HEALTH & WELLNESS: Recent Episodes
The Original Guide To Mens Health
Explore the intricacies of the Health Belief Model in this enlightening episode, where we delve into the factors influencing individual health decisions, the pivotal role of knowledge, and the impact of societal norms on men's health behaviors.
Join us as we unpack the significance of understanding perceived barriers, the benefits of behavioral change, and the instrumental role health practitioners play in shaping healthier communities. This discussion offers valuable insights into improving health behaviors and the various elements that motivate individuals to embrace healthier lifestyles.
The latest podcast episode wraps up the 'Real Talk on Men's Health' series with two informative presentations. The first part emphasizes the early detection of Prostate and Testicular Cancers, offering crucial information. The second presentation delves into new treatments for obesity, including insights on Obesity, Diabetes, and Metabolic Syndrome.
In our latest episode, we focus on two critical areas of men's health as presented during the October 25 live event, 'Real Talk on Men's Health.' These areas are Cardiovascular Disease and Its Management and Understanding and Managing Prostate Enlargement. This episode is an invaluable resource for anyone interested in gaining a deeper understanding of these key men's health issues.
This episode not only provides vital information but also serves as a comprehensive guide for men to understand and manage their health effectively. Tune in to stay informed and take proactive steps towards a healthier future.
Episode Summary: What are those aches and pains in your fingers, hand, elbow, toes, foot, ankle, and knee? What causes them? What do you do when they seem more severe and interfere with your activities? What are the various types of arthritis? Not all Rheumatological disease is arthritis; what else does this area of medical...
Episode Summary:In this episode, we explore our understanding of longevity with a leading longevity researcher.
Guest:Dr Matt Kaeberlein, PhD
Former Director, Healthy Aging and Longevity Research Institute
Former Director, Biological Mechanisms of Healthy Aging Training Program
Co-Director, UW Nathan Shock Center of Excellence in the Basic Biology of Aging
Co-Director, Dog Aging Project
Professor of Pathology
Adjunct Professor of Genome Sciences
Adjunct Professor of Oral Health Sciences
Dr. Kaeberlein’s research interests are focused on biological mechanisms of aging in order to facilitate translational interventions that promote healthspan and improve quality of life. He has published more than 200 scientific papers, has been recognized by several prestigious awards, and has Fellow status in the American Association for the Advancement of Science (AAAS), the American Aging Association, and the Gerontological Society of America (GSA). Dr. Kaeberlein is currently the CEO of the American Aging Association and has served on the Board of Directors for the Federation of American Societies for Experimental Biology (FASEB), AGE, and GSA. Dr. Kaeberlein is the founding Director of the UW Healthy Aging and Longevity Research Institute, the Director of the UW Nathan Shock Center of Excellence in the Basic Biology of Aging, Former Director of the Biological Mechanisms of Healthy Aging Training Program, and founder and co-director of the Dog Aging Project.
During This Episode, We Discuss:The Dog Aging Project
What makes us age?
What are the hallmarks of aging?
What we know about longevity determinants. Genetics or Environment or both?
Are there longevity genes?
What role do diet, exercise, and maintenance of muscle mass/ strength, play in longevity
What do we know about successful cultures that live longer
What research is exciting and ongoing? What we still need to understand.
Dr. Kaeberlein's thoughts on:
Longevity Clinics
Vitamins
Growth Hormone
Calorie Restriction
Medications (Growth Hormone, Metformin, Rapamycin)
Other Longevity Researchers, Practitioners …
Quotes:“ Updated hallmarks of aging, (11 or 12 depending on who you talk to), these are types of cellular dysfunction and damage that happen with age across all animals and are directly contributing to our increased risk of developing diseases of old age, developing functional decline”...
Dr. Matt Kaeberlein
“There are all these functional declines that go along with the aging process that from a quality of life perspective that I would argue of equally if not more important than the actual overt diseases”
Dr. Matt Kaeberlein
Recommended Resources:Twitter @mkaeberlein
Peter Attia: Podcast, book, articles
Episode Transcript: Coming soon!
Episode Summary: Chronic Pelvic Pain, Chronic Prostatic Pain Syndrome, Chronic Testicular and Penile Pain often have origins in abnormal pelvic floor muscle tension. Listen and find out how modern pelvic physical therapy can help.
Guests: Molly Riley, PT, DPT: Pelvic Health Physical Therapist, University of Washington, Northwest Outpatient Medical Center
Ken Berger, JD, MD: President of the Washington State Urology Society, Practicing Urologist, Tri-State Health, Clarkson, WA, Chair of American Urological Association’s Leadership and Business Education Committee.
During This Episode, We Discuss: The Evaluation and Management of Chronic Pelvic, Prostatic, Testicular, and Penile Pain.
Management of the abnormal voiding ( the non-relaxing voider ), improving post-operative stress urinary incontinence, and appropriate technique for strain-free bowel evacuation.
Chronic Prostatitis is now called Chronic Pelvic Pain Syndrome (CPPS): This is an effort to change the thinking that all chronic prostatitis is infection oriented. Many times CPPS patients respond very nicely to pelvic floor PT
Quotes (Tweetables): Referring to the steps in evaluating testis pain….” If I do all of that and I don’t find anything, that becomes a much more difficult problem for me as a Urologist to treat. That is when I start thinking about sending ( the patient ) to Physical Therapy.
Dr. Ken Berger, JD, MD.
Recommended Resources: Pelvicrehab.com: Use this as a resource to find a Pelvic Health Physical Therapist
Episode Transcript: Coming soon!
Episode Summary: A community-based initiative is partnering with multiple agencies and resources toward gun violence prevention. Learn what’s involved in this campaign.
Listen to become educated on opportunities to intervene and resources needed.
Guests: Will Jimerson, Regional Gun Violence Team for Public Health - Seattle & King County
The Regional Peace Keepers Collective - An Initiative Implemented by the RGV Program
During This Episode, We Discuss: Mr. Jimerson reviews all aspects of the program and the efforts and resources needed to effect changes in gun violence and outcomes.
Quotes (Tweetables): "Young folks of school age who are being exposed to a high percentage of a preventable cause of death, how can we insert those who have time or access to that population, such as school teachers or other community-based workers, organizations, or after-school programs."
Will Jimerson
"Consider one’s well-being, where they may be at in terms of just their life, where an opportunity exists in the model where a CBi component which is a Cognitive Behavioral Intervention, It’s almost like Cognitive Behavioral Therapy but is specialized with this particular population who have been impacted in a particular kind of way."
Will Jimerson
Recommended Resources: Can Community Programs Help Slow The Rise In Violence? By Alec Macgillis. Pro Publica January 30
Regional Gun Violence Community-Based Resource Guide
Episode Transcript: Coming soon!
Episode Summary:This month, we are collaborating with The Partnership for Male Youth to share their amazing podcast, Let's Examine This, hosted by Dennis Barbour. We will be doing a collaborative episode with them in June for Men's Health Awareness Month, so be sure to check out their show, and we'll be back with a new episode of The Original Guide to Men's Health in June.
What are some of the body image and eating disorders that young males are prone to? What is the difference between a body image and an eating disorder? How many young men are affected by these disorders? What are some of the other disorders that are present at the same time? What are some of the risk factors? Is there a genetic component? What role does the media play? What are some of the treatments for these disorders? Our two guest experts will discuss these and other issues.
Guests:Dr. Roberto OlivardiaDr. Jason Nagata
Recommended Resources:National Eating Disorders AssociationEating Disorders in Boys and MenThe Adonis Complex: How to Identify, Treat and Prevent Body Obsession in Men and BoysEating Disorders Helpline
Episode Transcript: Coming soon!
Episode Summary:Obesity is a chronic disease associated with related conditions such as cardiovascular disease(heart attack and stroke), type 2 diabetes, and certain cancers. The current understanding of obesity demonstrates biological and environmental factors like economics and infrastructure, as psychosocial and developmental issues as essential contributors, and a newer understanding of their role in influencing the hypothalamus.
New treatment strategies and medications demonstrate opportunities for success in the management of obesity.
Guest:Joshua Thaler, MD, Ph.D.
Associate Professor of Medicine, Division of Metabolism, Endocrinology and Nutrition.
Dr. Thaler graduated with a major in Biochemistry from Harvard College (Magna Cum Laude with Highest Honors and on the Dean’s List), then obtained an MD and a Ph.D. in Biomedical Sciences from the University of California, San Diego, and the Salk Institute (where he was a Chapman Scholar and a Lucille P. Markey Fellow). He short-tracked through the Internal Medicine residency program at UW and was an endocrinology/metabolism fellow working in Dr. Michael Schwartz’s laboratory. He is currently an Associate Professor at the UW Diabetes Institute.
*Research Interests*:Dr. Thaler’s focus is the hypothalamic regulation of energy homeostasis and the alterations to this system during obesity pathogenesis. His primary project investigates hypothalamic inflammation and its relationship to high-fat diet-induced weight gain, emphasizing the role of glial cells (astrocytes and microglia) in modulating the neuronal regulation of energy homeostasis. In particular, his research aims to determine whether glial cells provide a repair response to diet-induced damage to critical hypothalamic neurons and whether interventions targeted at the glia may influence obesity. A second study examines the role of inflammatory signaling in hypothalamic neurons and microglia in obesity-associated insulin resistance and diabetes. Additionally, Dr. Thaler’s research examines the metabolic role of POMC neurons through the modification of atypical protein kinase C signaling.
During This Episode, We Discuss:Obesity versus being overweight, what Body Mass Index (BMI) defines each condition?
Causes of obesity. New data on root causes
Health impact of obesity
The individualized approach to treating obesity
Investigations and Research into the role of the brain (Hypothalamus) in obesity and obesity management.
Successful strategies for managing obesity, including newer medications and Bariatric Surgery
Quotes (Tweetables):The US obesity prevalence was 41.9% in 2017-March 2020
BMI 25-30 = overweight
BMI 30 or greater = Obesity
Dr. Josh Thaler
“The (newer injectable)weight loss medications do not cure (obesity); if you stop them, the weight will come back…there is no reason to believe it changed your biology in some way that's permanent”
Dr. Josh Thaler
"Obesity, by many estimates, is at least 50%, if not more, based on inherited genes. The environment is acting on that susceptibility, You shouldn't take the fatalistic view I've got these genes, and there is no hope”
Dr. Josh Thaler
“The Heavier you are, the higher your energy expenditure. Thus we can’t say that, in general, people who are overweight have a slower metabolism”
Dr. Josh Thaler
“How much weight needs to be lost to reverse the established disease or lower the risk of the one that hasn't yet.. You don't have to go back to your original normal weight..What the data suggests is that even 5-10% weight loss from wherever your current weight is sufficient to reverse a lot of things(associated diseases) that are associated with obesity”
Dr. Josh Thaler
Recommended Resources:CDC.GOV
https://www.cdc.gov/obesity/basics/index.html
Obesity Canada ( formerly called, The Canadian Obesity Network). Obesitycanada.ca.
The Obesity Society www.obesity.org.
Kevin D. Hall, Ph.D. Multiple YouTube videos and publications
Michael W. Schwartz, MD University of Washington
Episode Transcript: Coming soon!
Episode Summary:In this two-part episode, we explore where the modern male finds himself. We review data demonstrating a trend of increasing gaps in educational achievement, increasing rates of male suicide, and addictions, the preponderance of males in the homeless population, and the decline in males participating in key careers.
We also hear about a Washington State bill to create a commission on boys and men and why it’s important and potentially unique.
If you're unsure if men are indeed in crisis, or are already familiar with some of the issues, listen as we explore, learn and hear not only the problems but solutions from our two very thoughtful, knowledgeable, and engaging guests.
Guests:Richard V. Reeves
Richard V. Reeves is a senior fellow in Economic Studies, The Brookings Institute, where he holds the John C. and Nancy D. Whitehead Chair and leads the Boys and Men Project. His research focuses on boys and men, inequality, and social mobility.
Richard’s publications for Brookings include his latest book, Of Boys and Men: Why the Modern Male Is Struggling, Why It Matters, and What to Do about It (2022), and 2017's Dream Hoarders: How the American Upper Middle Class Is Leaving Everyone Else in the Dust, Why That Is a Problem, and What to Do about It. He contributes to The Atlantic, National Affairs, Democracy Journal, the Wall Street Journal, and the New York Times. Richard is also the author of John Stuart Mill – Victorian Firebrand, an intellectual biography of the British liberal philosopher and politician.
Rep. Mary Dye
First appointed to the House of Representatives in 2015, Representative Mary Dye is a Republican from the Eastern Washington community of Pomeroy. She is serving her fifth term, representing the 9th Legislative District. As a ranking House Environment and Energy Committee member, Representative Dye prioritizes affordable and reliable energy protection, improving environmental and water quality and outdoor recreation. She also works to improve irrigation infrastructure to ensure irrigated farms are climate resilient. Representative Dye graduated from the Harvard Kennedy School Senior Executive Leadership program and holds a B.S. in Crop Management from the University of Idaho. She and her husband farm dryland wheat in Garfield County. Get more information from her website: www.RepresentativeMaryDye.com
During This Episode, We Discuss:The background data and trends supporting the issues are reviewed in an enlightened discussion with Brookings Scholar Richard Reeves
Learn from a Washington State Legislator, Rep. Mary Dye, about her efforts to sponsor a bill to create a Washington state commission on boys and men. They would address well-being, including educational achievement, suicide, homelessness, drug and alcohol addiction, overdose, and incarceration.
