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Interviewer: Age-related macular degeneration is a leading cause of vision loss in adults in the United States. The effects on the central vision caused by this disease can significantly impact your life, including the ability to do daily activities, the things you enjoy, and it could also lead to a loss of your independence. However, the good news is, if caught early, the progress of the disease can be slowed.

Dr. Monika Fleckenstein is a professor of ophthalmology and vision sciences at the Moran Eye Center. She's a retina specialist with an emphasis on this condition. Dr. Fleckenstein, let's start with what is age-related macular degeneration. What's going on?

Dr. Fleckenstein: Yeah. So age-related macular degeneration, and we usually say AMD, this is a disease in the back of your eye, and it causes that your central vision may get worse over time. As the name says, the most important risk factor is your age, where you cannot do a lot about it. But we also know other risk factors, which is, for example, smoking or unhealthy lifestyle. And we also know that there's a strong genetic component in this disease.

Interviewer: You called a . . . it impacts your central vision. Is that what you said? Explain what that means.

Dr. Fleckenstein: Yes. So if you look at a paper and try to read, you do this with your very central vision. So this is the area of sharpest vision. This is an area in your eye which we call the macula. And the very center of this macula is the fovea. This is actually the area of sharpest vision, and this is the area you need for reading, for recognizing faces. So this is the highest resolution in your eye.
How Age-related Macular Degeneration Impacts Daily Functioning

Interviewer: I want to know how age-related macular degeneration impacts people's vision in their daily functioning. Talk to me about that, from what you've seen with your patients.

Dr. Fleckenstein: We have different stages of age-related macular degeneration, early stages where you may not experience any symptoms, and then we have the later stages of the disease that you may develop a grayish area in your central vision. In certain subtypes of the disease, you may even develop a central dark area where you're not able anymore to recognize faces or read.

The symptoms patients experience is dependent on their disease stage, but usually, when I see patients with earlier stages, I actually ask them, "Do you have difficulties in dim light?" And so when you go to a restaurant and if you try to read the menu and the light is dimmed and maybe candlelight, this is actually where the patients realize first symptoms. Then also, when they come from bright light outside entering a room, and they may realize it takes them longer to adjust to these changing light conditions as before in their life or compared to the people they are surrounded by. So these are typically the first symptoms of the disease.

And so in later stages, when there is the real damage of the cell layers, the photoreceptors, patients may experience that they have difficulties to read. In very late stages, patients may even not be able anymore to recognize faces. And this is probably, you know, the end stage of the disease where they are not able anymore to read or recognize faces.
Early Detection of Age-related Macular Degeneration

Interviewer: And the importance of early detection in age-related macular degeneration, it's pretty critical, from what I understand. Can you expand on that?

Dr. Fleckenstein: Most sad situations are those where patients have the wet stage and did not receive treatment, and then you face a stage where treatment is not possible anymore or is not really effective anymore if patients have developed scar tissue. And this is why it's so important that if you realize symptoms, never hesitate to reach out to your doctor and ask to have a look.

And when I'm seeing actually my patients with earlier stages of the disease, I explain to them the symptoms of the later stages and tell them, "Please never hesitate to contact me and my team if you experience these changes." And I even tell them it's, you know, "Even if you do not have these specific changes, but if you have a weird gut feeling, please reach out," because sometimes, you know, patients just experience something is off, something is weird here. I cannot really say what it is. Never hesitate. Try to be seen by an ophthalmologist just to make sure that nothing is going on.

Interviewer: And if it's caught early, there are some things you can actually do about it. Tell me about that.

Dr. Fleckenstein: In the earlier stages of the disease, there are certain constellations or certain findings in the back of your eye where we would recommend that you take certain nutrition supplements. So it has been shown in a large clinical trial, the AREDS study, that a certain combination of supplements may delay the progression to late stages, but just if you have a certain constellation of the disease. So the study has also shown that just taking these supplements without having any sign of AMD will probably not have a positive effect. But if you have certain signs, it has been shown that the disease may be slowed down.

In general, we would always recommend, but this is more or less a general recommendation to the whole population, to have a healthy lifestyle, not to smoke. And actually Mediterranean diet has been shown, not only in age-related macular degeneration but also in cardiovascular diseases, that this can be beneficial to prevent the development of macular degeneration and also of the late stages. And Mediterranean diet, this means vegetables, fruits, olive oil, fish. So more a combination of nutrition into this direction.
When to Get Checked for Age-related Macular Degeneration

Interviewer: So since catching it early is so crucial, how often should somebody actually get their eyes checked for macular degeneration?

Dr. Fleckenstein: Yeah. So this really depends on age. So the American Society of Ophthalmology, they actually recommend to have an eye check when you become 40. Then it highly depends if your ophthalmologist finds anything, if you have any signs of a disease in the back of your eye. With ages of 65, we would recommend yearly eye exams. But of course, if you have a positive family history for age-related macular degeneration or if you have certain risk factors, I would recommend to be seen by an ophthalmologist more often and even in earlier ages.
Diagnosing Age-related Macular Degeneration

Interviewer: And in the diagnosis part, are you able to diagnose the disease? How far in advance before a person starts experiencing symptoms are you able to diagnose the disease with the equipment you have?

Dr. Fleckenstein: So we can see on a micron level changes in the back of the eye. Within the last decades, we have seen such a rapid improvement on resolution. And again, we can see tiniest changes in eyes. We indeed also see patients without any symptoms who are not aware of having any problems, and we may pick up earlier signs of the disease, and we can certainly see if macular degeneration is present or not.

Interviewer: That peace of mind is probably great for a lot of patients when you tell them, no, that's not it, that's something else.

Dr. Fleckenstein: Yes. But, you know, I tell my patients as well, as the time has changed so much and we have these dynamics right now, having the diagnosis of AMD today is something completely different than 20 years ago.

Interviewer: And why is that?

Dr. Fleckenstein: Because first of all, I believe within the next 10 years, you know, we will have more treatments available, and for the wet late stage where everyone is so scared about, we have wonderful treatment available, and this treatment really works well. And I always say I have respect for the wet late stage, but I'm not scared of it anymore because if this is treated well, patients can keep their vision for many, many years.

Dr. Jones: Your period is late and you got the test and you're pretty sure it says that it's positive, but this pregnancy wasn't planned. What are you thinking about and how do you feel?

Well, it turns out that in the United States and around the world, about half of pregnancies are unplanned. Unplanned meaning you weren't thinking about having a baby next month, it wasn't exactly on time, but unplanned usually means that you weren't planning on having a baby any time in the immediate future.

In the unplanned category, of these 50% of pregnancies that are unplanned, about half of them are mistimed. You might say that. A woman would say that she was planning on having a baby sometime, but just not right now.

And about half of those unplanned pregnancies are unwanted, meaning the woman when asked in interviews . . . And these interviews are done nationally about every five to six years through the National Survey of Family Growth and many other organizations who try to get a better understanding of this issue. In that spectrum of unplanned pregnancies comes a spectrum of different emotions.

In the virtual Scope studio today is Jamie Hales. And Jamie is a clinical manager at the Huntsman Mental Health Institute. She's here as a social worker to help us kind of think about what are the emotional responses to an unplanned pregnancy. So thank you for being in the studio, the virtual studio with us, Jamie.

Jamie: Thank you. I appreciate you having me.

Dr. Jones: So I'll give you a little bit of my background. I'm a reproductive endocrinologist and an infertility specialist. So, clearly, the unplanned pregnancy among my infertility patients is one that's met with often surprise and joy. But I'm also a family planning specialist and I've been an abortion provider for pregnancy termination.

And the spectrum of emotions is huge in terms of people who come and are faced with a pregnancy that they either didn't want now or didn't want ever. Can you tell me a little bit about your experience and what you've seen?

Jamie: I would completely echo that experience. What I most often see in my practice is more when somebody has had an unexpected pregnancy, it's a happy thing. They're excited about it. But I 100% see people where that is the exact opposite experience.

Sometimes our society, the idea is that, as a woman, you're supposed to be extremely excited about this new journey and chapter in your life. It isn't always that way for everybody, and that's not a bad thing.

And I think something that's really important when you're working with people who are childbearing age is to be as open-minded as possible about this because not everybody's pregnancy journey is the same. There is variation all over the place, and I think it can be hard sometimes for people to admit that, "Yeah, this is something that I'm really struggling with."

Dr. Jones: We go down this pathway of healthy baby, healthy mommy, and we don't spend a little time and say, "Why don't you tell me how you're feeling about this?"

Quite frankly, I'm a mother and a grandmother, and I planned my pregnancy down to the minute, but I was ambivalent. Even though it was highly planned, I was ambivalent thinking, "My life will never be the same." And there was a little bit of worry and grieving about that, even in a very planned pregnancy.

I think it's a matter of recognizing that it's an emotional rollercoaster. First of all, your hormones are different. You are now in a potentially new social domain going forward. You will now be a new person, if you choose to continue the pregnancy, called a mother. And then there's your own emotional makeup and you don't want to do that.

