Search for tag: "disease"

Interviewer: Ever since the first case of monkeypox was first identified in the U.S. in May of 2022, there's been concern about the virus and its potential to spread. With newsfeeds featuring images of patients with rashes and lesions, as well as the news that by August, monkeypox has been seen in nearly every U.S. state, it leaves some to wonder if this could be another pandemic.

We spoke with two virologists from University of Utah Health to get their professional opinion to better understand the virus, how it spreads, and perhaps most importantly, how to protect yourself.

Dr. Sankar Swaminathan is a professor and the chief of the Division of Infectious Diseases at University of Utah Health. Dr. Adam Spivak is a researcher and physician with the Infectious Disease Clinic.

Dr. Swaminathan, let's start with the basics. What is monkeypox, and how does it impact the body?

Dr. Swaminathan: It's a viral infection caused by a virus that is related to smallpox and causes lesions or sores on the body, and really can be any part of the skin or mucus membranes. That's the inside of the mouth and the genitals. So that's the primary symptom that people have. It can also cause fever and swollen lymph nodes.

The type of lesion can be quite variable, but generally speaking, they start out as bumps, papules, and they can have a little indentation or dimple in the center of that papule. They can become pus-filled, and eventually, they scab over and they fall off, and they can leave a scar. They're fairly deep-seated, so they can be quite painful. And especially if they're in the mouth or genitals or the rectum, these places obviously can cause a lot of pain.

Interviewer: Now, where exactly did the disease come from? I've never heard of monkeypox before until just a month or two ago.

Dr. Swaminathan: It's been recognized in Africa, in various parts of Africa for quite a while, for decades in fact, and there's been very little spread outside of local populations.

Interviewer: And why are we seeing it now?

Dr. Swaminathan: That's a very good question, and I think a lot of people are trying to answer that. Like I said, we haven't seen this sort of person-to-person transmission, particularly in Western Europe, and in the U.S., and other parts of the world, and now it's become essentially a worldwide problem. The WHO has declared it to be such.

And I primarily think it's just found a niche in people who have close contact, particularly sexual contact, and it's spreading in a way that it might not have been spreading before. It doesn't necessarily mean that the virus has changed, although I think that remains to be determined, whether there've been any changes in the virus that's making it behave in a new way.

Interviewer: And speaking of that, when the World Health Organization declared it an emergency, what are these different groups so concerned about with this particular disease, with its spread, etc.?

Dr. Swaminathan: We realized that there's potential for widespread transmission. And how widespread it's going to be or can be, I think, still remains to be determined, but there's enough of a risk that the WHO has alerted everybody to this.

I think it's compounded by several factors. One is I think our capabilities in terms of testing, vaccination, and treatment have all been somewhat limited, which has allowed the disease to spread pretty rapidly in some areas like New York, and I think the concern is that this could happen elsewhere.

Interviewer: So why don't we move on a little bit to talking about how to identify this disease? So we've talked a little bit about that it looks like a lesion, but some of the things I've been seeing online is it looks like an ingrown hair, or it can be really hard to spot. For someone who is concerned or wants to know whether or not they might have monkeypox, what exactly are they going to be looking for before they go and get help?

Dr. Swaminathan: First I think is how likely it is that they've been exposed. It's people who have been in situations, parties, or group encounters, or raves, or whatever, where they are in contact with a lot of different people, so that's the risk factor.

And if you have had recent intimate contact with somebody, and you don't know exactly what their recent contacts have been as well, it's possible that they may have transmitted it to you without your realizing it.

And like you said, some of the especially initial manifestations may not be particularly alarming or severe, so that transmission could occur even though people aren't aware that they are infected.

Interviewer: Do the lesions change over time, how it expresses itself on the skin?

Dr. Swaminathan: Yeah, they usually progress or evolve. Like I said, they'll start out as a bump and then can become more liquid-filled, pus-filled, can become more painful, and they can break down so that they form an open sore. But eventually, they will scab and fall over. And this can take a couple of weeks or more for it to be fully cleared, and for the person then to not be infectious.

Interviewer: So these particular lesions are . . . like you were saying, they're full of the virus. That's a major infection vector, is the lesions themselves?

Dr. Swaminathan: Correct.

Interviewer: Okay. Are there any other vectors for this particular disease?

Dr. Swaminathan: Certainly other intimate contact like kissing and so on could spread it, but mostly it's skin-to-skin close contact. It can be spread by infected or contaminated clothing, bed sheets, towels, things like that. So any time people are living together in the same household, there's a possibility for transmission even if they're not having intimate contact with each other.

And also, we think that droplets . . . This doesn't seem to be a primary means of spread, but droplets from person-to-person who are sitting in close enough proximity that coughing, sneezing, even a lot of talking could potentially have airborne spread in that manner through respiratory droplets.

Interviewer: Now, does the disease impact anything other than the skin, or is it just a lesion-based kind of virus?

Dr. Swaminathan: Like I said, the other systemic manifestations as we call them are that you can have fever, and swollen lymph nodes, and fatigue. There haven't been any deaths in the U.S. that we know of from this, but it can be quite a severe illness in terms of . . . Usually, there's actually spontaneous recovery, but can lead to fairly severe symptoms that would make somebody not want to get up and leave their bedroom.

Interviewer: Would it require people to get hospitalized for any reason?

Dr. Swaminathan: It could, but generally speaking, we haven't seen that. Hospitalization might be required for severe intractable pain, or inability to swallow, eat, getting dehydrated, or secondary infection, an infection on top of the lesions with a regular bacterial infection, for example. Those would be unusual, but possible reasons why people would have complications and require hospitalization.

Interviewer: So how does someone keep themselves safe from monkeypox?

Dr. Swaminathan: So I think avoiding those types of encounters as much as possible is really almost the only way to protect oneself. Having multiple sexual partners and not knowing very much about what their risk has been, what are their habits, and so on.