Those that feel this bill is serving a population that has already been privileged are looking through a narrow lens. These interviews demonstrate why vulnerable people, men in poverty, and BIPOC populations would all find an advantage in having such a commission.
Quotes (Tweetables):We have seen wage stagnation in males
Richard Reeves
⅔ of the lowest (high school) GPAs are boys
Richard Reeves
Men are less likely to get mental health treatment…. We are seeing so few men in caring professions (social work, psychology, education)
Richard Reeves
Within six years of parents separating, 1 in 3 boys will never see their dad again.
Richard Reeves
Children whose father is absent from the home are almost 279% more likely to carry guns and deal drugs. Where are these kids losing hope and losing a strong male mentor in their life? These are questions we want the commission to ask. Why are these things happening, and how can we do a better job
Rep. Mary Dye
Addictions and homelessness are issues we are not addressing correctly as a culture and are not addressing root causes…
Rep. Mary Dye
Recommended Resources:Of Boys and Men: Why the Modern Male is Struggling, Why It Matters and What to Do About It By Richard V Reeves
How Toxic is Masculinity by Zoe Heller, Books, The New Yorker August 8, 2022 Issue
Men Need Purpose More Than ‘Respect’ Opinion by David French, The New York Times, Feb. 12, 2023
https://lawfilesext.leg.wa.gov/biennium/2023-24/Pdf/Bills/House%20Bills/1270.pdf?q=20230116070700
Soulhealfilm.com. A film by Jose Enrique Pardo
Equality for Boys and Men – Advancing empathy and equality
https://equalityforboysandmen.org
Episode Transcript: Coming soon!
Episode Summary:This episode follows two Kidney Cancer expert Urologists in understanding Kidney tumors from diagnosis to treatment options.
Guests:John L. Gore, M.D. Professor of Urology, Surgery, Health Services Researcher, University of Washington. Urologist, surgeon, clinician, researcher, educator, and expert in clinical care guidelines and outcomes. Dr. Gore is the PI of a large pragmatic trial in bladder cancer and a quality of care expert.
He previously served as the American Urological Association (AUA) representative to the National Quality Forum, which endorses national healthcare performance measures. He has been on guidelines panels for the National Comprehensive Cancer Network (NCCN) for kidney cancer and the AUA for bladder cancer.
Brian Shuch, M.D., is the Director of the Kidney Cancer Program and the Alvin & Carrie Meinhardt Endowed Chair in Kidney Cancer Research. He completed his urology training at UCLA and a Urologic Oncology Fellowship at the National Cancer Institute. He is an accomplished surgeon (open/laparoscopic/robotic surgery and percutaneous ablations) and clinical/translational researcher.
He serves in leadership positions within various kidney cancer research organizations such as SWOG and the Society of Urologic Oncology. He is recognized as an expert in the genetics of kidney cancer. He runs a translational research program with over 140 peers reviewed publications, including primary research published in prestigious journals such as Nature, Nature Genetics, Proceedings of the National Academy of Sciences, Journal of Clinical Oncology, and Clinical Cancer Research. He is one of the few clinicians to bring bench science to the bedside in an upcoming therapeutic clinical trial for metastatic kidney cancer.
During This Episode, We Discuss:The types of Kidney Cancer
Non-cancerous kidney cysts (benign) versus cancerous kidney cysts
Solid kidney tumors, benign and malignant
Diagnosis of kidney cancers: Imaging and Biopsy
Risk factors for kidney cancers
Genomics of kidney cancer
Treatment of kidney cancer: Localized and Metastatic
Quotes (Tweetables):Back in the olden days, we used to talk about the triad of three symptoms people associated with kidney cancer. Those three symptoms were hematuria or blood in the urine, palpable mass, and flank pain. Realistically in 2023, this triad happens less than 1% of the time. What has changed is that there is a much higher frequency of use of imaging to diagnose problems in our bodies. Kidney cancer is one of the fastest-growing cancer types in incidence because of incidental detection.
Dr. Gore
Regarding tumor size, it all depends on the scenario. The larger the lesion, the more concerning it is for cancer, but even a 1 cm tumor can have some aggressive elements. There is no absolute size where you say a tumor below this threshold cannot be cancer.
Dr. Shuch
Most kidney cancers are what we would call sporadic in that it occurs in the absence of known risk factors. The two biggest risk factors that are more behavioral are smoking and obesity.
Dr. Gore
Recommended Resources:KCA: Kidney Cancer Association
Kidney Can
KC Cure
American Cancer Society
Fred Hutchinson
UCLA
Episode Transcript: Coming soon!
Episode Summary:Learn what we know about these often undetected conditions: cardiac disease, prostate cancer, high blood pressure, and diabetes (metabolic syndrome). We look back to relevant episodes and some important comments from our experts.
We also asked our producer Sean Fox for some of his favorite episodes from the past year.
Guests: Episode 36. Quick Virtual Workouts for Anywhere
Lauren Updyke, MS, American College of Sports Medicine Certified Trainer, Director of the University of Washington Whole U program.
Episode 6. Cardiovascular Health—How to Keep Beat with your Heart
Eugene Yang, MD: Cardiologist, Clinical Associate Professor, Cardiology, UW School of Medicine; Medical Director for UW Physicians Eastside Specialty Center, Governor of the Washington Chapter of the American College of Cardiology; Director of the Cardiovascular Wellness & Prevention Program at University of Washington
Episode 15. What Everyone Should Know about Tobacco, Smoking, and Vaping
Sarah Ross Viles, MPH: Director of the Tobacco Studies Program University of Washington, former Chronic Disease Program Manager Public Health, King County, Washington.
Tim McAfee, M.D. Affiliate Assistant Professor, Health Sciences University of Washington, Former Director, Office on Smoking and Health, Center for Disease Control and Prevention. Consultant with the CDC Anti-Smoking Media Campaign
Episode 4. Diet - Eat, Drink and Be Healthy
Marian L. Neuhouser, Ph.D., RD Fred Hutchinson Cancer Research, Program Head, Cancer Prevention Program Public Health Sciences Division, Affiliate Professor University of Washington, School of Public Health, Department of Epidemiology
ALSO:
Episode 27: Metabolic Syndrome, Diabetes, and Other Common Endocrine Health Issues
Arthi Thirumalai, MD. Assistant Professor, Endocrinology Division, University of Washington
Episode 16. Mental Health: Part 1—General Depression; Part 2—Deeper Depression, Suicide, and Suicide Prevention.
Daniel J. Singer Ph.D. Washington State Licensed Mental Health Therapist specializes in Counseling and Treatment of Mental Health Diagnoses.
Dr. Jeffrey Sung, M.D. University of Washington Instructor of Psychiatry and Behavioral Sciences, Board certified psychiatrist at the University of Washington, the Pioneer Square Clinic, and in private practice.
Episode 10. Prostate Cancer: A) Detection, Diagnosis, and PSA, B) Surveillance and Treatments
Daniel W. Lin, MD, Professor Department of Urology, University of Washington School of Medicine, Chief of UW Urologic Oncology, and The Pritt Family Endowed Chair for Prostate Cancer Research.
Episode 52: Hiking, Backpacking, and Staying Safe in the Wilderness
Lee Jacobsen, JD. Lee is a Seattle attorney and avid hiker and backpacker. He is a founder of the Washington Hikers and Climbers Facebook group, an 8-year running FB hiking community of over 200,000 people in WA.
Tim Durkin MD. Tim is a physician with board certification in emergency and sports medicine based in Colorado. Dr. Durkin is the chief medical officer for Base Medical, a wilderness medicine education company, medical director for the San Juan National Forest, SAR program coordinator for Colorado Highland Helicopters, and a responder with La Plata County SAR in Colorado. He is a former paramedic and Eagle Scout with over 25 years of technical wilderness SAR experience. Dr. Durkin practices emergency medicine at a rural hospital serving Native Americans and occupational medicine for public safety agencies. Opinions expressed today by Dr. Durkin are his own and not official positions of any of his employers or affiliates.
Episode 47: Dental Health and Care
Gary Burt, DDS. Private practitioner for more than 35 years in Seattle, Washington, USA. Specializing in General and Family Dentistry, Esthetic Dentistry, and Complex Restorative & Cosmetic Dentistry.
Episode 44: Grief, Grieving, and the End of Life
Jennifer R. Levin, Ph.D., MPH, MFT. Trauma and grief therapist, marriage and family counselor with extensive experience in counseling and education on trauma, death and dying, bereavement, and loss.
During This Episode, We Discuss:Please visit each individual episode page to review the discussion points.
Quotes (Tweetables):Please visit each individual episode page to review the quotes.
Episode Transcript: Please visit each individual episode page to review the episode transcript.
Episode Summary: Ophthalmology is a medical-surgical specialty concerned with studying and treating disorders and diseases of the eye. This episode reviews common conditions affecting the eye and our vision. Find out what you need to know to take appropriate care of your eyes. Learn how different eye diseases are diagnosed and treated. Listen to Dr. Alder speak about innovations in disease management. Learn how to preserve and optimize your vision.
Guest: Brian Alder, M.D. is a fellowship-trained cornea, external disease, and refractive eye surgeon. He received his medical degree from Duke University in Durham, North Carolina, where he interned and then advanced to Chief Resident during his residency. Dr. Alder published numerous articles and abstracts related to eye conditions and collaborated on cutting-edge corneal surgery research at Duke. Dr. Alder did his corneal fellowship training at Bascom Palmer Eye Institute at the University of Miami, recognized by U.S. News and World Report as the country's number one hospital for ophthalmology.
Dr. Alder worked side-by-side with the most prominent cornea specialists in the world to learn the most up-to-date treatment of corneal disease. Shepherd Eye Center proudly presents Dr. Alder’s unique corneal expertise to Las Vegas.
Dr. Alder is Board Certified by the American Board of Ophthalmology and is a member of the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery. Dr. Alder loves spending time with his wife and five children outside the office. His favorite pastimes include board games around the dinner table, playing sports, traveling, and watching movies with a family-sized bowl of caramel popcorn.
During This Episode, We Discuss: During This Episode, We Discuss:
Ophthalmologist vs. Optometrist, what is the difference, who should you see for eye care?
What to expect from a general eye exam
When should you begin to get eye exams, what changes in eyesight should lead to an exam?
Common Eye Conditions:
- Cataracts
- Macular Degeneration
- Glaucoma
- Floaters (what is a floater and what’s not)
- Retinitis Pigmentosa
- Dry Eye and Excessive Tearing
- Cancers of the Eyes
- Viagra and the Eye
Quotes (Tweetables):
As you approach age 60, start thinking about more regular eye exams, maybe 50s, if you are having eye problems, certainly start at that time.
Dr. Alder
Cataracts are probably the most common disease that causes blurry vision and the most common surgery in the United States.
*Dr. Alder*
The outside of the eye is the Cornea, the window through which light passes on its way to the back of the eye, the Retina….. The light must bend at different places to focus properly and bends at the Cornea but also through a lens…… the lens can develop some opacity, that’s a Cataract.
*Dr. Alder*
In the minority of cases, especially if a floater comes on suddenly, often associated with not just a floater but a flash of light certainly if associated with any blurry vision, that floater is not caused by the simple vitreous issue but by retinal damage and needs to be immediately evaluated.
*Dr. Alder*
Recommended Resources:
The American Academy of Ophthalmology
EyeWiki.org
Episode Transcript: Coming soon!
Episode Summary: This episode reviews the progress in developing biomaterials that allow for external and internal non-invasive interfaces with our various organs. A leading researcher examines the requirements for such materials and shares some recent device developments.
Guest: Dr. Chris J Bettinger, Ph.D.:
Christopher Bettinger is a Professor at Carnegie Mellon University in the Departments of Materials Science and Engineering and Biomedical Engineering. He directs the Laboratory for Biomaterials-based Microsystems and Electronics at CMU, which designs materials and interfaces that integrate medical devices with the human body. Dr. Bettinger has published over 90 articles and issued over ten patents. He has received numerous honors, including the MIT Tech Review TR35 Top Young Innovator under 35 and the DARPA Young Investigator Award.
During This Episode, We Discuss: * The challenges of interfacing device technology with humans. Think of fitting a device to curved tissue that's flexible, miniature, and allows for continuous monitoring. * Materials Science: Bio-Inspired Materials * Embedded Electronics * Noninvasive monitoring of the human Gastrointestinal tract
Quotes (Tweetables):
“In your gut, there are also 100 million neurons, organized into complex networks, localized computational functions, sensory feedback, mechanosensation, the gut is the third brain.”