Listen with an open heart. I don't know how to put that in any other way. It's rare to have someone who's so neutral that they've got nothing going on. I worry if I see that.

Jamie: That's a very good point. I think being completely neutral about your pregnancy probably is more of a red flag than having some strong feelings about it either direction.

And those feelings can change, right? One day you may be feeling absolutely fantastic about it, and then there may be other days where that is not the case. And ultimately, it isn't up to the people around you to decide what the normal range of emotion is. That's up to you.

It can be a very fraught topic, but it's also one that I think is very important for us to discuss because this is another one of those situations where you might be out there experiencing some of these thoughts and feelings and think, "Wow, I'm the only one that's dealing with this right now," or, "I don't want to say anything because nobody is going to understand." And it is much more common than I think people realize. 

Dr. Jones: So how do we begin to help women negotiate how they're feeling and what they're planning on doing, figure out what are the resources available to them?

Jamie: Resource-wise, there are a couple of groups that are done online through Postpartum Support International. They have a virtual group for medical termination and also one for post-termination support, even if it wasn't for medical reasons.

So there are really good resources out there, and I think it's important to speak up if it's something that you're struggling with.

Ultimately, at the end of the day, we're not the ones that have to make really tough choices around this. And what the person wants and how they're feeling about it absolutely comes ahead of what any of the rest of us may or may not think about that pregnancy.

If you're going to therapy, that's a really great safe space, I think, a lot of the time to bring up complicated feelings about stuff because it's confidential.

And not everybody in your life may agree one way or the other with your choice whether to continue, not continue, the fact that it happened in the first place.

There are a lot of factors that go into unplanned pregnancies. There's a change in identity. Everyone, I think, comes at it with a different background, a different degree of support and resources.

Dr. Jones: Right. And most women struggle in the sense that they are making a decision thoughtfully, and when they finally make their decision, they're usually pretty sure. But on the way, it's giving them the information that they need so that they can feel that the next 60 years of their life one way or the other is written in a way that they can feel comfortable and move ahead.

I want to thank you so much for joining us. And for everyone who's been listening, thank you for joining us on the "7 Domains."

"Should I call the on-call pediatrician?" It's a question you've probably asked yourself when you have a question for your child's doctor and the clinic is closed. I'll help you figure out when it's appropriate to call and when a question can wait until the next office day.

As a pediatrician, we all take call, meaning that we rotate with our colleagues when we answer after-hours phone calls from concerned parents.

Usually, the questions parents have are very appropriate. Sometimes parents are just looking for reassurance that they're doing the right supportive care for their little one. Sometimes they're wanting reassurance that taking their child to urgent care or the emergency room is the right decision and that they're not overreacting. And sometimes they just want to know how much fever reducer to give.

One thing I don't think most parents realize is that the job of the on-call pediatrician is to help determine if their child needs to be seen urgently or not.

We cannot diagnose anything over the phone. Parents will often tell me that they know their child has an ear infection, or strep throat, or a urinary tract infection. I can't tell if your child has any of those over the phone, so they need to be seen.

We absolutely cannot call in medications like controlled substances. We cannot call in medications in general, because if your child needs an urgent medication, they should be seen.

If they need a refill of a long-time medication, that's better to be addressed by your child's pediatrician specifically during office hours. Questions that are not urgent should wait until the clinic is open.

I have one colleague who answers her calls, "Hello, this is the on-call doctor. What is your emergency?" One reason for this is we've gotten questions like, "I'm in the baby food aisle at the store. What food should I get my 6-month-old?" or, "My toddler won't take a nap. What can I do to force them to take one?" or, "How old does my daughter need to be to get her ears pierced?" These are all questions I've gotten.

One thing I've noticed in my years of taking call are that parents often think I'm sitting in the clinic just waiting for their calls. More than once, I've been asked if they can just come in and see me or if I can meet them at the emergency room.

When you call the on-call pediatrician, we are at home with our families. We are not in the office. I've answered phone calls from soccer games, while doing landscaping, when I'm doing hospital rounds in the newborn nursery, when out to eat, and of course, from my bed in the middle of the night.

As pediatricians, we want to be there for you when you have concerns. Kids don't come with instruction manuals, and often things happen when the office is closed. If you have an urgent concern, you are always welcome to call and we will give you the best advice we can. If your concern is not urgent, it will be better handled by your pediatrician during office hours.

Your pediatrician knows your child and your family. They can address non-urgent concerns better than one of us who has never met your child before.

Interviewer: Amyloidosis is a rare and possibly debilitating disease, which affects about 4,000 people a year in the United States. If left untreated, the disease can cause severe organ damage, so early detection is critical. Dr. Aman Godara is an amyloidosis specialist at Huntsman Cancer Institute. Dr. Godara, first of all, what causes this disease?

Dr. Godara: So amyloidosis is a rare and complex disease where a protein misshapes itself, becomes the amyloid protein, and then deposits in different organs of the body causing damage.

Interviewer: So it collects in different organs?

Dr. Godara: Correct.

Interviewer: And for each patient, it could be a different organ. It could manifest itself differently.

Dr. Godara: The type of protein that's behind amyloidosis could affect what type of organ is involved in the body.

Interviewer: And the diagnosis for a lot of patients can be kind of an aha moment because it can manifest in different ways. Somebody could be experiencing some sort of abdominal pain and just really can't track down what it is, and it ends up being amyloidosis. Explain that a little bit more, that aha moment.

Dr. Godara: So the diagnosis of amyloidosis can be very challenging because, as we mentioned, there are several different types of protein that can cause several different manifestations in the body.

So usually, when a patient is being diagnosed with amyloidosis, the diagnosis requires a biopsy of an organ or a tissue in the body that we suspect would be involved with the amyloidosis.

There have been some newer developments in diagnosing amyloidosis, and that's the type of a nuclear scan that we have started using to diagnose a type of amyloidosis that we call as the ATTR amyloidosis.

Depending on the type of organ that's being damaged by the amyloidosis, the symptoms could vary along. If someone's heart is being damaged with amyloidosis, usually patients with heart damage from amyloidosis experience shortness of breath, they experience swelling in their legs, and when they go to see a cardiologist, they are usually identified to have heart failure.

When amyloidosis affects the kidneys, it can cause leakage of protein in the urine, which can manifest itself as a form of urine. Sometimes patients with amyloidosis have involvement of their nerves and that can manifest as painful neuropathy involving their arms or their legs.

Interviewer: So when somebody is experiencing some of those symptoms, they might go to their family doctor, right? And it sounds like this could be a lot of different things. Is it pretty easily misdiagnosed at first?

Dr. Godara: As the diagnosis for amyloidosis is so challenging, misdiagnosis occurs often because the type of symptoms that come along with amyloidosis can occur from other diseases and other conditions.

If a patient is experiencing symptoms of heart failure, that could manifest from a different number of reasons. When patients have kidney dysfunction, that can also occur from a list of different conditions that can damage the kidneys.

So often at the point of care, when these patients are experiencing symptoms that might be related to amyloidosis, the patients end up seeing multiple different types of specialists before they are diagnosed with amyloidosis.

And there are certainly some delays in diagnosis that, on an average, patients take 6 to 12 months to be diagnosed with amyloidosis from the time their symptoms start.

Interviewer: And that's important because time is really important with this diagnosis because the damage to that particular organ keeps occurring.

Dr. Godara: The damage from amyloidosis is progressive damage. So the longer we are taking to diagnose amyloidosis, the more damage would occur in that organ that's being affected by this disease. So timely diagnosis is of utmost importance.

Patients who are diagnosed earlier in the course of disease might have damage to that organ that could be reversible at that point. But ultimately, if we miss a diagnosis, and it takes a really long time for a patient to be diagnosed with amyloidosis, that damage to the kidney or to the heart could end up being an irreversible damage that even treatments would not be able to recover from.

Interviewer: That's really challenging because as a person that has a condition, sometimes you have to go through some multiple diagnoses to figure out what it is. Is there any piece of information that a patient might have that would indicate earlier than later that it is an amyloidosis?

Dr. Godara: So patients who are suspected to have amyloidosis usually require a comprehensive evaluation to identify the type of amyloidosis and to identify the manifestations of it. So the workup depends quite a bit on the type of amyloidosis that we are suspecting.

If we are suspecting lichen amyloidosis, that occurs from the excess of lichens, the first and the foremost test that we perform for those patients are blood and urine testing to identify if they have an excess of lichens, which could ultimately be causing amyloidosis.

If patients have an excess of immunoglobulin lichens in their blood or urine, the next step for those patients is to have a bone marrow biopsy to identify any clone in the bone marrow that might be producing these excess lichens and ultimately the amyloidosis.

The other type of amyloidosis that we commonly see is the ATTR amyloidosis, which occurs off a defect in the transthyretin protein that is being produced by the liver. Patients who have ATTR amyloidosis could either be patients who have developed this type of amyloidosis because of old age or this could also be the type of amyloidosis that runs in the family.