Interviewer: In my research, I have been finding some really strange ways to protect oneself. We've had people being like, "I know it's hot in the summer, but just wear a long sleeve t-shirt, and you'll be just fine." I've seen, "Put Carmex on your lesions, and you'll be able to prevent the virus from passing to another person." Are there any known ways to prevent the spread of this disease? And is there any merit to any of these?

Dr. Swaminathan: So I think that you can take precautions if somebody in the household is known to be infected. And I think it would be straightforward, even if it wasn't easy, to make sure that there are no shared utensils, and no shared bedclothes, towels, and all that kind of thing, and that those were properly sterilized in the wash and dryer.

However, as we said, because it's not just from the act of having sex, that intimate contact would be hard to prevent with barrier methods. You'd essentially have to encase yourself from head to foot to prevent skin-to-skin transmission. And once you have lesions, there's no question that you should seek medical attention, and you should isolate. Because until those scabs are all gone, you're going to be potentially infectious, and you should really not have any type of skin-to-skin contact with other people.

Interviewer: So if someone does contract monkeypox, if they see those lesions, what is the first thing that they should do?

Dr. Swaminathan: I think if there's a concern that there's monkeypox, they can get tested. And we have started testing here at ARUP. We can generally get tests back in two to three days, and maybe sooner. And hopefully, we can keep up with the demand because I have a feeling that demand is going to continue to increase. But it's very good that ARUP . . . There are many labs that have now been approved to do this kind of testing, and we're not just depending on one or two centralized state or CDC labs.

Interviewer: So Step 1, if you think you've got something, go get tested. If that test comes back positive, what's the next step?

Dr. Swaminathan: Like we said, prevent yourself from giving it to other people. So you would need to isolate and take the precautions, which you can get detailed instructions from a healthcare provider.

And there is an oral treatment, which is approved for smallpox but is not officially approved for monkeypox because it really hasn't been tested in clinical trials against monkeypox, but we think it would work. It works in animals against monkeypox, and it certainly works in the laboratory, and it's a similar virus. So this drug called Tecovirimat, or TPOXX, should work, but it's only approved and can only be given under strict regulations.

So we're restricted in who we can give it to, and it's basically for people who have severe disease. There are various definitions for that, but it has to be severe disease, not just mild, a few skin lesions. And also for people who are at high risk, so people who are immunocompromised, whose immune system is weak, whether it's from cancer, or an organ transplant, or advanced HIV infection, or other immune deficiencies. So those people would be eligible for being treated, and we can treat them if we think that they have monkeypox, or we know that they have monkeypox.

Interviewer: But for most people, the treatment is not necessarily approved for everybody that gets monkeypox?

Dr. Swaminathan: Correct.

Interviewer: So quarantine, what does that look like in a household? Are you closing yourself off in a single bedroom?

Dr. Swaminathan: That would be the easiest way to do it, but that doesn't mean you can't come out of your bedroom. You should probably not share the same furniture as other people until you are over your period of isolation.

Interviewer: And how long is that period?

Dr. Swaminathan: Three weeks or so. All the lesions have to have been essentially healed over.

Interviewer: And how long after they've all been healed over are you good to go?

Dr. Swaminathan: Once all the lesions are healed, you shouldn't be infectious any further.

Interviewer: Is there any potential long-term consequences for a monkeypox infection?

Dr. Swaminathan: Not that I know of, but again, we're somewhat in uncharted territory. But generally speaking, recovery is thought to be complete.

Interviewer: So not super life-threatening, but you might be left with some scars?

Dr. Swaminathan: Yes.

Interviewer: Severe scars? Mild scars?

Dr. Swaminathan: Again, it depends on the number and location of the lesions.

Interviewer: So let's talk a little bit about vaccination. Is there a vaccine available for monkeypox?

Dr. Swaminathan: Yes. So the one that's currently being given is a vaccine that is based on the same virus that's used to vaccinate against smallpox. We don't routinely use that live form of vaccinia of smallpox vaccine because we've stopped vaccinating people against smallpox since the '70s. That vaccine is available and is thought to protect against monkeypox as well, but the incidence of complications with that vaccine is high enough that that older smallpox vaccine is not being used for monkeypox.

What we have is a newer vaccine that's made with a weakened or attenuated form of vaccinia that can't replicate, but it can stimulate the body to make an immune response against smallpox, and monkeypox, and so on. And that is effective both in animals that are challenged with monkeypox as well as in the laboratory. So that's the vaccine that we can give, but it is in somewhat limited supply currently. And like I said, we prioritize people who are at highest risk for it.

Interviewer: Now, speaking to you, Dr. Spivak, one of the first questions I'd like to ask you just to get it out of the way, with your experience researching viruses and treating HIV, is monkeypox a gay disease?

Dr. Spivak: Nope. It's a human disease. I don't know that there is such a thing, certainly not in virology, not in medicine, and not in existence in the world that I'm aware of such a thing as a gay disease.

And by way of background, I'm a physician caring for people living with HIV, very interested in preventing HIV, and I study HIV in the laboratory. Certainly, there's some background to my answer there, as, of course, HIV as a predecessor to this one, this latest outbreak of monkeypox, was often labeled a gay disease.

And just to elaborate a little bit because that, of course, sounds purely like opinion, the number one risk factor for acquisition of human immunodeficiency virus worldwide is heterosexual sex.

Interviewer: Heterosexual sex, really?

Dr. Spivak: Yep. So there are about 75 million people worldwide that have ever acquired HIV infection. Approximately half of them have died of the disease in the last 40 years since we first discovered it. So there's somewhere around 35 million people living today on Earth with HIV. And again, the majority of those folks acquired this disease sexually through heterosexual sex between men and women.

There's a fairly complex and really fascinating story about why HIV is prevalent among gay men, among men who have sex with men, and transgender women in Europe and in the United States. And that has to do with the transmission of the virus as it evolved, as the epidemic spread, where it first originated in West Africa, out to Haiti, and out to the Western world through sex, but also through blood products.