Dr. Bettinger
“We could be interfacing with the neurons in the gut, and we are developing technologies that enable that interface.”
*Dr. Bettinger*
“Gut health is interesting and is underappreciated…. What is a leaky Gut? What about devices that could measure physical properties of the gut, where you could get a quantitative lens on what is now a semi-qualitative descriptor.”
*Dr. Bettinger*
Recommended Resources:
Carnegie Mellon University, Faculty, Dr. Chrisopher J Bettinger.
Episode Transcript: Coming soon!
Episode Summary:
A smart speaker and your Heart. “Alexa, is my heart rhythm normal”? An Electro Cardiologist interfaces a clinical problem with a smart speaker to identify cardiac arrhythmias.
Learn how innovation in biotechnology had led a cardiologist and his team to train Alexa to determine abnormal from normal heart rhythms. Still, in development, this fascinating interface highlights how leading innovators take technology and smart devices forward to enhance clinical care.
Listen as we review common cardiac arrhythmias, causes, treatments, and diagnoses current and future directions for innovation with devices and additional developments in Telehealth.
Guest:
Arun Mahankali Sridhar, M.D., M.P.H., is a cardiac electrophysiologist and a specialist in heart rhythm disorders. He is an Assistant Professor in the Division of Cardiology at the University of Washington.
Dr. Sridhar sees patients with both rapid and slow heart rhythm disorders and patients with a risk of sudden cardiac death. He has comprehensive expertise in the management of both common and complicated arrhythmias. He is an expert in catheter ablations for atrial fibrillation; atrial flutters (both typical and complex), supraventricular tachycardia, WPW, ventricular tachycardia (VT), and premature ventricular complexes (PVCs); stroke prevention in atrial fibrillation, including left atrial appendage closure. In addition, he is an experienced implanter of all types of cardiac device therapy, including cardiac pacemakers, implantable cardiac defibrillators (ICDs), and cardiac resynchronization therapy (CRT).
Dr. Sridhar’s research focuses on improving ablation techniques and patient outcomes in atrial arrhythmias. He collaborates with the UW computer science and bio-engineering department on various innovation projects to improve the care of heart rhythm patients utilizing advanced computing and novel low-cost patient-accessible technologies.
During This Episode, We Discuss:
- Cardiac (Heart) Arrhythmias: causes, detection and treatment options.
- Innovations in the diagnosis of arrhythmias.
- The benefits of a multi-disciplinary team in researching a very innovative solution to a common clinical problem.
- The role of adaptive, machine learning, signal processing, and clinical experience in moving technology forward.
- Future potential enhancements in current technology to diagnose other metabolic, cardiac, and respiratory conditions.
Quotes (Tweetables):
“At some point, patients can sit in front of a smart speaker and get a good, quick diagnostic test to see if their heart rhythm is normal without having to go to a hospital and get an EKG. Caution that this is still research and not yet ready for patient use.”
Dr. Sridhar
“Sometimes, even some dietary agents can cause an arrhythmia, one of the most common culprits is coffee, and excess alcohol can lead to arrhythmias. Alcohol-induced Atrial Fibrillation is very well described; people, especially college students who go on a binge drinking weekend, end up with a Monday morning arrhythmia, usually Atrial Fibrillation.”
Dr. Sridhar
“We converted a smart speaker into a short-range sonar device.”
Dr. Sridhar
Recommended Resources:
UW Cardiology website: Stopafib.org
Article: Using smart speakers to contactlessly monitor heart rhythms
Episode Transcript:
Coming soon!
Episode Summary:
Bio-Technology is exciting and rapidly expanding. It is the future of health and healthcare while the technology is far-reaching. One aspect is simulation technology. What is simulation technology? Consider how we use simulation to train pilots; what about using simulation to train surgeons and the surgical team? In this episode, we interview Dr. Robert Sweet, MD, a leader in simulation training for healthcare professionals.
Guests:
Robert M. Sweet, MD, FACS, MAMSE
Professor of Urology, Surgery, and Bioengineering (adj)
Medical Director UW Medicine Kidney Stone Center
Chief, Division of Healthcare Simulation Sciences
Executive Director of WISH and CREST
University of Washington
Dr. Sweet is a Joint Professor of Urology and Surgery and Adjunct Professor in Bioengineering at the University of Washington. He is the Inaugural Chief of the Division for Healthcare Simulation Science and the Founding Medical Director of the UW Medicine Kidney Stone Center.
Dr. Sweet founded and led the University of Minnesota’s SimPORTAL and cofounded the University of Washington’s ISIS, which was renamed the Washington, Wyoming, Alaska, Montana, and Idaho Institute for Simulation Technologies (WISH) when he assumed the Executive Director position. He is the PI for all programs in the Center for Research in Education and Simulation Technologies (CREST), including the “Advanced Modular Manikin.”
During This Episode, We Discuss:
- What is Surgical Simulation? How is it utilized?
- How today’s simulation differs from simulation technology of the past: Virtual Reality, Augmented Reality, and simulation in Mixed Reality.
- Applications for Paramedics, The U.S. Military, Emergency Medicine Physicians, Internal Medicine Physicians, Pediatricians, Orthopedics, ENT
- The ability of simulation to create unexpected or uncomfortable scenarios that the entire team can react to, review, debrief, and improve in a safe environment.
- Current limitations of virtual reality simulators and the current efforts to resolve and correct those limitations through more complex and life-like models using advanced materials science, integrated computer-generated models, machine learning, and Artificial Intelligence.
- The evolution of simulation science with computer scientists, electrical engineers, mechanical engineers, special effects artists from the film industry, sculptors and molders, graphic artists, human factor engineers, and clinicians.
Quotes (Tweetables):
“Simulation goes beyond Surgery and involves all members of the healthcare team, we are even beginning to use simulation for education for patients as well.”
Dr. Rob Sweet
"Teaching tactile physical and nontactile skills, for instance, teaching professionalism. Focusing on communication for teams in the form of debriefs in a safe environment, training for an uncomfortable scenario A shared mental model."
Dr. Rob Sweet
"The limitation of current robotic virtual simulators is that they can’t model soft tissue behavior. Actual complex things like dissection and navigating around critical structures are not quite there yet…a really important area for development."
Dr. Rob Sweet
"Allows us to build mannequins or physical parts that are smart, that have the capability to sense what we are doing and give feedback to our performance."
"We are beginning to make the tissue more dynamic."
Dr. Rob Sweet
"I would love to see and shift our focus in using the type of data we're getting in systems we're building in simulation toward a more predictive model (through Artificial Intelligence, Machine Learning). It will be exciting to see the next generation of robots with simulation in the background providing therapeutics and real-time protecting structures that we may not even see in real-time."
Dr. Rob Sweet
Recommended Resources:
Center for Research in Education and Simulation Technologies
CREST.uw.edu
WISH:
The WWAMI Institute for Simulation in Healthcare (WISH) is the University of Washington’s premiere simulation training facility for healthcare education. Its mission is to improve the health of the public through innovative programs for the development, application, and dissemination of simulation science throughout the five states: Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region.
Episode Transcript:
Coming soon!
Episode Summary:
We all or mostly all consider ourselves competent drivers. In this episode, a Driving Safety expert reviews health-related concerns and conditions that may negatively impact our driving skills and experience. She also reviews some very important data and recommendations on how to become an even better driver.
Guests:
Mi Ae Lipe is a Seattle-based writer, editor, and graphic designer who lives another life as a citizen traffic safety advocate. In 2011, she founded a blog called Driving in the Real World and is the author of a very popular monthly column on traffic safety and ADAS technology for Roundel, the national magazine of the BMW Car Club of America.
Along with fellow citizen advocate Mark Butcher, she has worked extensively with Washington State government agencies to strengthen their driver training, testing, instructor curricula, and licensing standards. In 2016, she and Mark organized and led a fact-finding trip to the UK by Washington State government officials and driving-school owners to explore that country’s traffic safety ecosystem, long considered one of the best in the world. In 2017, she and Mark were publicly recognized by NHTSA at the Lifesavers Conference for this work.
She is currently part of a government group that shapes strategy and policy around autonomous vehicle testing and implementation in Washington State, and she writes and consults about road safety for organizations both in America and internationally.
During This Episode We Discuss:
- Eyesight, night vision, hearing, mobility, physical restrictions, mental health, emotional health, fatigue, stress levels, and age-related concerns as they pertain to driver performance and safety
- Stats for men versus women regarding accidents
- The age range for most accidents
- A brief overview of Roadcraft, a UK methodology for advanced street driving, such as:
- Wear your seatbelts
- Reduce distraction
- Positioning
- Following distances
- Do not consider the space ahead of you as yours alone
- Road rage
- Don’t drive ahead of yourself
- Always signal a turn or lane change
- Constantly scan all your mirrors every 5 to 8 seconds for potential problems, developing road conditions, and hazards.
- Pay attention to how you feel behind the wheel and if you feel faint or not quite alert enough to drive, pull over immediately
- Adjust to changing weather and road surfaces
- GPS can be both a blessing and a problem
- Autonomous Driving Vehicles, where we are, where we will be
- Remind people to have the courage to intervene as passengers, bystanders, and drivers if we see unsafe behavior. This is really important. If all of us (or even many of us) exerted social pressure, it could make a real difference in road safety
- What should new drivers do to improve their driving skills? What should veteran drivers do to improve their driving skills?
- Should new drivers go to novice track events such as car control clinics?
Quotes (Tweetables):
——Fighter jet pilot vision tactics: overcoming saccades that cause us to miss seeing many things on the road; the cognitive problem that we’re more likely to see what we expect to see; the phenomenon of windscreen framing (including A-pillars and mirrors), which eliminates as much as 40% of what we see out our windows; why fast-moving things can seem stationary to us and we don’t notice them; and how our eyes are built for detecting movement, not low contrast; and recommend the video “Invisibility Training for Motorcyclists” on YouTube.
Mi Ae Lipe
—— There are also anatomical differences between men’s and women’s brains. Men have a bigger amygdala while women have a larger hippocampus, which affects thinking for both genders.
Mi Ae Lipe
— — The net result is that men consistently take more risks behind the wheel: They speed more, drink more, and engage in competitive behavior more (“I’m going to follow the vehicle more closely because I don’t want to let that person get ahead of me”). They also wear their seatbelts less. So, they crash more. (Interestingly, more females are likely to be killed or injured by crashes of equal severity for several reasons.)
Mi Ae Lipe
—— First, when it comes to traffic safety, we never call them “accidents,” which implies a lack of responsibility and absolves blame (“Oh it was just an accident”). So-called accidents are almost always preventable. Instead, we call them “crashes” or “collisions.” Language really does matter.
Mi Ae Lipe
—— Roadcraft, a UK methodology for advanced street driving; Mi Ae to mention IPSGA (Information, Position, Speed, Gear, and Acceleration) and MSM (Mirror-Signal-Maneuver); this forms the framework upon which all best-practice driving is based in the UK. The beauty is that it is a proven methodology refined over nearly 80 years that works in any vehicle under any road condition and any type of weather.
Mi Ae Lipe
Recommended Resources:
Driving in the Real World Mi Ae Lipe’s own traffic safety blog and website: http://drivingintherealworld.com/
A Fighter Pilot’s Guide to Surviving on the Roads by John Sullivan An astounding booklet about common vision issues that cause us to miss seeing many things while driving. https://www.gedandclaire.com/downloads/a-fighter-pilots-guide-to-surviving-on-the-roads.pdf
Invisibility Training for Motorcyclists Informative (and entertaining) YouTube video about common vision issues; includes principles from A Fighter’s Pilot’s Guide, listed above
There Are No Accidents: The Deadly Rise of Injury and Disaster—Who Profits and Who Pays the Price by Jessie Singer An amazing book that uncovers how “accidents” aren’t what they seem across numerous industries, from transportation to nuclear energy
https://www.simonandschuster.com/books/There-Are-No-Accidents/Jessie-Singer/9781982129668
Roadcraft Definitive guides to advanced UK police and motorcycle driving techniques
https://www.roadcraft.co.uk/
How Not to Crash by Reg Local
A terrific, approachable book for civilian drivers of all ages; uses Roadcraft principles
HPC (The High-Performance Course) Safety-focused performance driving for motoring enthusiasts (based in the UK)
http://www.high-performance-course.com/
High and Mighty: SUVs—the World's Most Dangerous Vehicles and How They Got That Way by Keith Bradsher
A deep dive into why SUVs are so unsafe for their occupants and others
We Save Lives A nonprofit that promotes citizen advocacy around drunk, drugged, and distracted driving; founded by Candace Lightner, founder of MADD (Mothers Against Drunk Driving); includes info on National Passenger Safety Week and the Courage to Intervene movement
My Car Does What? Consumer-friendly guide to advanced driver assistance technology (ADAS)
Episode Transcript:
Coming soon!