So if we are suspecting a patient with ATTR amyloidosis, and we suspect that they have some cardiac damage from it, there is a nuclear scan of the heart that can help us identify this type of amyloidosis. This scan is called as the PYP scan. Patients who have a more genetic form of ATTR amyloidosis, we have genetic testing that can be done either through a swab or a blood test that can help us identify the hereditary type of ATTR amyloidosis.

Interviewer: How reliable are these tests?

Dr. Godara: When patients undergo evaluation for amyloidosis, the blood and the urine testing usually helps indicate whether or not there is any damage that's occurring to the different organs in the body that we would suspect in a patient with amyloidosis. So they only tell us to a certain extent.

Ultimately, patients would require either a tissue biopsy or an organ biopsy to see that amyloid accumulation happening in that organ to have a confirmation of this type of diagnosis.

Interviewer: Many patients find information on the internet when it comes to this disease that can cause anxiety and apprehension. Why is that?

Dr. Godara: I think the answer to that lies in the complexity of the disease. When patients look up amyloidosis, one thing that they might not know at that time is the type of amyloidosis that we are suspecting that they have.

The workup for amyloidosis, the treatment for amyloidosis, and the prognosis of amyloidosis depends a lot on the type of amyloidosis that they have. So the information on the internet might not be very accurate to the fact to the type of amyloidosis that these patients have. And the generalized information can create a lot of confusion and apprehension.

Interviewer: So somebody could find out they have amyloidosis but not exactly know what kind, go to the internet, start doing some research, and then that can be scary place.

Dr. Godara: I think that's correct. When we see patients who are referred to us for amyloidosis, patients have very limited knowledge as to what this disease entails and why this diagnosis is being suspected. So my job for my patients is to explain to them why the suspicion exists, and what do we need to do to identify whether or not they have amyloidosis.

The information that's available for the patients before they have completed the evaluation could be very generalizable and might not be important to that type of amyloidosis that they have.

Interviewer: And let's talk about treatments for the condition. So you have a positive diagnosis, you know what kind it is, you know what it's impacting, I would imagine that the treatments that you would give depend a lot on the same kinds of things we've talked about up until this point.

Dr. Godara: So as there are so many types of amyloidosis that can inflict damage into the body, the treatment basically depends on the type of amyloidosis. So there have been a lot of developments and a lot of exciting work has been done for patients with amyloidosis in the last few years.

So when we see patients with lichen amyloidosis, just last year, we had a treatment that is specifically developed for patients with lichen amyloidosis that was approved by the FDA. This is a combination of four medications together that not only results in eradication of the clone that causes amyloidosis, but also helps improve the heart, kidneys, or any other organs that might have been damaged as a part of this condition.

So patients who have transthyretin amyloidosis have two different types of treatments available for them. One treatment focuses on stabilizing the transthyretin protein and preventing it from turning into amyloidosis. And the other type of treatment targets the liver and prevents it from producing the transthyretin protein, so that ultimately you cut out the source that would be causing amyloidosis.

So there's been a lot of progress and a lot of other new treatments that are in clinical trials for these two types of amyloidosis. For several other types of amyloidosis, we don't have any treatments available yet.

Interviewer: And for those patients, is it just managing the disease best you can, managing the symptoms? What's the strategy?

Dr. Godara: So patients who have types of amyloidosis that we don't have treatments for, our focus remains on the organs that are afflicted from this disease. We try to support the organs that are damaged as a part of amyloidosis, and sometimes these patients will end up receiving a kidney transplant, or a liver transplant, or a heart transplant depending on what type of organ was damaged, irrespective of whether or not we have any treatments available for that type of amyloidosis.

The first and the foremost thing for patients with amyloidosis is to identify these patients at the earliest, because the sooner we take to diagnose this condition, the sooner we can try to reverse this process.

Delays in diagnosis can ultimately hurt the patient, so we have to create awareness at all levels of our healthcare system to identify these patients who might or might not have amyloidosis so that they undergo the appropriate workup and have a confirmation on whether or not they have this condition.

So we need to create awareness not just at the level of the primary care doctor, but also the specialists that our patients see. And at the same time, we also have to increase the awareness about this rare disease with our patients, so that if they have one of the symptoms that we relate with this condition, our patients can come to us and be evaluated for the suspicion.

The one thing that patients with amyloidosis require is a comprehensive evaluation. So when we suspect amyloidosis in a patient, our patients require a multidisciplinary team to not just help identify whether or not they have amyloidosis, but also once the diagnosis has been confirmed, we can focus not just on the cause of what's causing the amyloidosis but also help support the organs that are damaged as a part of this disease.

So at the Amyloidosis Program at Huntsman Cancer Institute, our patients receive care under a team of specialists that includes representation from cardiology, nephrology, and neurology to provide the best possible care that our patients need.

Dr. Tarbox: Hello and welcome to "Skincast," another episode of the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox. I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hello, hello. This is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah. This is Part 3 out of three to four episodes in our series on cosmetics. We had Dr. Adam Tinklepaugh, one of our faculty at the University of Utah, here a few episodes ago. We've got Michelle back here, and we're going to spend today talking about procedures.

So, in a couple of our last episodes, we talked about sort of things you could buy over the counter, maybe stuff that you can have your doctor prescribe. And here is stuff that you can basically pay to have people do to you. And since 70% of my patients are kids, I'm going to lean on Michelle's expertise to talk about a lot of these things.

Dr. Tarbox: Well, there are a lot of different kinds of things that can be done in the office or in a procedural specialty to help improve skin health and appearance. And it starts off relatively straightforwardly and simple with an office procedure called a chemical peel.

Now, chemical peels have been around for a very long time. In fact, the idea of a chemical peel has been around for a very, very long time. There are some writings about how Cleopatra used to bathe in soured milk because it would make her skin softer and more clear-appearing. And what we know now was happening is that some of the acid degradation products of the milk were helping exfoliate the skin, some of the lactic acid and things like that that were in that preparation.

They were used medically for the first time in the 1800s by an Austrian dermatologist named Ferdinand Ritter von Hebra, who actually helped us understand the virus herpes and a lot of things about it.

But chemical peels are one of the first ways that we start to improve cosmesis in the office. A chemical peel involves the application of some kind of chemical substance, usually an acid that's a weak to mild acid that's placed on the skin, and then utilizes what we call the skin's “wound healing response”. And that plays a role in a lot of our regenerative therapies that we can do in the office.

Any time we engage the skin's wound healing response, we can improve cell turnover, we can improve collagen building, we can improve the appearance of fine lines and wrinkles, and also just pigmentation.

But it has to be done carefully because all of us have had wounding to the skin and have had it turn out in not as cosmetically-elegant a way probably as we'd like if we scraped our knee or we fell down and ground our elbow into the concrete. Many of us wear scars to remind us of that. So this kind of procedure does have to be done with care.

But when we do a chemical peel, we evenly apply typically a chemical substance over the surface of the skin we're trying to treat. That causes some level of damage or wounding to the epidermis, and then the skin's natural self-healing mechanisms are triggered, and you get replacement of some of the damaged tissue as well as new collagen synthesis and improved appearance.

Dr. Johnson: Isn't the human body amazing? And especially the skin, of course. It's always pretty awesome when we can use the body's natural procedures in order to achieve results that we're hoping for.

There are a lot of different kinds of chemical peels out there. Some of them are available over the counter, the mild ones, as you might expect. And they can be used for different things. So some of them are used for dark spots, some of them are used for fine lines and wrinkles, and then some of the more intense ones can be used for deeper lines and wrinkles.

Dr. Tarbox: And they're very useful. They have to be used by somebody who knows what they're doing, and the person has to be literate with many different skin types so that they know how oily versus dry or sensitive skin might respond to the peel, as well as different skin tones.

So certain darker skin tones might have a greater risk for hyperpigmentation, where the skin becomes darkened, or hypopigmentation, where the skin looks lighter after the chemical peel if it's done inappropriately in a patient of different skin color. So you have to be careful about selection of therapy for each patient, and each patient should be treated as an individual.

After our chemical peels, we can do something called a Photofacial. You might have heard of Photofacial. That's usually referring to an intense pulsed light treatment. Intense pulsed light is a laser-like device that creates different wavelengths of light for therapeutic targets that can range from pigment, so dark spots on the skin, to vascular, so red areas of the skin, to hair. It can actually help remove unwanted hair with the intense pulsed light.

So those are things that can be done relatively quickly in the office and don't require a huge amount of downtime for light peels. Medium peels will take a little more downtime.

Dr. Johnson: And some of these are fairly inexpensive. I know for some of these cosmetic procedures the price tag can shoot up pretty quickly. But in my experience, the chemical peels and the intense pulsed light aren't too bad.

Dr. Tarbox: And really, when it comes to medical procedures, there are a few things that play into the cost of those procedures. One of those things is the equipment it takes to do that procedure, whether that be an expensive laser, whether that be a consumable product that can only be used once per patient. That has to get factored into the cost.