It's a complex story, but in any case, there are some pretty well delineated and well-understood reasons why HIV is more prevalent among men who have sex with men, again, in the United States and Europe. And that, of course, did give rise to this false notion that this was a gay disease, that heterosexual individuals were not susceptible, that this was somehow something that could be attributed to a man having sex with a man, which is entirely untrue.

And I think that the way I try to summarize that for medical students is to say that the disease actually . . . In the case of HIV, of course, it can also be transmitted through injection drug use, but by and large, we consider it a sexually transmitted disease, and that means humans having sex. The disease does not tend to discriminate, but people do.

Interviewer: And so while we are seeing more cases currently in the U.S. among men who have sex with men, that does not mean that this disease is any . . . there's not anything about the disease that specifically impacts one orientation over the other.

Dr. Spivak: No. There is zero evidence of that being the case. It does appear to be disproportionately affecting gay men at present, but the best we understand . . . And again, I think it's worth pointing out that there are a lot of unknowns here, and I certainly would not ever claim to sit here and have all the answers. In any case, the best science now seems to indicate that this virus spreads through skin-to-skin contact. And that is to say contact with your skin against the lesion on someone else's skin. Sex is a fantastic opportunity for skin to meet skin.

I don't think we really have a good answer as to why it is occurring predominantly among men who have sex with men, but as far as we know right now, there is absolutely no reason to think that this could not be spread from any type of skin contact, again, healthy skin touching against skin where there is a lesion. And we all have skin.

Interviewer: So, with that in mind, is this technically a sexually transmitted disease, or sex just happens to be a place where skin-to-skin happens?

Dr. Spivak: Yeah, I think it's a really terrific question because certainly, the biological mechanisms are exactly as you said, that sex is a great opportunity for skin to be vigorously rubbing against skin, and so a great opportunity for the disease to spread. But that's not the only way that we come into contact skin against skin.

When we call something an STD or sexually transmitted disease, that obviously implies a specific route of transmission. I think this could be categorized as an STD. There are also implications for that, around calling something an STD, because of our morals and our discomfort, I think, in our society about talking frankly about sex. That, I think, has given a lot of people in medicine pause about calling this an STD.

And I think we're trying to be sensitive to the fact that there were lessons to be learned, and there are lessons to be learned about HIV. And as I shared with you, sort of a common misconception 40 years into an epidemic that frankly should be controlled, but isn't . . . and I'm talking about HIV . . . there's still this perception that this is a gay disease. As I shared with you, that's just not born out by facts. There's nothing about this virus that indicates that it has any predilection for gay men at all.

Interviewer: So circling back to the state that we're in right now with monkeypox, we see the news every day, it's on the rise, it's scary, it leaves scars, we've done pieces about how it's transmitted, etc., but are there any steps that someone can take to make sure to protect themselves from potentially getting infected?

Dr. Spivak: Yeah, that's a great question. And the answer in some respects is similar to what we've learned, unfortunately, the hard way with COVID, though you could argue the glass is half full there, and I'm getting at vaccines. We have a vaccine against monkeypox, which is pretty remarkable that we actually had the vaccine present before the outbreak. And again, that's the glass half full.

The glass half empty is there's not a lot, not enough to go around. We don't have it here yet. That's largely because the supply is limited, but the Department of Health to their credit acquired vaccine from the federal government and tried to disperse it quickly. The Utah AIDS Foundation led by Ahmer Afroz has done a phenomenal job at getting information out and actually getting vaccine and distributing it.

I think we have a long way to go there, meaning that a lot more folks probably should be vaccinated. And frankly, anyone who wants to be, thinks they may be at risk, should be vaccinated. I don't think at this point, and we're in mid-August of 2022, that we have enough vaccine to go around. And so there have been decisions made about who gets priority, which is unfortunate from a public health standpoint because this is going to allow the disease to spread.

It is a disease that's spread skin-to-skin and spread by touching or coming in contact with these lesions, and so what that means is beyond vaccines, which are preventive, if you think you may have this, you should come and get checked out. We have a great diagnostic test.

And ARUP has been at the forefront. They're a phenomenal lab. They're an international leader, and they came out in end of July with their own monkeypox PCR test. Our clinic managers, and the urgent care staff, and people in the ERs, and people in our primary care clinics have rapidly become aware that this is out there. We're seeing more cases because people are coming in, and then physicians, and physician associates, and APCs are recognizing it. And clinic managers, and nurses, and clinic staff are taking the right maneuvers to sample the virus, meaning there are collection procedures that have to be put in place.

All this happened very quickly, and I think COVID did teach our health system how to be a little more quick to respond. And so that's been really encouraging. Working together, we can recognize this. Led by Jeannie Mayer, a hospital epidemiologist here, we can really as a system start to adapt to a new disease. So that's all encouraging.

I would say that people need to be aware that it's out there. They need to come in and get checked. We have a great test, and we actually have a great treatment. I could keep going on and on, but I'll stop there.

Interviewer: There seems to be a lot of fear out there right now, especially with limited supplies of vaccines, etc. Do you think that fear is founded?

Dr. Spivak: I do. Yeah, I do. It's scary. I've cared for a few individuals with monkeypox, and I'd say one thing. Again, I tend to be a glass-half-full, optimist-type person. It's not COVID. And what I mean by that is people are recovering. We have, to my knowledge, yet to have a monkeypox fatality, and yet it is symptomatic. People experience a lot of pain with it.

I think, obviously, it's to be avoided, but it's not quite in the same ballpark, I think, when we talk about in the intensive care units across the country where there was no vaccine, no treatment, and it was spreading like wildfire. We're really not in that situation.

But on the other hand, as I shared earlier, there are a lot of unknowns here. Maybe this is a mild strain, and we're going to see it get worse, or who knows what. But I don't think so. I think this is going to be a little bit milder.

I think the fear is justified because our public health measures aren't enough. We don't have enough vaccine, and we should be vaccinating everybody that wants a vaccine. We don't have quite enough of this therapeutic medicine to go around. It's a bit of a headache bureaucratically to get it, though I'll say that is part of my job, and we'll do it, jump through the paperwork hoops. That's fine.