Episode Summary:
Humans have a long history of two healthy and accessible activities: walking & hiking. But being in the wilderness is more than a walk in the park. In this episode, experts from WA and CO discuss hiking benefits, preparation, safety, and respect for nature.
Guest:
Lee Jacobsen, JD. Lee is a Seattle attorney and avid hiker and backpacker. He is a founder of the Washington Hikers and Climbers Facebook group, an 8-years-running FB hiking community of over 200,000 people in WA state.
Tim Durkin MD. Tim is a physician with board certification in both emergency and sports medicine, based in Colorado. Dr. Durkin is the chief medical officer for Base Medical, a wilderness medicine education company, as well as medical director for the San Juan National Forest, SAR program coordinator for Colorado Highland Helicopters, and a responder with La Plata County SAR in Colorado. He is a former paramedic and Eagle Scout, with over 25 years of technical wilderness SAR experience. Dr. Durkin practices emergency medicine at a rural hospital serving Native Americans and occupational medicine for public safety agencies. Opinions expressed today by Dr. Durkin are his own and not official positions of any of his employers or affiliates.
During This Episode We Discuss:
- Walking and hiking have a multitude of health benefits for all ages: physical, mental, emotional, and social.
- To get into hiking, start easy and build your skills and physical strength. Walk a lot where you live to stay in shape for hiking! Many hikers started out as walkers in cities, towns, and parks.
- Consider conditioning/maintenance exercises that build your muscles for going uphill and downhill. Do more single leg work and planks. Working on glutes pays dividends going downhill.
- The Ten (+) Essentials are important for hiking safety on the trail. Many hikers carry more than 10 essentials when hiking in the wilderness. Note: one of these essentials—a fire starter—is not advised for use in many places in the western US, given the high risks of forest fires.
- Being prepared for wilderness hiking: have the 10 essentials, know details of your routes in advance, leave notice where you’ll be, be ready for weather changes, and be able to take care of yourself & others in the wilderness. Learn more in this episode on hiking in the wilderness. It’s helpful to know some first aid, wilderness first aid, avalanche awareness, map, and compass reading, and Leave No Trace practices. There are courses available on all of these through the resources listed below.
- We discuss Leave no Trace principles and examples. They are important to know and honor on our trails and in the wilderness. As more people get outside on trails, we all need to work to keep our impact on the environment and wildlife to a bare minimum, to keep it as natural and pristine as possible.
- There are lots of resources for beginner (and more experienced) hikers and backpackers (see resources below).
- Hiking and backpacking build new skills, improve physical & mental health, exhilarate and exhaust you, introduce you to new friends, and let you deeply experience nature in the wild.
- Backpacking in the wilderness requires more than the ten essentials: know how to use all the gear, undergo conditioning to prepare for walking on trails with a very heavy backpack, and know how to keep food, yourself, and the environment safe. Go with experienced people a few times to learn all the ropes. The rewards of learning, sleeping, walking, and walking in the fresh air and wilderness are worth every minute of preparation and sore muscles.
- When a hiker is 1 mile or 10 miles deep in the wilderness and they are in trouble, Search and Rescue Organizations (most are volunteer-staffed) send out wilderness-trained first responders. People get lost, injured, overdue, or sick in the backcountry. Having a satellite (or other) emergency communication device is critical for contacting help from the backcountry.
Quotes (Tweetables):
——“When I get out on a trail and look at mountains and the natural environment, the stress of life becomes secondary, you’re just there in the moment.”
Richard Pelman
—— “Hiking is a very zen-like exercise; you’re not in a hurry to get anywhere, you live in the moment.”
Lee Jacobsen
— — “Like a runner’s high, there’s a hiker’s high too.”
Lee Jacobsen
—— Tips for conditioning activities for hiking: “Build up walking/hiking mileage each week, so you’re doing 10+ miles across the week, to get ready for a one-day 10-mile hike”
Tim Durkin
—— When you are in the forests and mountains, “Remember you are a guest in an animal area, keep your distance.”
Tim Durkin
Recommended Resources:
- Washington Trails Association—A nonprofit organization. “Washington Trails Association mobilizes hikers and everyone who loves the outdoors to explore, steward, and champion trails and public lands.” Trail information is specific to Washington State, but there is much on their website that is useful to anyone—general hiking information and tips for hiking.
- For example, see Trail Smarts, which has a lot of how-to videos.
- The Mountaineers— A nonprofit “outdoor community of 14,000 active members in the Pacific Northwest. Founded in 1906, getting people of all ages outside safely and responsibly for over 100 years.”
- The Mountaineers have much to offer anyone no matter where they live:
- The Mountaineer's book publishing and information resources are useful to hikers worldwide, including maps and a range of books and guides that provide detail about hiking & climbing tools, techniques, skills, and safety in the wilderness.
- Base Medical — Their mission is “to empower a safe outdoor community through access to innovative and sustainable education.” They have some online training available. Our guest Dr. Tim Durkin is Chief Medical Officer for this organization.
- WHC - Washington Hikers and Climbers, public FB group “for Washington hikers, climbers, snowshoers, cross-country skiers, and other outdoor inclined residents of or visitors to the state.”
- NWAC —“The Northwest Avalanche Center exists to increase avalanche awareness, reduce avalanche impacts, and equip the community with mountain weather and avalanche forecasts, education, and data.”
- All Trails — An app-based retail organization that aims to connect people with the outdoors; large resource of curated trails and detailed trail information with global coverage.
- MeetUp Groups — There are thousands of walking and hiking meetup groups in the US and globally. A great way to meet like-minded walkers/hikers and learn and explore together.
- FB Groups — A great way to meet like-minded walkers/hikers and learn and explore together.
- REI — A cooperative retail organization that not only sells gear but also provides lots of information resources online and in classes and group events for hiking, camping, and staying safe in the wilderness.
Episode Transcript:
Coming soon!
Episode Summary:
The ear, nose, and throat (ENT) have their own medical specialty, based on proximity and function. Guest Dr. Ian Humphreys takes us through a range of basic ENT health issues, including chronic irritation of the sinuses, disordered smell, ringing ears, hearing loss, swallowing problems, vocal cord issues, and oral cancers.
Guests:
Ian M. Humphreys, D.O. Associate Professor of Otolaryngology-Head and Neck Surgery( ENT) at University of Washington School of Medicine. He is currently Director of the Division of Rhinology & Endoscopic Skull Base Surgery at the University of Washington Medical Center – Montlake. His research interests include cancers of the sinuses and skull base as well as fungal infections involving the sinuses. If patients want to learn more they can find us via this patient care link.
During This Episode We Discuss:
- Sinusitis symptoms can include difficulty breathing through the nose, constantly runny nose, pressure in the face, and alterations of smell and taste. These can be debilitating but are treatable. We have 8 sinuses and a nasal airway (like a hallway with doors along each side); any or all of these could be involved.
- Sinusitis is one of the top chronic diseases in prevalence and incidence in the US and around the world. In the US there are different subtypes of sinusitis, with different causes, each requiring different treatment approaches.
- The HPV vaccine is a preventative against HPV-related oral cancer. Not using tobacco in any way is a preventative against other oral cancers.
- Noise-induced hearing loss is the most common type of hearing loss and is not reversible. Noise-reduction safety regulations exist as a preventative against noise-related hearing loss. Noise-related hearing loss is of increasing concern for headphone/ear pod users. Reduce decibels and length of exposure.
- Men are less likely to seek evaluation or intervention for hearing loss; possibly because hearing loss and aids are stigmatized.
- Helpful tips: Be gentle to your vocal cords: clearing your throat is hard on them. How to clean (or not) your ears, and how to fix a minor nosebleed.
- Smell and taste are often affected by COVID-19. It appears most people recover fully or partially, but it is not yet known what any longer-term effects might be.
Quotes (Tweetables):
—“It turns out we have 8 sinuses, and sometimes all can be involved.”
Dr. Ian Humphreys
—“Sinusitis is really portrayed as if it’s one thing. It’s not. There are a variety of forms of this condition…”
Dr. Ian Humphreys
—“For COVID-19, we don’t yet quite know what the trajectory looks like [for smell and taste].”
Dr. Ian Humphreys
— “So if a person has diminished smell, they can expect diminished flavor. What do I mean by that? Well, taste is defined as sweet, sour, salty, umami, and bitter. Everything else is flavor. So that's what makes a raspberry different than a blueberry."
Dr. Ian Humphreys
Recommended Resources:
- American Academy of Otolaryngology-Head and Neck Surgery
- A rich source of patient resources and information
- To find an ear, nose, and throat doctor
Episode Transcript:
Coming soon!
Episode Summary:
Dental care for all ages has come a long way in the last couple of decades. There are new tools and methods for preventative and restorative care, and for reducing fear of the dentist. This episode gives you the basics plus these updates, and has helpful tips for optimizing your personal dental health, and even how to help pay for it.
Guest:
Gary Burt, DDS. Private practitioner for more than 35 years in the Seattle Washington USA area. Specializing in General and Family Dentistry, Esthetic Dentistry, and Complex Restorative & Cosmetic Dentistry.
During This Episode We Discuss:
- When to start dental care, and what care is needed at different ages: kids, adults, seniors. Different types of dentists: family dentist, periodontist, orthodontist.
- The importance of fluoride — especially for kids with developing teeth. In areas where water is not fluoridated, other sources (beyond toothpaste) are needed.
- Strategies for reducing fear and discomfort of dental procedures.
- Regular use of a soft tooth brush + water pik + flossing = good oral health and breath. Whitening toothpastes, and stiff toothbrushes can be damaging. Brushing your tongue or using mouthwash are optional.
- Significant advances in dental care include light cured resins and other technologies (e.g. higher quality porcelains) for restorative dental work (crowns, fillings, veneers).
- Damaging to oral health: sugars, candy, soda pop, chewing tobacco, smoking. Some health conditions (e.g. diabetes) may contribute to oral health issues.
- Poor oral health (e.g. gum disease) can contribute to poor health in other body systems (e.g. heart disease).
- Despite dental advances, and connections between good oral and overall health, dental insurance is not available for many people in the USA. Challenges and strategies for affording and accessing dental care are discussed (see also: Resources).
Quotes (Tweetables):
— “Good oral health..has manifestations beyond just a smile.”
Dr. Pelman.
— “My hygienists are big fans of a new instrument called a water pik. It's funny, cuz I remember this from a kid growing up, … …….. but it's come back big time now in the last five years.”
Dr. Burt
— “Is brushing your tongue useful?”
Dr. Pelman
— “Once you hit the golden age of 30 we kind of figured you’ve outgrown the decay years. But…”
Dr. Burt
— “I look at excellent dental health as really crucial to a high quality of life.”
Dr. Burt
— “Retired people don't have dental insurance. Self-employed people don't have dental insurance. And so what happens with that is that I coach people to set up their own plan.”
Dr. Burt
Recommended Resources:
- How to find a dentist: 1) Ask friends, family or colleagues for general dentist recommendations. 2) If you are new in town, try calling the local periodontist--they usually know most of the general dentists in an area. 3) https://findadentist.ada.org/
- For low cost, high quality care, visit the clinic of a University Dental School (e.g. in the Seattle area: https://dental.washington.edu/patient/clinics/ )
- Look for city, county or organizational health fairs that offer dental clinics (e.g. in the Seattle area: https://seattlecenter.org/skcclinic/. https://www.facebook.com/SKCClinic/
Episode Transcript:
Coming Soon!
Episode Summary:
Allergies occur when the immune system responds to an allergen threat. Mild and severe allergies are caused by environmental exposure & genetic predisposition. Listen to experts discuss the immunology, features and management of allergies to food, peanuts, pets, gluten, drugs, bees, mold, dust mites, latex, plants and more.
Guest:
Lahari Rampur, MD. Allergy and Immunology Physician, Kaiser Permanente, Seattle WA; Andrew G. Ayars, MD. Physician and Associate Professor of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle WA.
During This Episode We Discuss:
- What allergens and allergies are, and how the immune system is involved. Allergens in the environment (like peanuts or pollen) trigger immune responses, causing an allergic reaction.
- Characteristics of an allergic reaction. An allergic reaction can be mild or severe, and immediate or delayed. Common reactive areas include the skin (e.g. eczema, hives, itching), upper airways (e.g. runny eyes and nose), or lower airways (e.g. allergic asthma, wheezing, anaphylaxis [low BP, breathing impaired, other severe symptoms]).
- Types of Allergens. Allergens are around us all the time, but only some commonly cause mild or severe allergies. These include pet dander, pollen, crustaceans, mollusks, dairy, eggs, peanuts, gluten, drugs/meds, insects (bees, wasps, dust mites), latex, plants and more. Exposure can be constant, occasional or seasonal.
- Genetic Predisposition. Family history of specific allergies is useful to know, because seasonal, environmental, and food allergies can run in families.
- Managing allergies. 1) environmental controls to avoid exposure (e.g.HEPA filters, dust-mite covers) 2) widely available, cheap, and effective over the counter medications (like antihistamines, epipens), and 3) allergy shots, for more severe and persistent allergies.