So, with a peel, the cost is the peeling agent and then the supplies you use to apply the peel. And then we also have price modulation for different services based off of the complexity of the service and the requirement for aftercare.

So things that are what we call the lunchtime facial, the intense pulsed light, or something where the risk is pretty low and the follow-up care is pretty gentle, that tends not to be as expensive as something that takes more product cost, or is more complex to do in the office, or creates greater risk.

As we get to the higher percentages of chemical peels, the more aggressive chemical peels, those might go up a little bit in price. You also have to have more downtime for those more aggressive chemical peels.

Dr. Johnson: You talked about the intense pulsed light devices, a laser-like device. Let's talk about actual lasers. There's a number of them out there, and they tend to be used for different purposes.

A lot of them remove color on the skin, and there are different lasers that target different colors. So, if you've got dark brown spots, there's a laser for that. If you've got pink or red spots, there's a laser for that. And then there are also lasers that just sort of destroy the skin. But again, we can do that in a controlled way to take advantage of the skin's own rejuvenating powers in order to rejuvenate the skin.

Dr. Tarbox: And there are all kinds of lasers. There are what we call ablative lasers and non-ablative lasers. An ablative laser, if you see a picture where somebody's skin is red and it has maybe little white dots on it or it looks very irritated after a laser procedure, that's probably an ablative laser. We call them ablative because they in some way or the other go through the epidermis. So those are laser procedures that are going to require some downtime.

Our ablative lasers can include a CO2 laser. You may have heard of CO2 lasering, like Fraxel. You may have heard of Erbium YAG or Nd:YAG. Those can be ablative as well.

So these are different laser treatments that can wound through the epidermis, which can help engender that wound healing response and improve texture and appearance, but that does require some downtime. And it's a little bit more of a moment, as I like to say, as the patient experiences that laser. So it's a little more intense, but those are really good lasers that can be used to improve skin texture and appearance. The resurfacing lasers, or the ablative lasers, can be helpful in improving skin appearance in a relatively aggressive manner.

Then those ablative lasers can be used either fractionated or fully ablative where they're completely taking out every bit of the surface that they're treating on, or they can be using it in a fractionated way where it's little individual dots across the treatment area, which is going to give quicker healing time and less severe change after the laser. So that's another option.

Dr. Johnson: Poking a bunch of little holes in the skin is how I like to describe it to patients. And it's good for wrinkles. It's good for acne scars. And there's another type of device called a microneedling device that is sort of similar in concept in that it also pokes a bunch of little holes in the skin. But instead of using lasers, it uses little needles.

Dr. Tarbox: So a lot of what we do is controlled wounding of the skin where we're actually using a tool of some kind of, be that a laser, be that a microneedling device, to in a controlled way use the wound healing capacity of the skin to improve its health and appearance. So those are other ways you can handle that.

Microneedling can be used to improve acne scars. It's very good for that. It's also used to improve texture of skin on the face with fine lines and wrinkles. It improves discoloration. It also improves some of the scarring that can be left behind after an inflammatory process.

And microneedling can be used to introduce different medications to the skin. It can also be used with platelet-rich plasma or used to help improve hair growth at home. So there are lots of options with microneedling.

It can also be used with radiofrequency, where the microneedles themselves actually have radiofrequency energy that goes through them and bulk heat the tissue in another way to wound it to help improve the appearance, and texture, and turgor of the skin, meaning it gets tighter.

Dr. Johnson: Some of these microneedling devices are available over the counter. If you were to want to purchase one of those and use it, just make sure you follow the instructions, because if you don't know what you're doing, you could perhaps end up in trouble.

I think it's useful to know that in a lot of these procedures, microneedling and laser and stuff, you often need multiple treatments before you get the full results that you're hoping for. So, for example, in microneedling, it probably takes four to six total treatments to get the results that you're hoping for. So, if you're planning to do something like this, go into it with that in mind. The procedures are usually something like four to six weeks apart.

So what if it's not my face that's the problem? What if I've got spider veins or varicose veins in my legs? Can dermatology help?

Dr. Tarbox: So, for spider veins in the legs, there are lots of different ways that dermatologists can be beneficial. One of the ways that's more straightforward is our sclerotherapy treatment. So sclerotherapy actually involves the use of a medicine that is injected into the tiny vein that is broken. So we're actually injecting into the lumen of the vessel.

It's kind of like a fun skill game for dermatologists. I don't know about you, Luke, but when I'm doing sclerotherapy, I think that I understand people who play video games compulsively because of the sense of reward I feel when I actually get one of those little blood vessels cannulated. And then I see that whole mat of those broken blood vessels just blanch out as the medicine goes through them.

And what the medicine does inside the vessels is it makes the walls of those teeny tiny blood vessels that we don't use for anything . . . They're just there because we have usually a broken valve in a vein or something. Those little tiny vessel walls get sticky to themselves, so they kind of close down on themselves. And they don't have blood circulating through them anymore, so you don't see them on the surface of the skin.

And because these are basically dead-end, useless tributaries that we don't need for anything else, there's no damage to the patient by treating these. It just improves the appearance, and sometimes if there's pain associated, it improves the pain.

Dr. Johnson: Dermatologists could treat some of the little to medium type veins, I would say. If you've got a big old varicose vein, then it might need a vein specialist.

Dr. Tarbox: Yeah, vascular surgeons might be the right place for those big veins. Some dermatologists do the endovenous laser ablation. Some don't.

Dr. Johnson: What about body contouring?

Dr. Tarbox: So liposuction was actually developed by dermatologists. The person who invented liposuction was trying to find a way to treat lipomas, which are those little fatty tumors that some patients get. And so he sort of conceived of a device that was like a suction needle you could put into the lipoma and remove it that way.

We don't really use liposuction to remove lipomas, but it is used for a lot of body contouring and shaping. And it does fall within the purview of dermatology. A lot of dermatologists do liposuction. I was trained to do it when I was a resident, and it can be very useful.

Dermatologists can also use liposuction to obtain fat for fat grafting, which is a procedure that can be done to help improve areas of volume loss on the face or help improve a scar cosmesis following reconstruction.

Dr. Johnson: In recent years, there have been other devices that have been developed that have taken advantage of other technologies and other aspects of physics in order to perform this body contouring. They have names like CoolSculpting, and then there are also radiation ultrasound-type devices that can potentially perform some of these actions.

I'm not super familiar with them since I don't do a lot of cosmetics. How do you feel about these, Michelle?

Dr. Tarbox: So they don't not work. The gold standard is liposuction, where a cannula of some variety is inserted under the skin and is passed through the fat layer either mechanically through the arm motion of the operator, or ultrasonically through a sonic oscillation of the cannula itself that can withdraw the fat cells from the patient's body.

There are other things that are also using the fat's vulnerability areas. So our fat is more vulnerable to cold than other parts of our body. There's a kind of condition that often will happen with toddlers, where they get a popsicle and they just sort of let it sit on the face while they're enjoying it, called popsicle panniculitis where the fat actually dies because of the exposure to sustained cold.

And that's the premise for CoolSculpting, which I have tried to see what it was like. It is a doable procedure. It's not completely uncomfortable, but it is not pain-free. So you need to be aware going in that it's going to require a little bit of mental toughness to go through.

But CoolSculpting is based off of that popsicle panniculitis or that cold panniculitis property of fat where fat does not tolerate very low temperatures for prolonged periods of time.

When they do CoolSculpting, they apply a little gel matrix pad to the skin that is to protect the epidermis from the freezing so you don't also get frostbite of the skin. And then they use a sort of suction probe to suction part of the area of adiposity they want to treat into the treatment handle, which can then cool down and basically freeze that part of the fat that is being subjected.

And then once they remove the suction device, the fat is still frozen. When they do it on the abdomen, it makes something called a butter stick. So it's about that size. It's just frozen solid fat. Then the esthetician or the person doing the therapy for you has to massage all of that out to kind of break it apart, which does two things. It sort of mechanically agitates some of the fat cells that are already frozen, and that can break them up, which kills them. It also helps prevent there being any kind of focuses of increased damage because of temperature irregularity. So that's CoolSculpting.

Dr. Johnson: There are a number of other products out there that exist for specific purposes that have reasonable medical data to support them. So, for example, what dermatologists call submental fullness, or sort of a fatty under-chin or double chin, there's a product that you can inject that'll dissolve the fat and help it tighten up. The brand name is Kybella.

Dr. Tarbox: It's bile acid. It's just bile acid going into the skin. That also hurts. That also is a painful procedure.

Dr. Johnson: But it seems to work all right.

Dr. Tarbox: But it works. It does work.

Dr. Johnson: If you have cellulite, especially on the butt, there's a new product out there that has collagenase, which is a protein that will dissolve collagen, that has some efficacy behind it. I believe the brand name is QWO.

And then plastic surgery is, of course, its own surgical specialty and they can do all kinds of stuff to your face. Some dermatologists do some plastic surgery.