The first patient I've treated with this drug called Tecovirimat, which is specifically . . . It's not FDA approved, but they have what's called an investigational new drug application, and that allows us to give it for this indication. The very first patient I've used the drug for had a really exciting turnaround in his symptoms, severe pain, and rash, and within about 48 hours, he got better. Now, that is what we call in science an N-of-1, but no side effects and a great recovery. Obviously, we have a lot more to learn, but that's encouraging.

Announcer: Health information from experts supported by research. From the University of Utah Health, this is thescoperadio.com.

Interviewer: Peyronie's disease is a very treatable condition, but you have to seek help in order to get that treatment. Up to about 13 percent of men might have it. And those numbers might even be higher because a lot of men just don't even talk about it. Urologist, Dr. Alex Pastuszak is an expert on Peyronie's disease, also called PD, and has received an NIH grant to investigate the genetics and molecular mechanisms of the condition.

So let's talk about this disease because I did a quick internet search. Five minutes later, I was in the black hole. There's a lot of stuff out there. Let's clear up the misconceptions. Let's get the good information. So a couple of issues first, acknowledging that a man has it and then getting help for it. Those are kind of the two big things.

Dr. Pastuszak: Yeah. I think one of the big things with Peyronie's disease that brings guys out of the eaves really is knowing that it's highly treatable and knowing that a lot of other men actually have it, and that they really shouldn't be ashamed to see somebody about it because there are a lot of us that can actually treat it.

Interviewer: Yeah. It comes to shame, you think, is why men don't seek help? Because you've told me that a lot of men don't seek help, even though it's a very painful condition and not much fun.

Dr. Pastuszak: So I'm going to nerd out just for a second, but up to 50 percent of guys with Peyronie's disease can actually have clinical depression because of it. So it's not just shame, but there's a lot of psychological issues that can come with having just what somebody can consider penile curvature.

Interviewer: Okay. So, first, acknowledge that you have it, realize that you have it. Do you find most men that have it actually do know, so we don't really have to talk a lot about what the symptoms are? Is that worth going into?

Dr. Pastuszak: Yeah. That's actually a great question. So most men who have started to get curvature, know that they have it. Soon as they have an erection, they have curvature, they're like, "Wow. That's different than it was X time ago." There are some guys who'll come and see you and say, "You know, Doc, I have some pain in my penis, either when I have an erection or without that." And then you tell them that they need to be on the lookout for it, but they may not have it by definition yet.

Interviewer: Okay. So it sounds like there are two kinds of things to look for. A curvature, how severe is the curvature?

Dr. Pastuszak: It can be just not normal for the guy. That's all you need.

Interviewer: All right, and pain. Does pain always accompany the condition?

Dr. Pastuszak: No. It doesn't always accompany it. And the other thing to look for is sometimes guys find like "a knot" in their penis, a lump. So lump, bump, or curve is sometimes how we refer to it. And they find that troubling. They think, "Oh, wow, you know, hey, I've . . . Oh, shoot, you know, maybe I have penile cancer," and they come running. So those three things really are what bring men into the clinic.

Interviewer: And it's usually men around 50, 55?

Dr. Pastuszak: So the average age is 55. That's nationally. But there are plenty of younger men who have that and plenty of older men as well. I see men as young as in their 20s who have it.

Interviewer: All right. And it's caused by scar tissue building up?

Dr. Pastuszak: That's right. By and large, technically, it's an abnormal scar tissue formation in the penis.

Interviewer: And that's that lump or bump that you start to feel initially?

Dr. Pastuszak: That's exactly right. And then that can sometimes increase in size and that curvature can stay the same, get better or get worse.

Interviewer: All right. And is it something that most men do . . . And we kind of did touch on this, but does this progress pretty quickly, generally, the curving, or is it so slow that you might just one day go, "Look at that, that's not right"?

Dr. Pastuszak: So everybody's a little different when it comes to how quickly they progress. I've had guys come in and say that, you know, within two weeks of feeling pain or getting a bump on their penis, or whatnot, they had really bad curvature. And there are other guys who come in and say that it's been months or years, and it continues to get worse or has been the same for a long time.

Interviewer: So, when you start noticing those initial symptoms, is it pretty important to get in right away, or is it something you can kind of sit on for a bit?

Dr. Pastuszak: So I think it really depends on how important it is to you as the patient, because a big part of what defines what we as doctors end up doing in terms of treatment and treatment recommendations is how much it actually bothers you.

Interviewer: Okay. So if the guy's not feeling any pain and it doesn't bother him, then it's not something you necessarily recommend a patient come in for, or is it going to cause problems eventually?

Dr. Pastuszak: So that's probably going to be the million-dollar question today, to some extent because we don't know, definitively, whether it causes other problems. Some of my research has suggested that it can cause other problems, but we haven't linked it causally to the problem yet so we don't know for sure.

Interviewer: If you seek treatment more quickly, is it more likely you're going to have a successful treatment?

Dr. Pastuszak: Ultimately, you need to seek treatment or the best time to seek treatment is when your curvature is no longer getting worse because that's what's considered the stable phase of the condition. And that can take anywhere from six to 18 months to get to, at least based on the research that we have right now. So, you know, if you're treated when you're stable, great. There's a little bit more of a risk that you take if you're treated when you're in what we call the active or developing phase.

Interviewer: Oh, okay. All right, let's talk about treatments. There are four different categories, you told me. Let's just go ahead and go on down through those.

Dr. Pastuszak: Okay. I'm going to go ahead and start with traction therapy. So, to take a step back, the four categories are:

1. traction therapy,
2. oral therapies,
3. injection therapies, and
4. surgery.

Okay? So with traction therapy, this is something that men can do at home. And I'll tell them upfront, "If you don't want a doctor involved in your treatment right now, then I'll tell you where to get this device. You can go get it online, and then you can start your traction therapy." In terms of efficacy, we don't know exactly how effective it is. There are some early studies now that show that it can help improve curvature, but the jury's still out.