- Allergy Testing. Allergy testing can help target the main allergen source(s) of a person’s allergy symptoms. Start with your primary care Doc. See an immunologist or allergist if needed. See additional resources listed below.
Quotes (Tweetables):
“…So, in looking at an allergic response, which is based in our immune system, …there is a cascade of events that take place with recognition of an allergen….”
Dr. Pelman
“Kids can be allergic to a lot of different things, wheat, dairy, eggs…most of the time they grow out of those allergies. There’s a few that hang on into adulthood…the more common ones are peanuts and shellfish allergies.”
Dr. Ayars
“[If you have a history of allergic reaction to food], read labels and always carry an epipen… that’s life saving. Everybody with food allergies should carry an epipen.”
Dr. Rampur
“…cat allergen is a very sticky allergen so it's very difficult to get out of the house.”
Dr. Ayars
“...There's actually no such thing as a hypoallergenic dog breed… but individual dogs, regardless of breed, can be more or less allergenic than others.”
Dr. Ayars
Recommended Resources:
- American Academy of Allergy, Asthma and Immunology (AAAAI). Covers symptoms and treatment for a wide range of allergies and asthma.
- American College of Allergy, Asthma and Immunology (ACAAI). Lots of useful information on what allergies and asthma are, diagnosis and treatment.
- Allergy Free Skin Products safe for contact dermatitis allergies.
- The Original Guide to Men’s Health Podcast, Episode 13. Gut Health: Part B—Gut Microbiome (Part B starts at the 40 minute 30 second mark). Early life exposure to foods and allergens can influence a person’s lifetime gut microbiome and allergy risk.
Episode Transcript:
Dr. Pelman (00:00):
The Original Guide to Men’s Health is moving to a monthly release schedule. We will be releasing new episodes the first Wednesday of each month. We really appreciate you listening, and we hope you enjoy this episode.
Dr. Pelman (00:18):
Whatever you do, whatever you enjoy, you need your help. Welcome The Original Guide to Men’s Health, a podcast designed for men of all ages to learn about and access good health. This guide shares knowledge on how to be and stay healthy, maintenance and prevention strategies, along with reviews of conditions and issues affecting wellness are explored. Please join me, your host, Dr. Richard Pelman, as I interview renowned experts who will provide you with timely, relevant, and vital information so that you can embark on a journey towards better health.
Dr. Pelman (01:07):
On this episode of The Original Guide to Men’s Health, we'll be exploring allergy and immunology. What does immunology or your immune system have to do with allergies*? Everything! Our guests on this episode are Dr. Lahari Rampur, physician allergy and immunology, Kaiser Permanente, Washington. Dr. Rampur treats allergic disorders and immunodeficiencies and practices at Capitol Hill, Seattle, and in Everett, Washington with Kaiser Permanente. Additionally, we have Dr. Andrew Ayars. Dr. Ayars is an associate professor, department of medicine, division of allergy and infectious diseases, University of Washington School of Medicine. He serves as director of allergy and immunology training program at the University of Washington School of Medicine. Dr. Ayars, Dr. Rampur, welcome and thank you for joining us. Many people have concepts about allergies, have allergies, but I'd like to go into a little background about why our immune systems are involved in the allergic response. Dr. Rampur, why don't you take this first? And then Dr. Harris, we'll ask you to fill in.
*Allergies and Immune System: https://www.hopkinsmedicine.org/health/conditions-and-diseases/allergies-and-the-immune-system
Dr. Rampur (02:24):
Thank you. Thank you, Dr. Pelman for having me here. And yeah, that's an important question. So allergies are typically genetically predisposed. There is nothing much that you can do. However, there is certainly an environmental influence on development of allergies. For example, kids who are exposed to dogs or cats at home, you know, they can develop allergies to cats or dogs. But basically they are genetically predisposed with family history of allergies with parents and history of eczema* can also predispose you to develop allergies as well.
*Eczema: https://www.mayoclinic.org/diseases-conditions/atopic-dermatitis-eczema/symptoms-causes/syc-20353273
Dr. Pelman (03:00):
So in looking at, you know, just going into some basics of the immune system, Dr. Ayars, just give us a little background. What is the immune system? How does it work as far as allergic response?
Dr. Ayars (03:11):
The immune system is actually amazing. If you think about how many bacteria, viruses, parasites we have to fight off, not as much parasites in the developed world. But we're constantly bombarded with, you know, organisms that we have to fight off and your body has to be able to see what's a friend and what's a foe. And that can be very difficult. And frankly, our body's really good at it. It's incredible. I'm actually amazed by the immune system all the time that we're able to pick out what's a threat, fight it off, you know, form the immune response, which is extremely complex. Now I kind of think the immune system, or the immune problems and the multiple categories, there's immunodeficiency*, meaning your body just can't fight off infection. We see people like that every day in our clinics, people without immune system can't fight off infection.
*Immunodeficiency: https://medlineplus.gov/ency/article/000818.htm
Dr. Ayars (03:51):
Now there's mistakes in the immune system and they can manifest in different ways, either rheumatologic or allergic. And rheumatologic, your body accidentally goes after yourself. You can go after a lot of different things and that can present in a lot of different ways. And that's more of a rheumatology talk. Whereas allergy is a body goes after something that's benign in the immune system like a food, a pollen, you know that's not a threat. But our body for whatever reason, and we I'm sure we'll go into that later, sees that as a threat and forms, you know, an immune response. So things like pollen or cat dander or things like that. Or foods, you know, we're constantly eating foods and it's amazing how our body can pick out what's a friend and what's a foe. But you know the immune system, if it's off sees that food as a threat and amounts an immediate immune response* to an or delayed immune response. It's our immune system almost working too well, meaning it's going after things that shouldn't in the allergic. And with allergy it's things external, with rheumatologic it's things internal. So that's kind of a simplistic way to think about it.
*Rheumatologic/Rheumatic: https://www.mayoclinichealthsystem.org/locations/mankato/services-and-treatments/rheumatology/rheumatic-diseases
**Allergic reactions: https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/allergic-reactions
Dr. Pelman (04:48):
So Rampur, wet components are part of our immune system? I mean in our blood, what else? And what is in our blood that helps mount the immune response?
Dr. Rampur (04:59):
So the immune system consists of basically cells. So that are T-cells and B-cells, they're mainly white blood cells. I would look at them as sort of the leaders of the immune system, which drive all the other cells. So depending on what is being exposed, different categories of cells get activated. For example, if there is an infection, let's say there is an exposure to bacteria. So the bacteria has components that is recognized by specific types of immune cells, which then release other types of chemicals and molecules to attract specific component of the immune system. So if you are exposed to allergens that are different set of cells that are attracted. And if there are viruses, different type of cells are brought to the area of infection. And depending on the severity of infection, most of the time they are able to take care of the threat with some basic immune response that's called innate immunity*.
*T cells and B cells: https://www.genome.gov/genetics-glossary/Lymphocyte
**Cytokines: https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/immunotherapy/cytokines.html
***Innate immunity: https://medlineplus.gov/ency/article/000821.htm#:~:text=Innate%2C%20or%20nonspecific%2C%20immunity%20is,defense%20in%20the%20immune%20response.
Dr. Rampur (05:56):
However, if the innate immune response is not able to destroy the pathogen, or the threat, then the specialized forms of cells get activated. And they mount antibody response or long-term memory cells like memory T cells, B cells, which then come into picture. So the next time if you're exposed to a similar threat, the body can recognize easily. For example, in vaccination* so you're given an inactive virus and the body forms antibodies to these viruses. And there are also long-term memory cells. So the next time you are exposed to this specific virus, the body is able to recognize the threat immediately and form the antibodies in an effective manner and take care of it efficiently.
*Memory T cells: https://www.nature.com/articles/d41586-017-08280-8
**How vaccines work: https://www.cdc.gov/vaccines/hcp/conversations/understanding-vacc-work.html
Dr. Pelman (06:43):
And the antibodies are actually what type of cells?
Dr. Rampur (06:47):
So B cells are the cells which produce the antibodies. So antibodies are not cells. They are molecules or some sort of protein that are produced from the B-cells.
Dr. Pelman (06:58):
Okay. And Dr. Ayars, when we look at response and the immune response, we talked a moment ago about different types of cells from a bacteria or virus to an allergic response. What are those type of blood components that we see that respond?
Dr. Ayars (07:19):
I mean, there's a lot of different types of reactions. The classic allergy is something called IgE-mediated. That's, you know, seasonal allergies. That you watery eyes, runny nose, can cause asthma, can cause food allergies. And that's something called IgE. Dr. Rampur mentioned the antibodies, and they're basically little smart bombs. They have to see something. The body has to form the appropriate immune response. And then they have to be able to glom on and neutralize things like bacteria and viruses. And there's different types of antibodies. The most important is IgG**. That's the one we form that they can help fight off bacteria, viruses, very much essential to us to help fight off these organisms. There's different ones called IgA. There's one called IgE that historically helps us find out things like parasitic infections. Whereas historically, we were always bombarded by parasites and things like that.
*IgE-Mediated Reaction: https://www.rch.org.au/uploadedFiles/Main/Content/allergy/Non%20IgE%20Food%20Allergy.pdf
**Glom: https://www.merriam-webster.com/dictionary/glom
***Immunoglobulin G: https://www.uofmhealth.org/health-library/hw41342
Dr. Ayars (08:09):
We're not exposed to them as much anymore. And IgE, basically we in developed countries oftentimes we don't need IgE. But this type of antibody is what causes a lot of different allergies. It sits on these things called mass cells that we all have in the skin, GI tract, respiratory tract, and they're preloaded with all these different inflammatory mediators. And if they are preloaded with IgE, meaning they are predisposed to react to a pollen or a food, they will rapidly release their contents, release things like histamine, inflammatory mediators like prostaglandins**. I won't get too far into it, but someone walks into a room with a cat. If it's preloaded those mast cells, you know, if you get the cat in your nose that causes it to rapidly release their content. So things like histamine, and causes congestion, itchy, watery eyes, runny nose for those predisposed.
*Mass cells: https://www.aaaai.org/conditions-treatments/related-conditions/mcas
**Gastrointestinal (GI) tract: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gastrointestinal-tract
***Histamine: https://medlineplus.gov/medlineplus-videos/histamine-the-stuff-allergies-are-made-of/
****Prostaglandins: https://www.yourhormones.info/hormones/prostaglandins/#:~:text=The%20prostaglandins%20are%20a%20group,All%20Hormones%20Resources%20for%20Hormones
Dr. Ayars (08:57):
If you breathe it in, you can have asthma: wheezing, chest tightness, mucus production. You know people have food allergies, you know, if they're predisposed and they have that IgE say to peanut. When they consume the peanut, it causes wheezing, chest tightness and the upper airway congestion, you know, things like that, nausea, vomiting. So if you're predisposed and have that allergic antibody, that’s what causes a lot of the allergies that we deal with. Things like allergic rhinitis* or like seasonal allergies, things like asthma and things like food allergies. So we'll talk about this later, I'm sure. But when we do like skin testing or blood testing, we test to look and see if patients have those antibodies and little smart bombs. The things that they shouldn't like, foods and medications or aeroallergens and things like that.
*Asthma: https://www.mayoclinic.org/diseases-conditions/asthma/symptoms-causes/syc-20369653
**Allergic rhinitis: https://medlineplus.gov/ency/article/000813.htm
Dr. Pelman (09:42):
So in looking at a allergic response, which is based in our immune system, it would be fair to say there is a cascade of events that take place with a recognition of an allergen, and then the response. And the response is trying to contain the allergen, but also a mediated response that involves cells that release certain things that cause our body to have reactions?
Dr. Ayars (10:15):
Yep. It's called the adaptive immune response* meaning say we're exposed to a virus or bacteria, our body has to see that and it has to process it, and know it's a threat and it forms different types of cells. Body has to see something first, react to it and then form the appropriate immune response. That's why if you see a cold for the first time, it takes a while to get over it because your body's giving mounting the appropriate immune response. But if you've seen that cold before, you can fight it off much easier. So same with foods and aeroallergens, your body has to see it. And it has to see it as a threat, and that's inappropriate threat but it sees it as a threat and makes that immune response and forms things like T cell response. But the big one, we were about an allergy, is B cells which make antibodies.
*Adaptive immune response: https://www.ncbi.nlm.nih.gov/books/NBK21070/
Dr. Ayars (11:00):
And again that IgE, sometimes we call it the allergic antibody, which classically fights off parasites and things like that. But now it's just kind of more of a nuisance cause it's one of the underlying causes or that one of the major ones for, you know, food allergies or seasonal or allergic asthma. So again, your body has to see it, mount an immune response, and then it becomes predisposed to, you know, in best case scenario, fight off a bacteria or virus, you know. The worst case scenario, it affects things that are benign like a pollen or a food, or like rheumatologic disease even like rheumatoid arthritis, goes after our joints and things like that. So again, when the immune system is functioning appropriate it's very efficient. It sees it, processes it and has a memory. So it can fight it off if it sees it again. But in the inappropriate response, it either goes after itself in the body, or it goes after something that's benign, again like a pollen or a food.