And then we didn't really talk about Botox, or more generically botulinum toxin injections, or fillers. I think we've hit those in some of our previous podcasts. I think the short answer is that Botox . . . both Michelle and I are big fans of these botulinum toxin injections, and I think you'd heard Adam Tinklepaugh talk about them too. I like them. They tend to over-perform. They're good for wrinkles, especially rather small, rather shallow ones.

And then fillers add bulk to areas where you don't have bulk. So some people prefer to have more luscious-looking lips, for example. And then other people, perhaps because of the normal aging process, have just lost some of the subcutaneous fat in certain areas of their face, and filler can replace those.

That's my quick and dirty thoughts about those, Michelle. Do you have any thoughts that are slower and cleaner?

Dr. Tarbox: I really think Botox is a great treatment for facial wrinkles. Dysport and Xeomin are other types of neurotoxins that are similar to Botox. And they also help improve the appearance of the skin as well as decreasing unwanted facial movements.

There are studies that show us that we've reviewed on our other podcast, the more scientifically-based longer podcast that we do called "Dermasphere" . . . We've discussed the fact that long-term use of Botox actually improves brow position. So it helps improve the way the face ages over time. And it helps improve also some aspects of skin texture, so you have finer poor appearance often in areas that have been treated with Botox.

The fillers, there are a lot of different fillers. There's the Restylane product line. There's the Juvederm in product line. There are HA fillers. All of these definitely are usable in a different way to fill volume deficits, to improve tissue building, and to deal with lines and expression changes that happen over the face.

They should be used by somebody who knows what they're doing, because they are not without risk if they're done incorrectly or if there is just a day of really bad luck. People can have the filler get into a blood vessel accidentally, and that can either cause some part of the tissue that's supplied by that blood vessel to die. That's called necrosis, not something that you would want to have happen to you. Or in extreme cases, it can cause blindness. So they do need to be used by somebody who knows what they're doing and has been trained to select the right location and the right filler to use. And of course, they should only be done by medical professionals in a safe and clean environment.

Dr. Johnson: And that wraps up this three- to four-part series of cosmetics, but we might talk about cosmetics more later. Who knows? There seems to be a lot to talk about.

Thanks for hanging out with us today. Thanks also to the University of Utah for supporting the podcast and to Texas Tech for lending us Michelle.

And as Michelle alluded to, we have another podcast that's scientifically nerdy. It's called "Dermasphere." It's intended for other dermatologists and the dermatologically curious. And if you consider yourself dermatologically curious, come check that out. Otherwise, stay healthy, beautiful, and handsome, and we will see you next time.

You are pregnant and trying to do the right thing to keep yourself healthy and provide a safe place for your growing pregnancy. Is it time to get a COVID vaccine?

I have tragic memory of being part of a team that cared for a wonderful young woman who was pregnant and got influenza. Influenza isn't usually lethal to healthy young people, but it's dangerous in pregnancy. We knew this young woman. She worked in our unit, and she and her baby died of influenza. This was before my hospital required all employees to be vaccinated for the flu each year. Now we have over a decade of information about the influenza vaccine in pregnancy and safety, and we encourage every one of our patients to get the flu vaccine. It saves lives.

Now we have this other virus, COVID-19. COVID isn't new to us as humans. We've seen several other COVID viruses that were quite deadly in the past 20 years, but they didn't go that far and we see coronaviruses, the COVID family, make up some of the virus that caused the common cold. But COVID-19 is very contagious and causes severe illnesses and death all too frequently and lingering illnesses in many of those who weren't even really sick.

So when we first offered the COVID-19 vaccine, we had little information about COVID vaccine in pregnancy, but we had almost nine months of data on the COVID-19 virus infection and how it affected pregnant women. Here at the University of Utah, Dr. Torri Metz, a specialist in high-risk pregnancy, helped lead a national team to collect information about pregnant women who were infected with COVID-19. We talked with her, and she said it was sobering to see that young, healthy women who were pregnant had much more serious courses of the infection than women of the same age who weren't pregnant. They were more likely to get hospitalized, they were more likely to be admitted to the intensive care unit, they were more likely to be put on a ventilator, and if their oxygen levels became too low, they were more likely to lose their babies and sometimes they lost their lives.

But it took us another nine months to collect information about women who were pregnant and were vaccinated and compare outcomes to women who were pregnant and were not vaccinated. And the news is good and compelling about the safety of the COVID-19 vaccine in pregnancy.

So what is true? One, the Moderna and Pfizer vaccines had no adverse effects on fertility, pregnancy, and offspring in lab animals. Two, in 35,000 women who were pregnant and received the COVID-19 vaccine, headache, muscle aches, chills, and fever were less frequent in pregnant women than in non-pregnant patients. Three, injection site pain, where you got the shot, was more frequent in pregnant women, but it wasn't really all that bad. Four, the safety data following 4,000 pregnancies in women who were vaccinated showed no higher rates of miscarriage, no higher rates of preterm birth, no higher rate of newborn birth defects, or deaths compared to what we normally experience in pregnancy. I'm going to say that again. There were no higher rates of miscarriage, preterm births, or birth defects in women who were vaccinated compared to women who aren't vaccinated. Number five, women who are infected with COVID-19 have an increased risk of harmful abnormalities in the placenta. Women who are vaccinated don't have these harmful changes. Six, women who are vaccinated are five times less likely to get COVID-19 compared to pregnant women who are not vaccinated, one-fifth the rate of getting COVID compared to non-vaccinated pregnant women. Seven, women who are vaccinated give good antibodies to COVID-19 to their newborn babies. So there are seven true things.

What's not true? One, the COVID-19 vaccine causes infertility. It doesn't. Two, the Moderna and Pfizer vaccines have DNA in them and will alter the DNA of the fetus. Nope. These vaccines have mRNA in them, and these molecules are very short-lived and act mostly in the muscle around the shot. They don't change the DNA of the fetus or the mom. Three, the COVID vaccine has a microchip in it to track you. Really? I don't know where that ever came from, but it's one of the silliest of the vaccine myths.

Women who are pregnant are at high risk if they become infected with COVID-19. Pregnancy may lower women's immune responses, but the vaccine is still very protective against women developing complications from COVID-19.

With the information about the risks of COVID-19 infection to the pregnant mother and now the efficacy data from the vaccine outcome data collection and the safety information from more than thousands of women who were vaccinated while pregnant, the Centers for Disease Control and Prevention, the American College of Obstetrics and Gynecology, and the Society of Maternal-Fetal Medicine have strongly recommended that women who are considering pregnancy, trying to get pregnant, who are pregnant, or who are breastfeeding get vaccinated with the COVID-19 vaccine.

I think back to the day when I saw a young woman die of influenza and how much the flu vaccine is part of our counseling to pregnant women during flu season. So if it's flu season and you're pregnant or breastfeeding, don't forget to get your flu vaccine. And no matter what season it is, if you are pregnant, trying to get pregnant, or breastfeeding, please talk to your clinician and get vaccinated against COVID-19. And because no vaccine is perfect, please wear a mask that covers your nose and mouth when you're indoors in groups of people and practice social distancing if you're with people who aren't vaccinated.

And thanks for doing what you can to protect yourself, your baby, and those around you. And thanks for joining us on The Scope.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: It is the "Who Cares About Men's Health?" sideshow. Today's episode, "How Will Smith is going to get you back into the gym." Also, lessons we can learn from a very unfit at this particular moment in time, Will Smith. My name is Scot Singpiel. With me Dr. Troy Madsen, he brings the MD, I bring the BS.

Troy: I like that.

Scot: You like that?

Troy: I do like it. That's good.

Scot: So on Instagram and Facebook, I just happen to stumble across a post that Will Smith put up. And he posted a picture of him . . . the first one that I saw was a picture of him and he's in kind of these tight black shorts, and he's got this kind of zipper up sweatshirt unzipped. And he doesn't look like the Will Smith that we've seen "I Am Legend" or the other movies, right? And he goes, "I'm going to be real with y'all. I'm in the worst shape of my life."

So then I stumbled across another post from Will Smith where again, he's standing there and he's kind of pushing his belly out this time. And again, not the Will Smith we're used to seeing, right? And he said, "This is the body that carried me through an entire pandemic and countless days of grazing through the pantry. I love this body. But I want to FEEL better. No more midnight muffins. This is dead. Imma get in the best shape of my life. Teaming up with YouTube to get my health and wellness back on track. Hope it works."

So I saw that and I thought that that was pretty cool because there's got to be a lot of ego involved when your Will Smith, right? So to post these pictures of you not in the best shape of your life, I think it was really inspiring. And it made me think wow, that's kind of like me minus the movie star career, the perfect family life, and all that.

Troy: Did you actually tell what kind of shape he was in though? Or is he just like in a baggy sweatshirt? What did he have going on there?

Scot: I emailed the pictures to you so you could look and see for yourself. Yeah, check that out. And then we'll wait.