Interviewer: Yeah. I'm looking at one of these devices right now. They don't look fun. It looks like a torture device kind of.

Dr. Pastuszak: So you're probably looking at RestoreX or what's called the Andro-Penis. These things have great names.

Interviewer: Of course, they do, right?

Dr. Pastuszak: The one I actually probably recommend the most to my patients is called the Penimaster PRO. That's right, you can stop and giggle. It's okay.

Interviewer: Well, I mean, come on. This is an embarrassing enough situation and some company named it that?

Dr. Pastuszak: Well, yeah. Except the bottom line is that the thing works.

Interviewer: Okay. Well, you just have to get over . . . Okay.

Dr. Pastuszak: But they can be effective. All right. Moving on to oral therapies. So I actually don't use oral therapies very much, and we don't use them very much in our practice here in Utah because our professional society, the American Urological Association, in 2015, came out with guidance that they don't really work. Well, let me back that up, that there's no evidence that they work right now. That doesn't mean that some of these don't work, it's just that we can't prove it.

Interviewer: Got you.

Dr. Pastuszak: Okay? So I would just caution men who may be considering oral therapies, because some of these can be nutraceutical stuff you get over the counter, to think twice before they use it just based on the evidence that we have.

Interviewer: Are there some side effects that you're worried about? Because I would consider, you know, there's no evidence to show that they work, but maybe there's in some cases they do, then I have to look at, "Well, what are the drawbacks if I do take this?" Are there some drawbacks to these oral therapies if a man did decide to try them?

Dr. Pastuszak: So, ultimately, anything you take, that has drug potential, can have side effects, so that's another thing to consider. It's a good point.

Interviewer: All right. Number three is injections.

Dr. Pastuszak: Yeah. So injection therapies are drugs that we inject directly into this scar tissue that can either help dissolve it or prevent more of it from forming. And there are three, in particular, that have good clinical evidence that they work, and we offer those here at the University of Utah and at other major centers.

Interviewer: All right, number four is surgery.

Dr. Pastuszak: So surgery, there are numerous surgical options. And this is probably a conversation best had with your urologist, particularly a urologist who has done this a lot because the surgeries can get somewhat complicated.

And the right option should be really an intimate discussion between you and your urologist. But these are highly, highly effective, and you can be pretty much straight coming out of the operating room.

Interviewer: If you're counseling a patient on these options, what's your hierarchy of where do you start? Where do you end up? Do you start right at surgery, or do you try injections first?

Dr. Pastuszak: No. So I think shared decision-making is the way to go. You need to talk to your patient and figure out how much they want treatment, and how quickly and, you know, ultimately how much time they're willing to devote to treatment, and how aggressive they want to get will help determine what they end up doing.

Interviewer: All right, so it sounds like, if you're serious, you really should see a urologist, take a look at injections or surgery, probably, are your two best options. That's what I gathered out of this conversation.

Dr. Pastuszak: Yeah. And I think the traction therapies are really good options for guys who don't want to seek help from a physician right now. But, you know, I would encourage guys to come in, at least have a discussion because that way you can know what the evidence is, one way or another, and make your decision based on a level playing field.

Interviewer: And my final question is, a lot of times when you do a search on the internet, you'll see people that have a condition and they say, "I've been to all sorts of doctors and nothing is working." What if a man has seen a urologist and it's just not getting better? What do you do at that point?

Dr. Pastuszak: So I think if a man is seeing a urologist, that's already a step very much in the right direction, but not all urologists are created equal. There are definitely subspecialties within urology. And so, if a man has not seen a male sexual dysfunction specialist, so somebody who is specifically trained in managing these types of conditions, and there are a handful of us across the country, then they should seek someone out like that.

Announcer: Have a question about a medical procedure, want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today, "The Specialists" with Dr. Tom Miller is on The Scope.

Interviewer: Fatty liver disease affects more than 80 million Americans, and many of them don't even know they have it. Dr. Tom Miller, why does fatty liver disease concern you as a doctor?

Dr. Miller: Well, fatty liver disease is becoming the most common chronic liver disease in the industrialized Western world, and especially in the United States. And it used to be, we had viral hepatitis as a cause of liver disease and a major cause of transplantation, which it still is, but very shortly the major reason for liver transplantation due to liver failure is going to be fatty liver.

Interviewer: And not necessarily caused by alcohol. I always thought it was, you know, people that drank a lot tend to get fatty liver disease.

Dr. Miller: Well, they get liver disease. It's not necessarily fatty liver disease as you would think about it, and it was and still continues to be a cause of liver disease, but because of our lifestyle and the fact that 30% of the people living in the United States have obesity, fatty liver disease is now the most common cause of chronic liver disease.

Interviewer: Yeah, 80 million Americans, that's quite a . . . that's almost an epidemic, isn't it? Like, if 80 million Americans had any other sort of disease, we would be freaking out.

Dr. Miller: Right. I think the term might be just a little bit . . . The categorization of it is a little bit misleading because not everyone with fatty liver disease goes on to develop liver failure. In fact, a small percentage of those people end up with liver failure, but given the large number of people with fatty liver disease, a significant number of Americans will end up with end-stage liver disease.

Interviewer: And what exactly is going on? So I think the name implies that there's some fat, maybe excess fat deposits in the liver, but why is that bad?

Dr. Miller: Fat is a cause, a driver of inflammation, and we don't exactly know why, but when people gain weight, some of that weight is stored centrally and also stored between the cells in the liver. So if you look at a person's tissue from the liver, you will see if they have fatty liver, which is called non-alcoholic fatty liver. You'll see fat stores or globules in between the cells. For whatever reason, this causes inflammation, and inflammation predisposes to damage, fibrosis, and destruction of the active cells in the liver which help us cleanse our body of toxins.

Interviewer: And you're talking about scarring.

Dr. Miller: I'm talking about scarring.

Interviewer: That's why I used those words, yeah.

Dr. Miller: Fibrosis leads to scarring.

Interviewer: Yeah.