Dr. Pelman (11:51):
So going back, before we talk about various types of responses and where they're manifest in the body and how they're manifested, Dr. Rampur had said that a lot of this is genetically predetermined. That your immune system is going to turn itself on when it sees something based on sort of genetic code that you were born with. Dr. Rampur?
Dr. Rampur (12:12):
Yes, that is true. So if you're genetically predisposed, you are more likely to have allergic conditions like eczema, seasonal allergies, sort of environmental allergies, as well as food allergies. So here's an interesting thing about how kids with eczema may develop food allergies later on. So eczema is mainly a condition where the barrier, the skin barrier, is affected. So normal skin when it is exposed to food allergens or some other irritants, it has a good barrier. It doesn't react. However, kids with eczema has an issue with a barrier. So if the food is exposed through the skin, the skin can, the body gets sensitized to that allergen and can cause allergic reaction. So they may develop antibodies, which may recognize these allergens in the future as a threat. For example, a kid with horrible eczema is constantly exposed to peanut dust or peanuts at home. So their body processes that peanut as a threat. So normally when you eat peanuts, you may not become allergic. However, if there is an issue with the skin, if it's exposed through a different route, it can become allergic. The next time the body's exposed to the peanuts, these antibodies can attack the peanut molecules, and they go and tell the mast cells to release the histamine. And that's when you start having the reactions like itching or hives or anaphylactic type of reaction. So these are genetically predetermined, you know, parents with history of asthma, parents with history of eczema, or seasonal allergy type of history.
Dr. Pelman (13:48):
So let's look a little bit at some of the common type of allergic responses. We just talked about eczema. And again, a lot of this is based upon what you're being exposed to, what you're allergic to, and we'll go into some of those in a little bit. But generally, you might classify allergic responses in the skin and where else?
Dr. Ayars (14:12):
So itchy, watery eyes, runny nose, rash and post-nasal drip, sneezing are kind of the classic. And that can be, do a lot of different aeroallergens, things like dust, dust, mites, pets, grasses, aeroallergens, grasses, trees, molds, things like that. So classically upper airway. And the lower airway, you know, asthma causes, you know, wheezing, chest tightness, shortness of breath. You know, historically it's been called hay fever*. That's kind of a misnomer cause you don't get a fever with it. You felt sick. So that's why they got that name again. The fever is a misnomer, but you kind of feel like you have a cold basically when you're exposed to those aeroallergen, either a certain time of the year or if you're in an environment with dust mites or you have a pet allergy. That's kind of how the upper airway manifestations present.
*Hay fever: https://www.mayoclinic.org/diseases-conditions/hay-fever/smptoms-causes/syc-20373039
Dr. Pelman (14:57):
Yeah. You mentioned asthma. A lot of people think of asthma as a pulmonary disease, but asthma is really based in a allergic response?
Dr. Ayars (15:07):
Asthma is like arthritis. There's a lot of different types of asthma, and allergic asthma is certainly one of those types. Basically just like it causes inflammation in the upper airway and those that are genetically predisposed, it can cause lower airway inflammation. And classically, it seems like wheezing, chest tightness, shortness of breath. So we always ask patients, you know, you get asthma symptoms when you're in a room with a cat? You get at a certain time of the year? What are your certain triggers? So it's a broad question, and there's a lot of different types of asthma. But allergic asthma is what we see a lot of, especially in young kiddos. We see that a fair amount.
Dr. Pelman (15:41):
Okay. So let's take a look at some of the more common allergens in categories. So I'm going to throw out drugs. We have people who are allergic to medication, Dr. Rampur, what happens there?
Dr. Rampur (15:58):
So there are different types of allergic or hypersensitivity responses to medications as a broad category. It could be immediate or delayed type of responses. Immediate responses are, you know, as soon as you take a medication. For example, penicillin is one of the most common drug allergies. So the moment you take it, within like 15 minutes or half an hour, in most of the cases it happens within a few minutes of taking, you may feel itchy, flushed red, or hives all over your body or lip swelling or tongue swelling, throat closing type of sensation or wheezing or asthma type of response. Those are immediate type of allergic reactions. And this is where testing is most helpful. There's another type of reaction where when you take a medicine, initially nothing happens. But after seven days of taking, you may start to notice the rashes all over your body.
Dr. Rampur (16:48):
So most of the delayed rashes are benign. They just go away on their own after a few days after stopping the medicine. However, there are other types of delayed responses where it can be pretty severe. So where your internal organs may get affected, or you may have massive skin peeling type of response. Meanwhile, your internal organs or mucus membranes like mouth or gastrointestinal tract is called severe cutaneous drug responses. So like these, there are several different kinds, but you know, we often get asked about them. This patient had vomiting type of reaction to a medication. Can you test them? So vomiting by itself without any other symptoms is not an allergic response. It could be some kind of an intolerance and testing is not indicated. In studies have shown that more than 90% of the time, allergic response to any medication, you know, does involve a skin response like itching or hives. If somebody has a subjective breathing difficulty without any objective evidence of wheezing or anything, it's less likely to be a true allergic response.
Dr. Pelman (17:55):
And because we have people concerned currently about COVID vaccination and drug reactions. Dr. Ayars, I know that the reaction to the current vaccines as far as allergic response are rare, but can you go through a little bit about people who are concerned about that? What the risk? I know it's small and also how you might mitigate it. If say you've had allergic responses to other medications, does that necessarily make you more at risk for a COVID vaccine reaction?
Dr. Ayars (18:31):
The reactions are exceedingly rare. You can get, like Dr. Rampurl talked about, immediate type reactions: immediate wheezing, chest tightness, shortness of breath, lightheadedness. Those are very rare, but you can see them. So evaluate this all the time. And frankly, most of the time we're able to clear that to get the second vaccine or their booster. So, you know, even if there's a, you know, a fairly immediate reaction, oftentimes we can clear them and there's different components in the vaccine. But again, for the most part, it's very well-tolerated. Now there are delayed reactions that have been described, but again, those are exceedingly rare as well. You know, delayed rashes, a few other things that can happen after a few days. But for the most part they're really safe and really well-tolerated in almost anybody. You know, what we always ask people, “Have you had a reaction to a vaccine in the past?” And we try to characterize that. Drug allergy can be pretty tricky cause we don't have a lot of tools to diagnose it.
Dr. Ayars (19:24):
So it comes down to the history. What happened and what type of immune response do we think it was? So, you know, with the COVID vaccine, I always ask, “Have you reacted to any other vaccines? If so, was it immediate? Was there immediate wheezing, chest tightness, shortness of breath?” And if it was more mild, we've usually cleared them to get it. And we oftentimes will tell them to take a few anti-histamines. And instead of waiting around the average 15 minutes, we usually say, just stay about a half hour instead just to make sure nothing severe happens. But you know, I've seen, I'm sure Dr Rampur is the same, I've seen hundreds and hundreds of hundreds of these type of reactions. And most of them were able to clear. Most of them were able to tolerate the vaccine moving forward.
Dr. Pelman (20:01):
So when you say clear, do you mean you giving a medication to treat them or they just resolve spontaneously?
Dr. Ayars (20:07):
They clear them to get their second vaccination. They had a, you know, some chest tightness during the first vaccine. You know, we always ask about other symptoms. Did you feel like you're going to pass out? Did you have, you know, skin symptoms? And if they didn't usually we, again, clear them so that you can have that vaccine, but you might want to pretreat with some anti-histamines. I usually say Zyrtec, Allegra, or something like that. And then just wait a half hour instead of the standard 15 minutes that most facilities require. So there are people that have had a severe reaction to the first vaccine and that's where it can get tricky. But if there is a severe reaction to the first vaccine, that's when we always recommend see an allergist, an immunologist, and tease it out. And they can kind of have risk stratify if you will. So even if they've reacted to a different vaccine in the past, that's not a contraindication to getting COVID. And even if it's a mild reaction to the first COVID vaccine, oftentimes they're able to receive their back second vaccine or booster without an issue.
Dr. Pelman (21:01):
Dr. Rampur. So if you had a patient who is hesitant about receiving any COVID vaccination because of prior allergic reactions, would you pre-treat them? Or just monitor them and say, “We can treat you on the spot if something happens.”
Dr. Rampur (21:17):
So I have never recommended pre-treating any patients. I would ask them to take the vaccine and we monitor them, depending on the anxiety level, half an hour to 60 minutes. Yeah. I mean, it's out of abundance of caution. You know, of course people with history of severe anaphylaxis to, as you know, some of the medications and food, according to CDC guidelines, we monitor them for 30 minutes. But we don't necessarily know that they're actually at increased risk of having severe reactions to COVID vaccine. So there is a lot of anxiety. Of course, I do see a lot of patients with these concerns. So another aspect that I wanted to touch upon is that patients with previous history of severe reactions to another vaccine, we consider that a little bit more serious. We, first of all, true allergic reactions are extremely rare. However, if somebody said they had hives or low blood pressure, hypertension, chest tightness type symptoms with a, you know, let's say diptheria, tetanus vaccine. Some of the vaccines do contain similar components as COVID-19 vaccines. And that's when we also consider testing for, let's say polyethylene glycol, which is present in Pfizer and Moderna vaccines, and polysorbate*, which is presented in Johnson & Johnson vaccine. And polysorbate and polyethylene glycol, they cross-react with each other. And that's when we also consider testing to make sure.
*Polyethylene glycol: https://medlineplus.gov/druginfo/meds/a603032.html#:~:text=Polyethylene%20glycol%203350%20is%20used,it%20is%20easier%20to%20pass.
**Polysorbate (polysorbate-80): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015121/#:~:text=Polysorbate%2080%2C%20also%20known%20as,surfactants%20%5B1%2C%204%5D.
Dr. Pelman (22:43):
So as Dr. Ayres suggested, first of all reactions are extremely rare to the COVID vaccines. Two, If somebody does have a true allergic reaction to a different type of vaccination, they should see an allergist, immunologist, be tested and sort that out. And they still could potentially be a candidate to receive a vaccine, but they would go in having been evaluated. Dr. Ayars?
Dr. Ayars (23:09):
Certainly. We get a lot of referrals for people that have reacted to even a different vaccine. So with drug allergy, the biggest thing is the history. What happened? You know, what was the timing? What were the symptoms? And that really helps us risk stratify, you know, who is at risk for having a more severe reaction to the COVID vaccine, who isn't. So again, it comes down to the history. And if there's any question we always recommend seeing an allergist and immunologist for evaluation. Whether testing is necessary, that really depends on the history. But again, the biggest thing, we just need to sit down with them. What was the previous reaction? And that helps us risk stratify. You know, who is it likely to react to the COVID vaccine?
Dr. Pelman (23:46):
Well, let's go now to the common allergies. We talked about drugs. Let's talk about food. Now food is a very general term. We need food to sustain us. And it seems like, how can somebody be allergic food? But we know gluten. So let's review gluten for a sec., gluten allergy. What happens there?
Dr. Rampur (24:07):
Gluten allergy is a very broad term, and people kind of misuse gluten allergy, pretty much for all kinds of symptoms. You know, I do hear a lot of patients complain that they do have gluten sensitivity. So sensitivities, allergies there's is a huge difference, what can be tested and what cannot be tested. So gluten is a broad term for, you know, grains that contain gluten. But allergic response is typically to a specific allergen, not broadly to the gluten. For example, people can be allergic to wheat, contains gluten, but you are not allergic to the gluten component. When somebody say allergic response to an allergist, we think that the true allergic responses are itching, hives, slips, filling sort of immediate responses. And that happens because of preformed antibodies. Let's say you're allergic to wheat. You should have IgE antibodies, which can be tested. But when people say that I feel bloated and crampy after eating some gluten containing food, is this an allergic response? May not be. It could be some kind of an intolerance, or it could be gluten sensitivity, which is another immunological disorder. It's nothing to do with allergic response. It is because of antibodies to like they are called celiac antibodies, anti TTG antibodies, basically. And that's what we test them for. But this is not an allergic response.
*Food allergy vs food intolerance: https://www.mayoclinic.org/diseases-conditions/food-allergy/expert-answers/food-allergy/faq-20058538
**Anti Tissue Transglutaminase (TTG) antibodies: https://celiac.org/about-celiac-disease/screening-and-diagnosis/screening/
Dr. Pelman (25:33):
Dr. Ayars?
Dr. Ayars (25:34):
Yeah. I kind of categorized quote unquote, gluten or wheat allergy, or I say, quote, unquote allergy and the three categories. Ones, you can be allergic to wheat in form the classic immediate wheezing, chest tightness, lightheadedness, nausea like we talked about Dr. Rampur with the IgE. Actually that's pretty darn rare, especially in adults. I don't never see a true wheat allergy. Then there’s celiac disease* with Dr. Rampur also talked about. That's a different type of immune response to the gluten, which causes inflammation in the gut. And that usually presents with weight loss, you know, abdominal pain, diarrhea, things like that. And the way you test for that is actually do have to do a biopsy in the gut is the gold standard. And that's somewhat rare. Although a lot of people do have celiac disease. And then the most common is basically non-celiac gluten sensitivity, which is kind of a wastebasket term.