Troy: Is there an attachment? Oh, here's the attachment. What is going on with this email here? Yeah, he's definitely showing off his bod there. Yeah, he's put on a little weight, you know? Yeah. And this is a guy . . . I've always thought about Will Smith being in an incredible shape. So this is good. This is good. I mean, this is good for all of us. Like, yeah, this happens so.

Scot: And I could totally relate to that because, unlike you Troy who upped your physical activity and your output during the pandemic, I kind of went the way of Will Smith, like I just really went south.

Troy: So we've all been in this position though, Scot. This is how I felt a few years ago. Like, I feel good right now. But we've all been in this position, or we're in this position right now, where maybe you felt like you were in good shape and things just went downhill.

Mitch: For a 52-year-old, I mean, it's not a pooch. It's a ponch he's got going on.

Troy: Yeah. And he's 52.

Scot: And what's the difference between a pooch and a ponch? I didn't realize there were . . .

Mitch: I think I have a pooch. It's small. It's like a little fanny pack. Right. And then he's got like a full backpack.

Scot: Wow. The other picture that was really inspiring that I kind of came across at the same time. And this is how I was inspired back into the gym was a picture of him sitting on a shoulder press bench with what looks to be maybe 10-pound weights, dumbbells that he's pushing above head. And it says, "Crazy that this photo was taken right before I picked up the big ones, dang."

So he's joking around. But we've got a great lesson to learn from him here because if you do go back into the gym, and this is kind of what I want to talk about that. He kind of offers us some good lessons about getting back into a fitness routine. So I will say I've been back to the gym, and I've gone . . . I had to go out of town. But while I've been in town, I've gone every other day. And I've done some exercises and it feels great. So thank you Will Smith for inspiring me. If you want to come on the show, I'd love to thank you in person. So see if that happens.

Troy: Yeah, you're welcome to join us on the show, Will Smith, too. If you can . . .

Scot: And then, he also joked about weights here in another Instagram video.

Will: This guy says let's just get the movements. Let's just get your body back into making the movements, so we avoid injury, right? But what that means is he'll just give me the bar with no weights on it to do a bench press. And I'm like, we're not shooting that. Nobody's going to have a video of me bench pressing with just the bar with no weights on it.

Scot: All right, just so you know, afterwards, then they cut to a clip of him squatting a bar with no weights on it. So once again, totally willing to just let it all be out there that Will Smith, who we think of is in great shape is starting slow, starting light. He's easing his way back into it. And I think that was another inspirational thing.

And we've talked about that before on the podcast that you don't want to rush right back into it, because if you do, you can hurt yourself first of all, but it could also kill your momentum after a couple weeks. It just might be too exhausting, so you just might quit. It makes it non-sustainable. And then there's a danger you might not continue.

So I really appreciate Will Smith not only posting that picture, admitting that the pandemic has impacted him, put him in some pretty bad shape. And that you know what you don't go back in and lift weights like you were Will Smith in "I Am Legend" when you're Will Smith after the pandemic. So those are some good lessons for me about getting back into a fitness routine from Will Smith. Any thoughts either one of you guys?

Mitch: One of the things I was thinking is that I really appreciate this, this idea of I love this body, him posting it, non-edited, etc. because the other photo that has been circulating on the internet right now about getting, "back into shape" was Chris Hemsworth getting in shape for "Thor" and he just has the biggest, giantess bicep you've ever seen. And it's just, that doesn't inspire me, right? That kind of gets me in this "I'm not Chris Hemsworth," you know?

Scot: Yeah, or I'll never attain because, I mean, when we talk to Rashago, excuse me, who is our bodybuilder that we talked to, we learned that that takes a lot of work that's not sustainable for the average guy.

Mitch: Right. So seeing this, it's cool. I really, really appreciate this because I've been trying to get back into fitness. And just this idea of I love this body, right? This idea that it's not like a shame. It's not like, no, this is bad. He wants to feel better. It's not all about looking your best. It's about feeling your best.

Troy: Yeah, I mean, just seeing him looking like that. And it's not like it's airbrushed or anything like that, like some of the celebrities they want to present an image. And he's just very real about and says, yeah, I was in great shape. I'm not in great shape now. But I'm working to get back into good shape again. And again, I think we've all gone through cycles similar to that. So it is inspiring to see someone basically saying, yeah, this is not where I want to be, but it is who I am. And I'll keep working to get back to where I was before or somewhere at least kind of close to where I was.

Scot: The other thing that I love about this Will Smith thing is just being humble enough to post, Will Smith doing 10-pound dumbbells. Because for me, I did go back to the gym, and I did go back to doing weights because that's something I've done off and on my whole life. And I just needed something easy. It was something that felt comfortable to me.

But what doesn't feel comfortable when you go back in there, especially here at University of Utah, where you've got all those young students in there is they're moving massive amounts of weights. And then I go and I have to put it on the light stack, right? But reframing why I'm doing it and just going, "You know what, it doesn't matter. I'm doing this for me, I'm doing it for this reason," really helps. And you just kind of got to go, "You know what, nobody's going to see it, nobody's going to care."

And one of the things that I really try to concentrate too on is form, because over my years, I've noticed muscle imbalances start to develop. So instead of just making it about how can I move this weight in any way, shape, or form possible, just to say I've moved a lot of weight. How can I move this weight in a way that is achieving my goals of giving me better mobility and flexibility and balanced strength? So I really watch my posture when I do my back pull downs because, as we've talked about, in a previous episode, I've got this dowagers hump. So I'm trying to get those muscles strengthened and stretching so that will kind of start to straighten out. So those are my priorities now. So that's what's helped me.

Let's move on to the next segment of the sideshow. I guess I should also say a couple other episodes to check out. So we've got the one with Ernie Rimer about the basics of strength training. That's Episode 24. That'd be a good one if you're interested in just starting out. It's good for beginner. Episode 54 getting active again, we talked to Caleb Meyer, he's a strength and conditioning coach who went through kind of a similar thing. So he talked about getting back into it. And then we also talked to Caleb in Episode 58 about kettlebells, which is some exercises that you could do at home learning how to exercise with kettlebells so.

All right, Troy, get out that stack of articles what might we hear about today? Troy's going to go ahead and give us some titles of some articles and we're going to pick which one we want to hear.

Troy: Yeah, Scot, you know, I always love searching through the medical literature, see what's out there. Some of these are articles that have appeared also just in general science magazines, things like that. But I will give you some ideas here, some topics. You pick what you like. So to start us off, we have a randomized trial of oxycodone and acetaminophen versus acetaminophen for musculoskeletal pain. So opioids versus just plain old Tylenol, is there a difference?

Scot: Oh, that's a good one, okay.

Troy: Could there be a dramatic hidden impact of not having a regular bedtime? We've talked about that before. Characterization of scooter injuries over 27 months. It is scooter season now if you've been downtown. We've been almost hit by scooters many times. Extreme exercises carries metabolic consequences. All right . . .

Scot: So I think that's enough choices. I think . . .

Troy: Scot, I can keep going. The flimsy evidence for flossing. How could you pass that one up?

Scot: Next time let's just limit it to three. And then we'll choose from that because I don't even remember what the first three were at this point. Mitch, did you hear one that intrigued you?

Mitch: I'm always interested in scooter injuries because Jonathan broke both his arms.

Scot: Oh, really?

Mitch: Yes.

Scot: Over sleep, over sleep? I would think the sleep one would be better.

Mitch: Yes.

Troy: Jonathan broke both of his arms on a scooter?

Mitch: Yeah, at the same time. He like fell off the scooter with a heavy backpack and he broke both of his arms. And so he was like a mummy all wrapped up for two months.

Troy: People don't talk about it a lot. But yeah, the logistics of breaking both your arms with scooters are awful. We don't get into the specifics. But it really limits you. And when I see people will come will break both their arms, I'm just I'm so sorry about this, like, "Yeah, this is a bad situation to be in. And you're going to be in this for six weeks." So scooters. You want that one, scooters?

Scot: All right. We'll hold on to the sleep ones later. I know that some of the sleep interviews are our most popular ones. So I do want to do those sleep ones for sure. But scooters hits home, so to speak, for Mitch.

Troy: It hits home. Yeah, it does hit home for Mitch, and it is scooter season. And I'll tell you scooters kind of . . . The reason I kind of include this article is I hoped you would pick it because I've done a lot of work with the scooter research and published on that. And it's one of these things that really hit the news where we had articles in "The Washington Post" and "The New York Times" about some of the stuff we did at the University of Utah. And we were one of the . . . not one, I think we were the first site to really look at this and say what happened here. What kind of injuries did we see after people started using rental scooters in Salt Lake? They rolled out. Everyone's using them. What kind of injuries are we seeing? And it wasn't just that we saw people with bumps and bruises, we were seeing people come to the ER who were major traumas, who had very serious injuries, major head injuries.

