend or family member to support them to be more knowledgeable about it? What would you kind of recommend, or for a spouse even, what would you recommend they think about or how they react to this?
 
Dr. Levin: I think first thing, you know, see a healthcare provider early and often. Get the diagnosis, something that's a commitment. You want to make sure it is MS because there are things that can mimic MS. So that's the first thing I would recommend. You know, that first year, I think psychologically, is tough on people with MS and that's where they need support. I mean, think about it for a minute, those relapses or attacks come randomly; we can't predict them. And so, I always tell people with MS it takes about a year to get used to the diagnosis. The average relapse rate in an untreated MS patient is about one attack per year or one attack every two years. So, you're going to feel well, most of the time, but just having that fear every day that you might wake up in the middle of an attack is difficult. So, I think one: support that person psychologically, two: encourage them to go to health care providers, three: use credible sources on the internet. 
 
Almost every country or every part of the world has their own MS Society and that's where to get the most accurate information. And if they don't feel well, call their provider if they think they're having a relapse, call their provider that day. Don't wait. And then I guess the other thing is just be patient with that friend or family member. They're going to have relapses, so you could be planning a vacation or planning something, and they may not feel well enough to go that day. And I would just say be sensitive to that.
 
Host: That’s great advice. Dr. Levin to close us out, you mentioned MS Society is a great resource. Where specifically, or where else would you recommend folks go for more information about MS - about the disease, about treatments, all that kind of stuff.
 
Dr. Levin: In the States, the National Multiple Sclerosis Society is great. In Canada it is called MS Canada, the name of their MS Society. And there's one in the UK and then there are several across Europe and other parts of the world.Besides the MS societies which are scattered throughout the globe, I think the Merck Manual gives really understandable information that's digestible and very accurate. And then finally, local support groups I think played a really important role.
 
Host: Well, Dr. Levin, thank you so much for joining us on this podcast. Certainly, it was a great conversation busting some of the myths around MS. I really appreciate you being on. So, as we close out, I'll let you leave our listeners with the final word.
 
Dr. Levin: Medical knowledge is power. Pass it on.



PODCAST Multiple Sclerosis Myths with Dr. Michael C. Levin

podcast-multiple-sclerosis-myths-with-dr-michael-c-levin

Season 5 | Episode 8Joe McIntyre (Host): Welcome to the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions...

PODCAST Rosacea and Dandruff Myths with Dr. Jonette Keri

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Understanding Highly Pathogenic Avian Influenza (HPAI) and Minimizing Transmission Risk
Since January 2022, highly pathogenic avian influenza (HPAI) has been spreading across North America, affecting both wild birds and poultry flocks. As of May 2024, over 92 million HPAI cases have been reported in poultry and nearly 10,000 cases in wild birds in the US, with the virus confirmed in every state except Hawaii. This outbreak has also led to cases in mammals, including humans. Recently, there has been reported transmission from infected poultry to other animals (such as goats, cattle, and cats) and to humans in direct contact with these animals. However, signs in infected humans have been mild and self-limiting. Understanding the nature of the virus and implementing preventive measures is crucial in combating its spread.
Key Facts about HPAI:

    HPAI is an influenza A virus, classified by surface protein variants.
    The current outbreak involves the H5N1 strain, with an HA 5 protein and an NA 1 protein.
    The virus is highly transmissible and durable in the environment, surviving for extended periods in water and feces.
    Birds, especially waterfowl, are the primary carriers and transmitters of HPAI, with minimal clinical signs.
    HPAI causes severe disease in infected birds, with high mortality rates.

Recognizing and Addressing HPAI:

    Veterinarians treating wild and outdoor companion birds are most likely to encounter HPAI cases.
    Awareness of HPAI outbreaks in the area is essential, with regular updates from the CDC.
    Screening patients using prioritized biosecurity measures based on exposure risk is crucial.
    Infected poultry may show respiratory distress, lethargy, neurologic signs, and sudden death.
    Examination of outdoor birds should be conducted in isolation, with thorough disinfection protocols.
    Indoor birds may be at lower risk but should be evaluated based on owner's exposure to outdoor birds.

Reducing Transmission Risk:

    When handling suspected cases, use of personal protective equipment is essential, including masks, gloves, and gowns.
    Proper disinfection of facilities and equipment after each examination is crucial.
    Timely examination of outdoor birds and minimizing environmental viral particle survival is recommended.

Highly pathogenic avian influenza (HPAI) primarily affects birds and is not easily transmitted to humans. However, in some cases, human infection with HPAI strains has occurred. Notably, human infections with HPAI are extremely rare but can have severe consequences.
Transmission to Humans:

    Direct Contact: Human infections usually occur through direct contact with infected birds, their bodily fluids, or contaminated surfaces.
    
    Occupational Exposure: Individuals who work closely with infected birds or cattle, either in the poultry or dairy industries, may be at higher risk of exposure.
    
    Limited Human-to-Human Transmission: Although rare, there have been a few documented instances of limited human-to-human transmission of HPAI strains. However, sustained human-to-human transmission has not been observed.

Impact on Human Health:

    Severity: Human infection with HPAI strains can range from mild respiratory symptoms to severe illness, including respiratory distress syndrome, organ failure, and death.
    Case Fatality Rate: The case fatality rate varies depending on the HPAI strain, with some strains having higher mortality rates than others.
    Severity Factors: The severity of the illness may depend on several factors, including the individual's overall health, age, and any underlying medical condition.

Reporting and Testing:

    Suspected cases of HPAI must be reported immediately to the USDA and state animal health officials.
    Each state has specific guidelines for reporting, and veterinarians should contact their state veterinarian's office for guidance.
    Polymerase chain reaction and agar gel immunodiffusion testing are available for HPAI detection in poultry.

By staying informed about HPAI outbreaks, implementing biosecurity measures, and promptly reporting suspected cases, veterinarians play a vital role in preventing and managing the spread of this highly pathogenic virus. Education and awareness among pet owners are key to reducing the risk of transmission and protecting both avian patients and public health.
 
References:

    Centers for Disease Control and Prevention (CDC):
    
        Bird Flu Virus Infection in Humans: Bird Flu Virus Infections in Humans | Avian Influenza (Flu) (cdc.gov)
        Influenza Type A Viruses: Influenza Type A Viruses | Avian Influenza (Flu) (cdc.gov)
        Avian Influenza A(H7N9) Virus: Archived - Asian Lineage Avian Influenza A(H7N9) Virus | CDC Archive
    
     
    
    World Health Organization (WHO):
    
        Fact Sheet: Influenza (Avian and other zoonotic): Influenza (Avian and other zoonotic) (who.int)
    
     
    
    Food and Agriculture Organization of the United Nations (FAO):
    
        Global Avian Influenza Viruses with Zoonotic Potential situation update 
        Preparing for Highly Pathogenic Avian Influenza: i0808e.pdf (fao.org)
    
     
    
    Merck Manuals:
    
        Avian Influenza - Infectious Diseases - Merck Manual Professional Edition (merckmanuals.com)
    
    
     
    DVM 360:
    
        Assessing the risk of avian influenza (dvm360.com)
    
    


Understanding Highly Pathogenic Avian Influenza (HPAI) and Minimizing Transmission Risk

avian-influenza

Understanding Highly Pathogenic Avian Influenza (HPAI) and Minimizing Transmission RiskSince January 2022, highly pathogenic avian influenza (HPAI) has been spreading across North America, affecting...

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