*Celiac disease: https://medlineplus.gov/celiacdisease.html#:~:text=Celiac%20disease%20is%20an%20immune,wheat%2C%20rye%2C%20and%20barley.
Dr. Ayars (26:24):
You haven't a reaction to it. It's not an immune one. And classically it's, abdominal pain, nausea, bloating, things like that. So again, there's the classic allergy, which IgE or the immediate reaction, which is very rare. Or celiac disease, which has the delayed reaction, which again in the gut causes diarrhea, abdominal pain, things like that. And then again, the most common is non-celiac gluten sensitivity. And I always tell you, say sensitivity is very real. It's just not an allergy. We don't have testing for it. So if you rule out the other two, the immediate reaction and celiac, basically it goes into this non-celiac gluten sensitivity. So people generally just don't feel well. And mainly GI symptoms with gluten.
Dr. Rampur (27:04):
I would also like to add that a lot of people have chronic abdominal bloating and gastrointestinal symptoms. They sort of think that they could be allergic to many different foods and they start avoiding these foods. You know, when somebody has symptoms chronically and they feel like they're reacting to everything, they're less likely to be allergic to the food. But there might be something wrong with their gut itself. So I would recommend gastroenterology evaluation rather than, you know, allergy evaluation at that point to see if that is some kind of an inflammatory bowel condition or an intestinal condition.
Dr. Pelman (27:38):
Thank you. Well, let's look at crustacean or shellfish. That's a common food allergy that some people have. Do you want to break that down a little bit? Dr. Ayars?
Dr. Ayars (27:48):
Yeah. So as kids, a lot of kids have developed food allergies. And the reason for that is very complex. And we can talk about that later if you want, but kids can be allergic to a lot of different things. You know, wheat, dairy, eggs, things like that. Most of the time they grow out of those allergies. There's a few that hang onto that into adulthood. But the more common ones that go into adulthood are about peanuts and shellfish allergy, you know, shrimp, lobster, crab, You can be allergic to finfish as well, salmon, cod, things like that. So yeah, that is, it's a very common and especially me seeing mainly adults. That's the most common allergy, that along with peanuts and other nuts that can cause that type of reaction. So it is one of the more common types of allergens. And so what we do see a lot of that, especially me seeing mainly adults, that's the most common that again and peanut or the most common ones that we see. Again, the other ones that a lot of kids can be allergic to like wheat, milk, you know, things like that, most of the time they grow out of that by the time they hit adulthood,
Dr. Pelman (28:46):
Dr. Rampur, when people have shellfish allergy, I've heard people say, “I can eat one type of shellfish, but not the other." If somebody has a reaction, should they stay away from all shellfish? Or how do you distinguish what kind of crustaceans they can consume?
Dr. Rampur (29:02):
So generally I would categorize shellfish allergy as shellfish, as crustacean and mollusks. Examples for crustaceans are shrimp lobster, crab, and mollusks are clam oysters and scallops. So crustaceans have, you know, they're more than 50% cross-reactive. So if you're allergic to shrimp, you could also be allergic to crab, but I've also seen patients who can just be allergic to shrimp, but not allergic to crab n' lobster. It kind of depends on the history, but if they are allergic to shrimp, I generally ask them to avoid all types of crustaceans. Because if you eat at a restaurant, that is a significant chance of cross-contamination. But the patients with crustacean allergy are not necessarily allergic to mollusks. Some people are, but that cross reactivity is lower compared to the cross-reactivity among the crustaceans. So when they are eating at a restaurant, I asked them to avoid all types of shellfish, but if they're pretty short at home and if they are re recently eaten clams, if they had an allergic reaction to shrimp, and if they're doing okay with the molluks, I would let them eat if they are a hundred percent sure. Yeah.
Dr. Pelman(30:10):
And you know, a common question is have people had this all their lives or can people develop these sort of shellfish allergies or mollusk reactions later in life?
Dr. Ayars (30:23):
You can develop an allergy at any time. Most commonly it occurs when they're younger, when they're a kid, when they are first introduced. The foods are seen in teens, twenties, it's very rare, but I see people develop it later in life. We don't know why that is. We're not entirely sure. So most commonly people develop allergies when they're fairly young and initially close to the foods, just kind of step back. I know it's a little off topic, but you know, say like peanut allergy, their old dogma used to be wait and don't administer it. Don't give the kid if you're predisposed to allergies until they're four or five. But there was a study a few years ago called the Leap Study where peanuts, where they randomized the groups into either early introductions, around six months versus three or four years. And the difference is totally different. The people that introduced early had a much lower incidence of allergies. So I remember sitting in a room as a fellow and people argue back and forth early versus late introduction. Now it's clear, introduce it as early as possible around six months. And that significantly decreases the risk of developing a reaction, specifically to peanuts. But you can associate that with other foods as well.
Dr. Pelman (31:26):
So An infant at six months, won't be able to chew a peanut, bu peanut butter?
Dr. Rampur (31:31):
Yeah. One of the reasons they realize this is in Israel, there's a food called Bamba that a lot of parents will give their kids. It's a peanut base, but it can really melt in the mouth. Actually, my kids loved it as well. And they introduced that earlier and they had a lower incidence of peanut allergy and that's one of the reasons they started this study. So there's a lot of different forms of peanuts that you can introduce. But the classic is Bamba, which is a very common, you can see it in most supermarkets. And that's what I gave my kids when they were around six months.
Dr. Pelman( (31:58):
And looking at the concern. I know that even if peanuts are in the air, the airlines have stopped circulating peanuts. If somebody has a definitive peanut allergy, what steps should they take to protect themselves?
Dr. Rampur (32:11):
So basically I advise no touching or eating. You know, if somebody next to you is eating, usually it's not a problem. It's not like inhaled in the air. And it's very less likely that they develop an allergic reaction without touching or eating. If you have a history of allergic reaction, make sure you read the labels of everything that you're eating or coming in contact with, and also carry an EpiPen. And never forget too, that's life saving. So everybody who has a food allergy should carry an EpiPen.
Dr. Pelman
Dr. Ayars?
Dr. Ayars (32:42):
I agree completely. The biggest thing is epinephrine and always having that available. Early epinephrine is life saving. You know, we do studies where again, to the studies and testings, you have to actually put, you know, kids or adults into reactions. We know the earlier we give epinephrin, they do much better. So there's a stigma about epinephrin and it's actually a very safe medication. So I tell patients if you're on the fence, you think you may be going into reaction, just take it and we'll tease it out later. So I agree with Dr. Rampur. The biggest thing is having an epinephrine. obviously reading labels and things like that is very important, but you know, having a strategy and things like Benadryl don't cut it. So, you know, epinephrine is by far and away the best treatment. So for those who have a severe allergy to anything, you know, shellfish peanuts, the biggest thing is having an epinephrine auto injector available at all times.
Dr. Rampur (33:29):
For when someone is in doubt, its always important to use epinephrin, rather than not using it. And one of the biggest causes of severe reactions, which turned out really bad, is that delay in using epinephrine. That's one. So when you're having a severe allergic reaction, people can have low blood pressure. And during this time, if you don't use epinephrine, but you stand up too quickly, or walk around, people can collapse and even die. So that's when severe reactions can happen. So when you're having a severe reaction take epinephrine, go call for help, call 9 1 1, because that's not the complete treatment, they still need to be monitored. EpiPen, lay down quickly, there where you are, and then call for help.
Dr. Pelman( (34:10):
Excellent. And we touched briefly on egg and milk. Do any of these travel together or do they distinctly separate the egg and milk allergies? Dr. Ayars?.
Dr. Ayars (34:19):
I mean, people that are predisposed to allergies, you're more likely to have multiple allergies, but there's no cross-reactivity between the two. It's just people who are predisposed to develop food allergies are more likely to develop it to multiple allergens like Dr. Rampur, you know, discussed, you know, crustaceans and things like that. That's much more likely to react to one versus the other, whereas like milk and peanuts, soy they're unrelated. Just those people are predisposed to develop that reaction.
Dr. Pelman (34:45):
And you said earlier that kids who have milk allergies can outgrow them.
Dr Ayars (34:50):
Yeah. It's very common in milk. So, things like that and egg. they're most likely able to grow out of those. It's the ones like peanuts, tree nuts and shellfish that people are much less likely to grow out as they get into adulthood. Now it's important to establish with an allergist and they test annually often, depending on the patient, just see whether they have the skin test positivity or the blood test positivity. So we just monitor that. Okay.
Dr. Pelman (35:15):
And before we leave, food's just one last. Sulfites? How do people present with sulfite? Where do they find those?
Dr. Rampur (35:21):
So sulfite in wines and certain types of food, like lettuce, can cause primarily asthma type of reaction. I haven't seen this commonly, but it's less likely to cause anaphylactic type of reactions. But there is no way to test this. You know, some people believe that they're allergic to sulfites in wine and alcohol, but there's no way to test them or prove.
Dr. Ayars (35:45):
Yeah, it's a distinct mechanism from the classic allergy. So it's much easier to diagnose, and usually the reactions much less severe with sulfides.
Dr. Pelman (35:54):
Well, let's look at moving off of foods to things that are common here in the Northwest. Mold. So I hear a lot about, you know, have your house suspect from mold. What happens? What's the manifestation of mold in your environment?
Dr. Rampur (36:10):
So, typically more allergies can cause now chronic sinus issues, inflammation inside your nose, and asthma, wheezing and chest tightness. And it can also cause a chronic hypersensitivity condition called ABP, called allergic bronchopulmonary aspergillosis. It's a condition where it presents like asthma, but the routine asthma treatment not work. So they present as difficult to treat asthma. And that's when we do the blood testing and also do a CT scan of their chest to diagnose. Apart from this, you know, I also hear people say, you know, toxic mold syndrome and some of weigh other symptoms, but there is no evidence that molds are actually causing the problems. And there are many types of molds in that environment. Not everything is harmful. Just because somebody is able to visualize it, easy to attribute their symptoms to the mold. But many of them do not even cause symptoms. There are a variety of toxins produced, but some are totally harmless. So there are some of them which can cause, in which can commonly cause respiratory issue, are aspergillus**, alternaria, penicillium, cladosporium. These are some of the common ones that we do test. And if they're positive, we can do allergy shots and things like that. But not every mold is harmful. I have to say.
*Allergic Bronchopulmonary Aspergillosis (ABP): https://www.aaaai.org/Conditions-Treatments/Related-Conditions/allergic-bronchopulmonary-aspergillosis
**CT scans: https://www.mayoclinic.org/tests-procedures/ct-scan/about/pac-20393675
***Aspergillus: https://www.mayoclinic.org/diseases-conditions/aspergillosis/symptoms-causes/syc-20369619
Dr. Pelman (37:26):
Another source for allergies would be pet dander. So what happens there? What kind of reactions do we see?
Dr. Ayars (37:36):
Pet danders, you know, like I mentioned cat, you know, think over 50% of the country in the households have a dog now. And our mantra is, you know, even if you're allergic people get rid of their allergists before their animals, you know. You know, dogs and cats are family. So they do manifest, you know, upper airway, itchy, watery eyes, runny nose, congestion, asthma. Where people predispose, wheezing, chest tightness, shortness of breath, things like that. And classically it's when you're exposed, although specifically cat allergen is a very sticky allergen. So it's very difficult to get out of the house. You know, with dogs, there's some evidence to say, you know, if you're washing your dog or keeping it clean, that can help somewhat. But cats, it's very difficult. And I do want to step aside and say, there's actually no such thing as a hypoallergenic breed. I hear that all the time. They did a study a few years ago, it looked at this. What they found is actually the individual dogs themselves have vastly different amounts of allergic protein. So it's actually not the breed itself, it's the individual. Actually in that study, the lowest was labs, which is not quote unquote hypoallergenic. So yeah, there is no such thing as a hypoallergenic breed but some dogs seem to be more allergenic than others.
Dr. Pelman (38:44):
Interesting. So looking at somebody who, like you said, they'll get rid of their allergist before they get rid of their pet. I want to keep my dog. I want to keep my cat. What do we do?
Dr. Ayars (38:55):
Medical therapies are where we always start. You know, for upper airway, topical steroids, things like flonase, nasonex*, anti-histamines things like Zyrtec, Allegra, things like that. So there's medical therapies, you know. Like I talked about, there's some evidence that bathing them twice a week can decrease the allergenic protein but that's somewhat controversial. And the final thing that I'm sure we'll touch on this is allergy shots. That's the one thing that changes your body's underlying immune response to those. So a lot of my patients who say get a dog and obviously they don't want to get rid of their pet, they'll come to us. One for medical therapy, you know, obviously we diagnose that with skin testing or a blood test. And if the medical therapy isn't cutting it, that's when we often times go to allergy shots, which work fairly well for most people, but they’re a lot of work. So we kind of saved them for last line.