Dr. Miller: Now, again, most people with fatty liver don't end up with inflammation, and we don't exactly understand why some people have problems with inflammation related to their fatty liver versus those who don't. And not everyone who has inflammation in the liver goes on to develop cirrhosis.

Interviewer: But it's certainly a path you don't want to go down and find those things out.

Dr. Miller: No, definitely not, and it can be treated.

Interviewer: All right. So, when a patient comes into your office, can you look at them and tell if they have the bad kind of fatty liver disease that could lead to transplant or death?

Dr. Miller: I think the way that we think about it now, I believe the way we think about it now is if you're obese, that is you have a body mass index greater than 30, your chances are pretty high of having non-alcoholic fatty liver disease. So, basically, the same thing that we've talked about on these shows in the past, right diet, right weight, right exercise is your best treatment to prevent it. This is a problem with industrialized countries having too much food and the wrong kinds of food available.

Interviewer: Yeah. And once that scarring happens, there's no cure for it. It eventually will lead to liver failure.

Dr. Miller: Once you start down a path of scarring, your chances of ending up with end-stage liver disease and needing a transplant are pretty high. Not only that, you are predisposed, with that scarring, to liver cancer.

Interviewer: And if you start to lose some weight, I understand it doesn't take, necessarily, a lot of weight reduction to reduce the number of fat cells in the liver and kind of start backing that thing up if scarring hasn't occurred.

Dr. Miller: Right. I think one, again, wants to head for a normal BMI, which is between 18.5 and 25.

Interviewer: Okay.

Dr. Miller: And that's not easy. I mean, I tell you that that's the treatment, but attaining that treatment for everybody is difficult because we don't have a medication for weight loss that works, and basically it's a lifestyle adjustment, which is hard for people given the abundance of food.

Interviewer: And there are tests that you can do to determine, for sure, if there are.

Dr. Miller: There are. So we basically start looking at the issue of inflammation in people who we think might have fatty liver disease by looking at the enzymes that the liver produces on a blood test. If these are elevated, there are a number of causes, but eventually, if you can rule out sort of the medical, the drug-associated causes and other causes, that is if they're not drinking, you can think that this is probably related to a non-alcoholic fatty liver disease. And if you really want to know damage to the liver, you're going to have to do a liver biopsy. There's another test now that's non-invasive, but liver biopsy is still the gold standard.

Interviewer: And we haven't really hit on this, but it often doesn't have symptoms.

Dr. Miller: The vast majority of people with non-alcoholic fatty liver disease are not symptomatic.

Interviewer: Yeah.

Dr. Miller: And, in fact, you're only symptomatic towards the end . . .

Interviewer: When it's kind of too late.

Dr. Miller: . . . with this disease when you have fibrosis and scarring or liver cancer. So, again, we want to look at obesity and lifestyle as a response to prevent this.

Interviewer: So get that body mass index back into a reasonable area?

Dr. Miller: Well, it's the same thing we talk about for all of the things that we now kind of associate with the Western world diet, which is high blood pressure, heart disease, metabolic syndrome, type 2 diabetes. They're all in a basket, including this non-alcoholic fatty liver disease. And, again, the treatment is at our hand, but it's not easy to achieve.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Interviewer: Do you have chest discomfort, or are you short of breath when you're walking from the parking lot to the grocery store or maybe taking a flight of stairs? Dr. Steven Lofgren, what could be causing that?

Dr. Lofgren: One of the potential causes of these symptoms would be coronary disease or heart disease. That can be caused by a restricted amount of blood flow to the heart muscle itself.

Interviewer: And if somebody's suffering from these symptoms, what do you recommend that they do?

Dr. Lofgren: We would absolutely want to have a patient with these symptoms have what's called a stress test done. A stress test is nothing more than putting the body under some degree of stress and seeing how the heart performs. Benefits of doing this test is you can have an immediate diagnosis of a potential blockage in one of these coronaries, which then can be fixed very simply with a process called angioplasty. If you find that you have these symptoms, it is absolutely critical that you go in and see your doctor for further testing.

updated: March 23, 2021
originally published: April 1, 2019

Interviewer: Can compression socks prevent varicose veins? Dr. Claire Griffin is a vascular surgeon. Do they help?

Dr. Griffin: Compression socks help prevent the backup of blood, which is what leads to incompetent veins, and incompetent veins is what leads to varicose veins.

Interviewer: So they can help. So if your doctor prescribed them, you should wear them?

Dr. Griffin: Yes. In fact, if you don't wear them, no insurance company will help pay for any of the treatments of varicose veins. The first step is always wearing your compression socks.

Interviewer: Okay. And you have to wear them all the time or just once in a while okay?

Dr. Griffin: Every day until bedtime is the ideal, particularly on days when you're either on your feet or immobile for long periods of time.

Interviewer: And over time, research does show that they do make a difference?

Dr. Griffin: They make a difference, and often people notice an immediate symptomatic improvement in how their legs feel at the end of the day.

updated: December 10, 2020
originally published: January 10, 2018

Interviewer: Lyme disease. What is it, what are the symptoms, and what you can do about it? That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. John Kriesel is a physician and researcher in the Division of Infectious Diseases at University of Utah Health. And today, we hope to learn more about Lyme disease. Let's just start with the beginning, what is Lyme disease?

Dr. Kriesel: Lyme disease refers to Lyme, Connecticut, which is a region in the country that had a long-standing mysterious disease. It was later found to be due to a bacterium called Borrelia burgdorferi. So Lyme disease refers to infection with Borrelia burgdorferi.

Interviewer: All right. So how do you get this infection?

Dr. Kriesel: Well, Lyme disease is generally tick-borne infection and it's found commonly in the northeastern part of the United States. Also in the Midwest and the southeast part of the U.S., occasionally in the western U.S. You get it from ticks, generally, that harbor the Borrelia organism and then transmit it to people.

Interviewer: All right. So at some point, if you have Lyme disease, a tick got on your skin and did what ticks do, put their head in and gave you the bacteria?

Dr. Kriesel: That's right.