So this article actually appeared in the "American Journal of Emergency Medicine." It is slated to be published in July of 2021. So it will be published very shortly, but it's appeared online. And this article, they looked at patients at a level one trauma center over it's about a three-year period since November 2017. And had 442 patients who came in there who were injured on electronic scooters. And basically they said, "Okay, how serious were these injuries?" They said that hospital admission for those who came there was 40%. So these aren't patients coming in who were just saying, oh, I bumped and I got a laceration or even just a broken bone. These are 40% of their patients were admitted to the hospital, and 3% of these patients went to the intensive care unit. So these were serious head injuries, very, very serious injuries. They found that people who are more likely to admit it were those who were older than 40, who had alcohol use or other substances, who lost consciousness, or who came in by an ambulance. So kind of some obvious stuff.

But one of the most surprising things for me, both in this article and in the research we did, is the fact that no one uses a helmet. I mean, it's not surprising when you're out there seeing people. But when scooters are going 15 miles an hour, it's a pretty fast rate of speed you're moving on that. We found that in our study that no one reported helmet use. In their study, it was 2.5% of people. The other surprising thing is just that we found a lot of people were intoxicated. I think a lot of people are using scooters to bar hop, things like that. It's dark out, you're riding a scooter, you're . . . at least had a couple drinks. And that's going to increase your likelihood of getting injured. They found that people who had used alcohol or were intoxicated in some way were much more likely to have a serious injury.

So takeaway from this for me is it's a lot of stuff we already know. But it was interesting to see this now in a larger study. Bottom line is electronic scooters I think they're a great way to get around and quick way to get around. But if you're using it while you're intoxicated, that's an issue. It would be great if you had a helmet. I know no one does. But we see a lot of serious head injuries from this, so just be aware. It's summertime. Great time to get out. Great way to get around short distances on scooters. But be aware of the potential for injury, as you're well aware, Mitch.

Mitch: Yeah, and that's what's interesting is hearing that study because when we were in . . . we went to the hospital like 6:00, 7:00 at night. Jonathan had both of his arms broken. And the nurse there was saying, "Oh, well, you're the least severe e-scooter injury I've had today." And that was the most telling thing, where like I'm sitting there and I'm like, "What do you mean?" And she's like, "Well, I can't go into specifics or whatever. But that's all I can say." And it was just he has two broken arms, like how is it . . . And the idea of today. Just how many people are getting hurt with these e-scooters? So it's just really interesting to hear that.

Troy: Yes, and we've looked at that too. Yeah, I mean, the numbers have increased over time that we're seeing which makes sense as more people are using e-scooters, you're going to have more injuries, but yeah, we are seeing more and more.

Scot: Usually within the first two or three times you use it that you're going to get injured. Isn't it? Isn't that kind of the average.

Troy: It's correct. I wouldn't say usually within those times, but your likelihood of getting injured within the first two or three times is much higher. So it doesn't mean that all the injuries or most of them happen then. It just means that people who use it, like, it's their first or second time on the scooter, they're more likely to get injured than someone who's used 10 times so . . .

Scot: Which makes sense because I think it's a whole new way for some people to travel, right? And you've mentioned before they go a lot faster than you might think.

Troy: You go fast. Yeah.

Scot: And you hit something in the sidewalk. And if you got to bail on that, I mean, running 15 miles an hour recover, you're probably going to go down.

Troy: Your legs can't keep up. You're going to fall.

Scot: So I think one of the takeaways for me on the scooter thing too, was if it's your first couple of times, play it conservative till you kind of get used to how that thing works.

Troy: Yeah, take it slow.

Scot: How it's going to react on the sidewalk, how the brakes work, that sort of thing. Don't just get on it and start scooting.

Mitch: And the big thing for Utah, especially with Jonathan yeah, don't drink and ride these scooters. But these-scooters were developed in warm, sunny places. Jonathan fell because there was a little bit of ice on the ground, like the smallest amount of ice and the scooter just . . . whoop. So it's be careful when it gets colder out there because these scooters are still out there. They don't bring them all home so . . .

Troy: Yeah, and it's not just the ice. It's just slick sidewalks after a little bit of rain, something like that. These wheels are so small, and they don't even . . . they're nothing even like a mountain bike. They are not studded at all. They're not going to hold you on any sort of uneven ground or any slick surface. So yeah, I think that's the takeaway. You see people on them all the time. You think, "Oh, so easy to jump on. Great way to get around." But again, it's surprising to me not that we're seeing injuries. That doesn't surprise me. The surprising thing to me is how serious these injuries are. We have seen people who have died because of scooter injuries because of massive head injuries. This is something we have seen, other sites have seen too, so . . .

Scot: And then, any of the-scooter injuries that have come in, have you gleaned anything from any of those patients? They say anything to you that stuck with you?

Troy: The biggest things for me if I had three takeaways it would be if it's your first time on a scooter, like you said, Scot, take your time, make sure you know what you're doing. A lot of people were like, "It was my first time on it. I was going way too fast. I didn't know what to expect." Second thing, carry a helmet. I mean, if I could tell you one thing, like if you're going out just carry a helmet, maybe people will think you look stupid with a helmet on on a scooter, but cite this study if people give you a hard time. I've got some research. Come on, guys. Third thing, don't ride while intoxicated. Those would be the three simple things. And that's what the research drives home too. Again, it doesn't eliminate all potential for getting injured. But I think those are the big things where we see people getting serious injuries where they hit their head. And that's what puts you in the intensive care unit. So not nearly as fun as the green urine article. I was hoping you were going to pick that one. But probably more informative.

Scot: There's always next time.

Troy: I'll save it. It'll continue to reappear so . . .

Scot: All right, thanks for listening to "Who Cares About Men's Health?" the sideshow. We have numerous different shows. So if you're interested in nutrition, activity, sleep emotional health, that's called the core four, be sure to check out our core four episodes. If you're interested in men's health essentials. These are conditions that affect men, be sure to check out our men's health essentials section. And of course, this was the sideshow where it's a little looser, but we still do try to talk about health and tie it back in.

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Scot: Welcome to the "Who Cares About Men's Health" Get Rid of Your Clutter challenge. This is check-in number 2 for week number 2. We've got Mitch here, Producer Mitch. We've got Dr. Troy Madsen, who's an emergency room physician. And we've got psychiatrist Dr. Benjamin Chan. We've all agreed to take this challenge to get rid of our clutter, to improve our mental health, and this is our check-in. So how's everybody doing? Dr. Chan, welcome back. How are you today?

Dr. Chan: I'm doing great, and I guess I'll just lead off. I care about men's health, and I have failed in the past week since our last check-in to get rid of the mattress, boxspring, and headboard.

Scot: Oh, no.

Dr. Chan: Complete and utter fail.

Scot: What happened?

Dr. Chan: I was on call, got busy with work, life happens. So I failed to make it a priority, but I am not afraid to say that to you and all your listeners.

Scot: And how are you going to . . . do you have a plan in place to make sure this doesn't happen again, or is it just it is what it is in your life?

Dr. Chan: Well, having this recording helps me kind of put it back up the priority list because I feel a little shame in coming in front of this esteemed group of scholars and not doing it. So yeah, this weekend we'll do it.

Scott: All right. Well, that's good. I think that's an interesting point, why maybe some of us fail, right? You might start out kind of excited to get rid of some stuff, but then life starts happening again and it's pretty easy to fall to the back burner.

That's true with any health change, right? Sometimes you have to reengage with it multiple times before you can actually start making it a habit or making it stick. So good lesson. Even though you failed, you brought us a good lesson. Did you even know that, Dr. Chan?

Dr. Chan: That's the beauty of doing this podcast. We teach each other principles, and we hope to grow by them. So I'll stick with that.

Troy: Well, that's a good lesson too, Ben. You mentioned just the accountability. You talked to us about it. Our listeners know they're going to hold you to it. Honestly, and I'll talk a little bit more, but the accountability piece of it has been a big part for me.

Scot: The accountability piece of it stressed me out, and much like Dr. Chan, I kind of failed. I haven't done much since that first initial 72-item purge when I misunderstood what the rules were.

Again, kind of the framework . . . and anybody can do your own framework. It could be one thing a day. It could be the one thing on Day 1, two things on Day 2, three things on Day 3, etc.

I haven't done anything since then, but here's what I'm going to do. I'm going to make a promise. I have kind of a big ticket item that I need to list on eBay. I have a Apple MacBook Pro. I upgraded and I need to list that, and I hate it. I hate putting stuff on eBay.

And I think this is where a lot of us can run into problems too when we start decluttering. We're like, "Well, maybe it might be worth something." There's so much time invested and it's so much activation energy to get over that hump of going and researching, looking it up, listing it, finding the box, weighing it, shipping it, that maybe sometimes you've just got to go, "Maybe not this thing. Maybe I just get rid of this thing because I know the expense and my time is going to be more."

But with this MacBook that I have, I know I can make a little cash. So by the time we talk next time, I will have that sold on eBay.