Interviewer: Okay. And there are some places in the United States that have it. There are some places that don't. Not all ticks carry it, it's just certain varieties. Is that correct?

Dr. Kriesel: Right. It's these Ixodes ticks. They're small ticks. There aren't many of them in Utah and we don't have any endemic cases in Utah that we know of. We've looked, believe me.

Interviewer: Yeah.

Dr. Kriesel: But we do have Ixodes ticks. We just don't have any Ixodes ticks that carry the Borrelia organism as far as we know.

Interviewer: Yeah, as far as we found. Okay. Who's at risk for Lyme disease?

Dr. Kriesel: Well, I think people that live in endemic areas are relatively high risk. And of course, I think men are at higher risk than women possibly because they get more outdoor exposure, typically. People who work outside in their yards or in their occupations often become infected.

Interviewer: What are the symptoms of Lyme disease?

Dr. Kriesel: Well, people get an initial febrile illness and then they get a rash. I call it erythema migrans rash. You can certainly look up pictures of that, but that's considered to be . . . tick exposures, usually people don't find a tick because they're too small. But tick exposure in areas working outside or being outdoors and then getting an erythema migrans rash with a febrile illness.

Now, the illness often includes fatigue, lethargy, headache, sometimes neck stiffness, muscle aches, joint aches. And when patients travel in and they have a compatible illness, to Utah, we certainly ask them about possible tick exposure and then any rash that might develop.

Interviewer: And how do you diagnose that?

Dr. Kriesel: The acute disease is a clinical diagnosis, so you have to have exposure to an endemic area and then you have to have a compatible illness. Usually I think 80% are followed by the rash. So if you have those things, then you don't need to do a test. You just need to treat the patient.

Interviewer: Okay.

Dr. Kriesel: But chronic disease is harder. So somebody who has, say, a facial palsy, or heart rhythm abnormalities, carditis, or arthritis in one or more joints, or some sort of a neuralgia pain syndrome, this is a much more difficult thing to diagnose. And that requires antibody tests called serologic tests that we do in the blood.

Interviewer: So it really comes down to if you catch it early enough, if somebody sees a tick on them and then starts having these symptoms and gets the rash, pretty much case closed. You've got it figured out.

Dr. Kriesel: Right. Well, again . . .

Interviewer: As much as one could have a case closed in medicine.

Dr. Kriesel: Again, most people can't see the ticks because they're so small. But if they have a compatible exposure and a compatible illness, yes, that's a diagnosis of the acute illness.

Interviewer: But the trick is, somebody had an exposure, they didn't realize it. A few months later, they start experiencing some symptoms that they try to track down, then that's when you have to do the antibody test.

Dr. Kriesel: Exactly.

Interviewer: And it can be confused for a lot of other diseases, I've understood.

Dr. Kriesel: Well, it's a serologic test, so you're looking at antibodies that people make against Borrelia burgdorferi, right? Either by ELISA test or another test called the C6 Test or Western Blot Confirmatory Testing. So these are all special antibody tests, but there are other spirochetes in the world. So Borrelia are not the only spirochetes. Syphilis is a spirochete, Leptospirosis is a spirochete, so there could be cross-reactivity between diseases. So the first stage in serologic testing for Lyme disease involves an ELISA or an EIA, enzyme immunoassay test. And that's the screening test. It's like the HIV screening test, right, only it's for Borrelias.

And then if that's positive, then it goes on to a confirmatory test. The confirmatory test is called the Western Blot Test that involves specific bacterial antigens on a paper and then you see if there's antibodies that react to those antigens. So that's how that works and there are very specific criteria set forth by the CDC in these accredited laboratories to make that diagnosis.

Interviewer: And it could be a tricky diagnosis to make.

Dr. Kriesel: It could be tricky. It is tricky and frequently misinterpreted.

Interviewer: Lyme disease, probably prevented by keeping the ticks off you. Is that about the best way to prevent it?

Dr. Kriesel: Right. You can refer to the CDC. They have some specific recommendations. Actually, there's nice little brochures and I think the Utah Department of Health may have something similar.

Interviewer: All right. And then, if it's been determined that I have Lyme disease, what are the treatment options at that point?

Dr. Kriesel: That's a good question. I think we treat patients with doxycycline initially. There's also been some interest in treating possible exposures, post-exposure prophylaxis, but we don't really have occasion to do that very much here because the prevalence is so low.

Interviewer: So is this a shot? Is this some oral pills?

Dr. Kriesel: No, no, no, it's a pill. It's antibiotic pills.

Interviewer: An antibiotic pill.

Dr. Kriesel: And there are a number of different pills that could be used.

Interviewer: Okay. And then, is it ever completely treated or will you kind of have the symptoms or have the disease? It can only be controlled?

Dr. Kriesel: My understanding is the disease typically is cured, that the antibiotic treatment is curative. But there are always concerns about so-called post-Lyme syndrome. What are the diagnostic criteria for that? How do you make that diagnosis in patients? And that's kind of a more of a gray area. But can there be persistent infection? Well, not as far as I know.

Interviewer: Okay.

Dr. Kriesel: Right. But people can be re-infected and people can have difficult, prolonged infections and people may have symptoms that go on even after the spirochetes are eradicated.

Interviewer: That would be related to the fact that they did have Lyme disease?

Dr. Kriesel: Potentially.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Interviewer: You have a loved one and you've been told they have an aortic dissection. What does that mean for them in the short term, and more importantly, the long term? That's next on The Scope.

Dr. Jason Glotzbach is a cardiothoracic surgeon at University of Utah Health and if somebody's been diagnosed with an aortic dissection, let's kind of break that down a little bit and help them understand what that means. Generally, it's probably not going to be that person that had it that will be finding out this information because it's a serious thing.

Dr. Glotzbach: Absolutely. So the aorta, as we've talked about, is the largest blood vessel in the body and the aorta has several layers to the aortic wall. It's kind of like plywood where the layers should be stuck together without any space in between them and sometimes due to high blood pressure or other things, you can get a small tear in the inside of the aorta, which then allows blood to travel in between the layers of the aortic wall.

We call it dissection because it dissects into the aorta and then once that blood gets in between the layers of the wall and separates them, that can cause major problems with the aorta.

Interviewer: So when it's in between those layers is it going to break out eventually and you'll be internally bleeding or what happens at that point?

Dr. Glotzbach: It can proceed to that, although more that's rare. More commonly, the blood dissection inside the wall of the aorta will travel kind of along the length of the aorta and it can block off the branches coming off the aorta. So it can prevent blood flow from going to all the branches of the aorta which can affect any area of the body because of those arteriole branches.

Interviewer: Including the brain?

Dr. Glotzbach: Absolutely, so it can involve the carotid arteries. Obviously if the carotid artery blood flow is decreased or impaired and then it can cause a stroke. Similarly, the blood vessels going to the liver or the spleen or the kidneys or the intestines, if those are blocked off then you can have major problems in the abdomen. So it really is a critically dangerous problem once it develops.

Interviewer: And I understand that there are two different types of aortic dissections that somebody might be diagnosed with. For the understanding of, you know, a loved one that might have another loved one that's dealing with this, could you explain briefly what those two are?

Dr. Glotzbach: Absolutely, and we break it down anatomically by kind of location within the aorta and so the two types are type A and type B.

Type A aortic dissection involves the first part of the aorta coming right off the heart, so also known as the ascending aorta. And a type A dissection is a surgical emergency. Those patients need to go as quickly as possible to the operating room with a cardiovascular surgeon to repair that.

Type B aortic dissection involves the rest of the aorta, so from the aortic arch on down and including the abdomen. And so type B dissections are a little bit more complicated or nuanced in that they may require surgery or a procedure. They might not, but they definitely would need to be in the hospital.

So those two distinctions are critical for the initial treatment phase, although all aortic dissections really should be thought of as a chronic disease and so once this happens to the aorta, patients will need lifelong surveillance with imaging studies and follow up with an aortic specialist to make sure that problems don't develop down the road.

Interviewer: And what caused that to happen? Is it something that the patient did or did it just happen?

Dr. Glotzbach: It can be both. There are risk factors including smoking and high blood pressure. There are some genetic conditions or familial patterns that can predispose people to have this problem. One of the biggest risk factors for aortic dissection is developing an aortic aneurysm, which is an enlarged area of the aorta which gets thinned out and weakens, so that's more susceptible to a dissection. But a lot of times these are just bad luck and this happens to someone who's never had an aortic problem before and this just kind of happens out of the blue, so it can be a devastating problem.

Interviewer: Are there any sort of warning symptoms that would come before the actual emergency event?

Dr. Glotzbach: Unfortunately, there are not a lot of warning symptoms. A lot of, you know, an aortic aneurysm is largely asymptomatic. High blood pressure can cause a bit of a warning, and then obviously people that have known aortic problems. But most people who have a dissection have no warning sign or nothing that suggests this is about to happen until it actually does happen.

Interviewer: All right and once . . . How is it diagnosed?

Dr. Glotzbach: Typically it's severe pain and so patients who have a dissection have severe chest pain or back pain or abdominal pain or all three, and a lot of times it could mimic a heart attack or other kind of acute problems. So most people know something is going wrong and they have severe pain, which then usually people come to the emergency department with the symptoms and then it's diagnosed from there with an imaging study.

Interviewer: And how do they get fixed in the short term and then what's their long term look like?

Dr. Glotzbach: Absolutely. So for a type A dissection like we talked about, that's a surgical emergency so those patients go to the operating room and we will replace the ascending aorta at least and sometimes more. Sometimes the aortic valve can be involved or the coronary arteries need to be reconstructed. Basically need to stabilize that first part of the aorta so that the blood flow to the brain and to the rest of the aorta is preserved. So that's a type A.

For a type B, which is involving the rest of the aorta, the most critical thing is to keep the patient's blood pressure under control and then to determine if there is any problem with blood flow to any of the other organs. So we look at blood flow to the liver, the gut and the legs, the kidneys, all those things. As long as there's blood flow to those organs, typically we can manage those patients medically.

Interviewer: And what does life look like after somebody has an aortic dissection? Likely I'm talking, you know . . .

Dr. Glotzbach: Long term.

Interviewer: Three to five years.

Dr. Glotzbach: Absolutely. So once we've stabilized after the initial event, then it becomes kind of a chronic disease that needs to be managed and watched closely like any chronic disease. And so the way we do that for aorta, number one, is blood pressure control so we have to . . . most patients are on one or multiple blood pressure medications and then we do long term follow up with imaging studies. And typically that's a CAT scan or a CT scan, which is a three-dimensional X-ray that gives us a very good picture of the aorta and tells us exactly what's going on.

And so we'll have the initial imaging from when it first happened and then we'll get every, between six months to a year or so and every year after that we'll get CT scans watching how that aorta is changing or not and if things start to change then sometimes we need to do procedures in the future and sometimes not, sometimes people just remain stable and we just keep watching them.

Interviewer: So what I'm getting is that it's something that could happen again to somebody who's had one.

Dr. Glotzbach: It could, and once you've had an aortic dissection your aorta's at risk for life and so this is something that is, you know, can be managed and stable and people can go on living with it but it's not something that will ever heal completely and so people just have to be aware that they need lifelong surveillance and I think that's where a true aortic program comes in where you have a dedicated team of physicians and nurses and radiologists and people that are used to watching these over long term so that we can pick up on problems as they begin to develop, before they turn into big problems, we can intervene.

Interviewer: And what about quality of life?

Dr. Glotzbach: I think that this is a very serious emergency. When these happen, they're life threatening and should be taken seriously and treated immediately at a hospital and so the quality of life after that, once you've stabilized and treated from the initial event, people can go on living normal lives and do almost anything that they want to do provided they have good follow up care and we keep an eye on things and make sure that that aorta remains stable and doesn't develop complications down the road.

updated: August 25, 2021
originally published: August 23, 2017