Mitch: Scot, I think it's interesting you bring that up because I've been trying to sell things on Craigslist and some of the local things too. It's not just the energy of listing it. It's the energy of also dealing with some of these people. I've been getting some like, "Will you take $5 for it? I'll come over right now." And it's just been like, "Dude, no." There is this extra chore that comes with all of it. So for me, there are some items that I might just be donating to just get it out of my head.

Scot: Yeah, just so you don't have to deal with that, right, because it's not worth the stress.

Mitch: Nope.

Scot: Troy, how are you doing?

Troy: I am going to sound like the total nerd in the room now and the total front-of-the-classroom gunner guy, but I'm . . .

Dr. Chan: Yahoo.

Troy: Thanks, Ben. I'm well over 500 items. Well over.

Scot: What? What did you do?

Dr. Chan: Wow.

Troy: We have done a major purge here, and part of it has been the accountability.

Scot: Okay. So "we" . . .

Troy: Well, I have carried my weight in this. So yes, you are right. I am the pack rat in the family. My wife, Laura, is the one who's always trying to get me to get rid of stuff, and she heard about this, and she just started getting rid of stuff. She said, "I'm not going to get rid of your stuff, but we're doing this." She started clearing out stuff from the kitchen.

And for me, the way this has worked . . . we talked about the one thing Day 1, two things Day 2, three things Day 3, or double it every day to get it to 10 billion, which I haven't done. But the way that it has worked for me is I get some momentum. I just say, "Okay, I'm just going to start," and then I get that momentum. And then I'll get a pile of 500. No, not 500, but maybe 100 things, and then I'm just like, "Okay, I'm doing this. I'm committed. I'm going to do this. I'm going to get rid of these things."

Then I find I have to get them out. We have to donate them. I can't let it sit there, because my pile that I built up the first day, I then gradually pulled things out of that pile and said, "Well, I can't get rid of this. This means a lot to me. We've got space for it. Why do I have to get rid of it?"

But that's how it's happened. I've gotten rid of 50 DVDs. I've gotten rid of at least 10 different bags, just like duffel bags or backpacks. We've cleared out a number of kitchen items, sporting equipment, office items, things from our office closet that have just been sitting there. And I have also gotten commitments from people to take some big ticket items, a couch, a mattress, a TV.

Scot: Wow.

Troy: Even a hot tub. So all of these items are moving out.

Dr. Chan: We need to stop the podcast. This is revolutionary. We can't top this.

Troy: This is a big thing for me, honestly. I was not trying to be dramatic saying I was struggling with this. I have been struggling, but I've tried to ask myself as I do this, "Number one, have I used this item at any point in the last year?" And if the answer is no, then I probably need to get rid of it unless I can see a good justification that I'm going to use it within the next year.

And so trying to go through that process with these things has really helped. And it's been a good feeling to say, "Hey, I'm not the stuff I own. I am who I am. I'm not these items. These are not me. I can get rid of them if I'm not using them." That's been helpful.

Scot: Good. Wow. So quite a turnaround, because in the beginning you were stressed and anxious and didn't know that you'd participate even.

So Laura's participation, your wife's participation, do you think that's helped, or could you have done this even if she hadn't gotten excited and behind it?

Troy: She definitely got the ball rolling. It was her just doing this and saying, "Hey, let's just get going and let's do this."

Also, I think it's very helpful if you're in this situation with someone else to certainly respect their boundaries and say, "Hey, I'm not going to touch your stuff. That's your stuff. If you want to go through it, great." That's been very helpful.

Then it's been where I've thought, "Well, I'll just start to go through it and see." And as I've done that, just kind of getting some momentum.

I think the whole one on Day 1, two on Day 2, that helps. At least for me it helped just to say, "Okay, I'm just going to get rid of a few things." But then as I got some momentum, I was like, "Keep going."

Scot: That's what that minimalist documentary said, is that will just get the momentum going for you.

Another thing too . . . I don't know a couple years ago if you remember. . . I don't remember what her name was, but it's the KonMari method of decluttering and getting rid of stuff.

Mitch: It's Marie Kondo.

Scot: Yeah. Marie Kondo. Thank you.

Mitch: We did it really big. I have a story, but that's all right.

Scot: So her thing, Troy, was when you've got something you want to get rid of and you're like, "Am I going to use this in the next year?" and you're having a hard time getting rid of it, just thank it for what it's done for you, thank it for its service, and then know it's going to go on to serve somebody else. It sounds so weird, but it worked for me.

Troy: That sounds weird, but that helps. It really does help. Pretty much everything we've donated . . . there have been some things that just aren't in condition to donate that we've tossed, but it's been really helpful just to take it down there, donate it, and be like, "Hey, someone is going to use this. I'm not using it. Someone else is going to use it."

I admit the things I've struggled getting rid of are gifts, like gifts I've received from people, even though I haven't used them just because of that sentimental piece. I'm still struggling with that a little bit. So still a few things that were given to me as gifts that I have not gotten rid of, but I just haven't used. They were in the pile and I pulled them out of the pile. So we'll work on that.

Scot: Some of those favorite DVDs of yours, those movies, they're going to go bring joy to somebody else.

Troy: Oh, man.

Scot: So that's fantastic.

Troy: Trust me. When I pulled those out and I saw "Napoleon Dynamite" and "Dumb and Dumber" in that stack, I struggled. But then I said, "If I want to watch 'Napoleon Dynamite' or 'Dumb and Dumber,' I can stream it."

Dr. Chan: Troy, do you think you would have donated them or gotten rid of them if we didn't have streaming services? I'm just curious your thought process on that.

Troy: Yeah, great question. I don't know if I would have because I still would have thought to myself, "Yeah, I'll watch this at some point. Some of these are shows that are just such extremely high quality great shows. I can't get rid of 'Dumb and Dumber.'" So you're right. I think that that was a part of it. But knowing I could stream it was helpful.

Scot: All right. Let's go to Mitch. How are you doing?

Mitch: I'm doing pretty well. So this week I decided to tackle clothes. That's kind of interesting that you brought up Marie Kondo because we did . . . my partner and I, Jonathan, we did a purge when Marie Kondo was big two years ago, when she first came out with her Netflix series and everyone was into it. He had just broken both of his arms and he was up on drugs from the e-scooter accident, and he decided, "We've got to purge. Now."

And what was funny is he got competitive and started getting rid of things because I had a smaller pile than him. And so there is this interesting, "No, Jonathan, I think you need more work shirts." And he's there with both arms in the slings being like, "No, we have to get rid of these." And sure enough, at the end, he had gotten rid of too much and we had to go get new clothes and stuff because he had gotten rid of so many things.

So with this latest purge, understanding that kind of situation, I just got rid of things that . . . I don't know what it is. It seems like maybe just the Sears family, but it seems like men get free shirts at events and then hold on to them for 20 years. I had high school events, these shirts for . . . literally, I had a shirt for Llama Fest 2008. There are 75 llamas and an obstacle course. It was fun. But I had held on to that Llama Fest shirt for 20 years now. It's time to let that shirt go. I haven't worn it. It's just the thing that sits in the back and takes up space.

So I got rid of clothes that didn't fit, clothes that I hadn't worn in a couple years, and then anything that had a hole in it. It seems like I always hold on to that one pair of good socks that has just a little hole in it. No. If it had any sort of hole in it, I got rid of that too.

So I ended up getting rid of a good almost 50 pieces of clothes if you count all the socks and underwear. I've got space now for maybe new clothes. I just got rid of the stuff that I'm not using.

Scot: Dr. Chan, I've got a question for you. I believe that when a man can finally get to the point in their development where they can look at their socks and actually get rid of them before they have holes, that's when they've truly developed. Do you agree with that from a psychiatrist's point of view?

Dr. Chan: Yes, 100%, and it's just funny you mentioned that, Mitch. I love that example. I've got these favorite dress shirts and I just kind of rotate through them, and I only really donate them or get rid of them once I rip a hole usually in the elbow.

It's something about . . . I think men, we're just kind of comfortable in our outfits. I've got my favorite pair of khakis and I just . . . yeah, when I go out and purchase them, I just buy three of the exact same. That way, when I kind of run through one pair, I go to another. It's just fascinating how we approach this.

Scot: Yeah. I never felt more like an adult when I started getting rid of stuff before I'd worn holes in them.

Troy: Well, I have not matured to that point yet, Scot.

Scot: I guess that's a good update. So that's good. We've had some successes. We've had some opportunities to learn. I'm not going to call them failures. I'm going to call them opportunities to learn, Dr. Chan and myself. We've seen Troy come from very skeptical to getting all behind it and feeling pretty good about it.

And if you'd like to join us in the declutter challenge, just go to facebook.com/whocaresmenshealth and share your story. You can share your pictures. We're sharing our pictures of our stuff there. You can do however you want to do. The way we recommend is you get rid of one thing on Day 1, two things on Day 2, three things on Day 3 just to get the momentum going, or you can just do it however you want. Help your mental health and get rid of all your clutter with "Who Cares About Men's Health."