*Flonase: https://www.flonase.com/allergies/what-is-fluticasone-propionate/
**Nasonex: https://www.rxlist.com/nasonex-drug.htm
Dr. Pelman (39:42):
Dr. Rampur, any thoughts on pet allergies?
Dr. Rampur (39:45):
So there are also certain things that you can do at home to reduce the pet dander. HEPA air purifiers have shown to reduce dander exposure. And we also ask people not to expose or not to allow pets inside their bedrooms, especially when they have severe allergies or asthma. Yeah. These are some of the things that you do. And yes, allergy shots, as Dr. Ayars mentioned is a way to go if you still have persistent symptoms
Dr. Pelman (40:11):
And do people have carpeting versus a bare wood floors do better or linoleum floors without carpeting who have pets? Are there any tricks that way?
Dr. Ayars (40:21):
Yeah, no. The carpet is certainly a reservoir. The bedroom is as well. We have people that cover their sheets if they have dust mites, which is one of the most common allergens at least in this part of the country, the Pacific Northwest. Dust mites are basically our dominant year round allergen other than pets. So you can get dust mite covers, cover the sheets, mattress, things like that. Yeah. So there are strategies to limit it. A lot of patients, if they can, tell them to get rid of the carpet in the bedroom specifically. But that's not always an option for people, you know, other reservoirs for things like dust mites or stuffed animals or old, you know, old carpets in the bedroom or things like that. So I tell them to try and get rid of it, specifically with dust mites, to get rid of as many reservoirs as they can.
Dr. Pelman (41:02):
So deep cleaning HEPA filters; try to get rid of reservoirs; topical treatments that you can take; all will help mitigate responses to things like dust mites. Let's talk briefly about insect because that can be, I know people have certain bee allergies and reactions. Dr. Rampur, you want to take that?
Dr. Rampur (41:25):
Sure. You know, the common types of stinging insects are honeybee, yellow jackets, white faced hornets, yellow faced hornets, wasps, and fire ants. People can have pretty severe reactions to these. They can have anaphylaxis hypertension, people can collapse. Or they can also have local reactions like itching and swelling, localized swelling. So how we can do allergy shots or venom immunotherapy shots for these as well, especially for people who've had severe reactions. So studies have shown that people who have a severe reaction to a stinging insect are more likely to develop future severe reactions. And for these people, we recommend testing as well as allergy shots. So there are some people who get large local reactions, meaning they get stung and the entire limb gets swollen. So this is also some type of an allergic response. Generally, they may not be at a very high risk of developing severe reactions. However, if you are a beekeeper and you are constantly at risk of exposing yourself, we do recommend testing and they can consider allergy shots as well.
Dr. Pelman (42:35):
You mentioned fire ants. They have a friend who had never been subjected to a fire ant bites. It was out in the garden and did, and got severely systemically, really, almost an anaphylactic type of reaction. Would you advise that person then to have allergy shots or, you know, for a rare fire ant? Or could just carry an EpiPen? Or what sort of things should they do?
*EpiPen: https://www.epipen.com/en
Dr. Ayars (43:01):
Dr. Rampur brought up a nice distinction there. There's that large local rash, which I get. If I'm stung my upper arm might swell all the way down to my hand. Now I've never been tested. I don't need an EpiPen. I don't eat allergy shots cause I'm not much higher risk than the general population to react. We always distinguish that from immediate wheezing, chest tightness, whole body hives, lightheadedness. That's a different story. Those patients are at a much higher risk. If they're stung, they're at a 50% chance to react. Now if we get them an allergy shot, that gets down closer to around 5%. So it's an incredibly effective therapy for it. Obviously we always have them carry an epinephrine auto injector, but if your friend had a severe, immediate reaction, you know, we don't see fire ants around here, but down south, you know, when fire ants answer native, yes, we do recommend that they at least consider starting allergy shots. And certainly we recommend they carry an epinephrine auto injector.
Dr. Pelman (43:50):
Excellent. And I want to touch on latex allergies, which we see a bit. How would that manifest and how does somebody know if they had a latex allergy?
Dr. Ayars (44:00):
So latex allergy can be IgE mediated, meaning they can have antibodies to latex. So when they come in contact with latex, they can have immediate onset hives or swelling or anaphylactic type of reactions. Latex allergy, these days, is very rare and testing is also not greatly sensitive. We can do blood tests or we can do skin tests, but I've never seen a positive latex allergy. And there are also certain types of food like fruits, like banana and avocado, can cross-react with latex. You know, people with latex allergy can have reactions to these fruits, and people with reactions to these fruits may have maybe a higher risk of reacting to latex. But I've never seen a positive latex, truly positive latex study.
Dr. Ayars (44:46):
And latex was a big issue in the nineties, late eighties, mainly because people started wearing gloves more mainly because of the HIV epidemic. So they used to see it a lot. Or not a lot, but it used to be much more common. I agree with Dr. Rampur, I very, very rarely see a true allergic reaction you know, to latex. It can be an irritant, especially if you're breathing it in and it can cause irritation. But you know, most of the products we use, especially in the medical field, are not latex based. So it's a much less common problem than it was, you know, 20, 30 years ago.
Dr. Pelman (45:18):
And lastly, let's look at plants, you know, weeds, grasses, and hardwood, deciduous trees a far as seasonal allergies that a lot of people suffer from and the pollen counts are up. Let's talk a little bit about what would somebody do? Spring allergies, fall allergies, summer allergies. What do you see? What do you advise? What do we do?
Dr. Rampur (45:40):
We treat pollen allergy, grasses and weed pollens, as you said. Trees are common in the spring season; grasses in the summer season between May and July. And weed pollens are common between June, July, and they go on up until September, October. So if somebody has severe allergy seasonal allergy, we would treat them consistently with antihistamines or nasal sprays. If they have sporadic, once in a while type of symptoms, they can just take medicines as needed. However, if they have persistent severe symptoms, I would ask. Let's say their symptoms are starting in February. I would start end of January or beginning of February, start the medication to prepare your respiratory system. Better to take on that allergen lower and stay on that consistently. But if you feel like your quality of life is being affected with symptoms every year, I would recommend allergy shots for them.
Dr. Pelman (46:35):
Dr. Ayars?
Dr. Ayars (46:36):
It depends on where you're listening to those podcasts. There's different pollen seasons, depending on where you are in the country. So, you know, if they are bothering you, most people, you know, we don't see most people with seasonal allergies cause most of the time now that a lot of these medications are over the counter, like Zyrtec, Claritin, Allegra, Flonase. Most of the time they can control it, but we see the more severe cases. And if that's the case, it is a good idea to get tested. You know, what I do is test all our allergens and I know what our pollen seasons are in this part of the country. So I say around this part of the year, start taking, you know, this nasal spray or this anti-histamine. And stop it, you know, at the end of the grass season, whenever that is, where they are in the country.
Dr. Ayars (47:14):
So it depends on where they are, but if you're not getting by with medications, you know, again, and that's why we test for things like dust mites, where you can do environmental controls, things like that. We usually try environmental controls, medications. And if that doesn't cut it, then that's oftentimes when we'll talk about allergy shots, which again, work very well, but are very labor intensive. So we try to, you know, environmental controls and medications first. And again, the classics are the anti-histamines and the nasal sprays like Flonase, Nasonex, Nasacort, things like that.
Dr. Pelman (47:43):
These are over-the-counter now as long= as well as a lot of the common anti-histamines right?
Dr. Ayars (47:48):
Yes. And they're very accessible. They're very cheap. So yeah, most of the time people can get by just doing those. But if they're not, that's usually when we say see an allergist get tested, cause we can come up with other strategies as far as what time of the year. Again, dust mites around here are the major allergen. So there's things we do as far as environmental control. So if you're not getting by with those medications, that's usually what I recommend getting tested.
Dr. Rampur (48:10):
So if you’re allergic to just grasses, you can take grass tablets. They are a sublingual form of immunotherapy. It's easier that you can take it at home. Usually the first dose is given in the allergy clinic and we monitor to make sure there's no allergic reaction. But you can take the rest of the doses at home every day. So it's easier for people who are just sensitized to process.
Dr. Pelman (48:33):
And we spoke a lot about allergy testing. Dr. Ayars, do you want to just explain what happens? Because a lot of people don't know. They go, well, how do you get allergy tested? Is it a patch test or what is modern allergy testing look like?
Dr. Ayars (48:47):
That's a great question. And it depends on what type of reaction you have. For things like asthma, you know, seasonal year round allergies, what we most often do as allergists is a skin prick test*. Basically it's just purified allergen. We put it on the skin, exposed to those things called mast cells that we all have. And if it forms basically a bump or a hive, that means you're positive. So that's most commonly what we do as allergists cause it's done in 15, 20 minutes and you have your results. We can go over them in real time. There's also a blood test to look for like we talked about that IgE or the allergic antibody, and that gives us similar information just not readily available. So either of those look for things like seasonal allergies, asthma, food allergies, that's another way to do it as well. So that's the most common way to look at that. Now there's other types of allergic reaction. I won't get into things like contact dermatitis, like poison ivy, things like that. That's called a patch test where we leave the individual allergens on a skin for several days, and then look to see if there's a reaction. By far and away, the most common tests, if you do go see an allergist, is a skin prick test, which again takes 15 to 20 minutes and you have your answers.
*Allergy Skin Tests: https://www.mayoclinic.org/tests-procedures/allergy-tests/about/pac-20392895
Dr. Pelman (49:50):
And then desensitization we talked about. Is this allergy shots that we're talking about?
Dr. Rampur (49:56):
Yes. So desensitization is a broad term which can be done for environmental allergens, but it doesn't mean that your allergies are going to completely resolve. So once you stop the allergy shot, some people may have recurrence of symptoms up to sometime as well. So we do desensitization for medications as well. For example, somebody has a history of allergic reaction to penicillin, and we do the skin testing and the skin test is positive. That means that they are allergic. So what we do is slowly introduce penicillin and with a very small dose, and we keep increasing the dose every 15 to 20 minutes to reach the maximum level. That's also called us desensitization, a drug desensitization
Dr. Pelman (50:42):
As we wrap up, I always like to give our listening audience the opportunity to look towards some resources that are available. So if either of you have some favorite resources for allergies that you would give patients or put out there, let us know, go ahead and just list them. Dr. Ayars, do you have some favorite resources?
Dr. Ayars (51:03):
Not really. I have my group of, you know, handouts that I give patients. The biggest one is dust mite control measures. Again in this part of the country, and a lot of the country that's the major year-round allergen. So, you know, things like dust mite covers, you know, washing the bedding at a certain temperature, things like that. But the American Academy of Allergy Asthma and Immunology is a great resource as well. Same with the American College of Allergy Asthma and Immunology. Those are our two big groups and they put out great information for patients. I've gone to that website is another great spot.
Dr. Pelman (51:32):
So say those again, the?
Dr. Ayars (51:34):
We call it the quad AI, American Academy of Allergy Asthma and Immunology (AAAAI). And the other one is the college, American College of Allergy Asthma and Immunology (ACAAI). So AAAI, ACAAI are great resources.
Dr. Pelman (51:48):
Excellent. And people can find those online?
Dr. Ayars (51:51):
Yup.
Dr. Pelman (51:52):
Dr. Rampur, do you have any other favorite resources?
Dr. Rampur (51:55):
I agree with Dr. Ayars and you know, one of the things that my patients find helpful is allergyfreeskin.com. So this is recommended by one of the contact dermatitis specialists. So contact allergies are due to like preservatives and creams or personal care products that you use. They can cause chronic allergy types of symptoms. And we do something called patch testing that goes on their back. And this is not like an immediate skin prick testing that we do for other allergens. So once we find what they're allergic to, I typically give them the handout from the website on what they're allergic to and what they have to award. They can also find the allergen-free products on this website called allergyfreeskin.com, which is recommended by a national expert as well. Obviously, they have to verify before using the products, but they generally find this helpful.
Dr. Pelman (52:47):
And resources for their patients public out there would be primary care physician, family, doc, and then referral to allergy immunology as necessary.
Dr. Ayars (52:59):
Yeah. Most of the patients go to their primary doctor first, who are, but most of them are very good at managing this and, you know, go through the initial therapies. The anti-histamines like we talked about, the nasal steroids, things like that. But you know, still having symptoms despite that, that's when we usually recommend a referral to an allergist.
Dr. Pelman (53:17):
Excellent. Well, I think we covered a lot of ground. Anything else that either of you wanted to contribute that we forgot to mention or go through?
Dr. Ayars (53:25):
One thing I find fascinating is Dr. Rampur mentioned genetics in allergy. Allergy is actually a relatively new phenomenon. You know, the first case of seasonal allergies or quote-unquote hay fever was diagnosed in England in the 1870s, and in the US around the same time before that. It wasn't really an issue. And it's in industrialized places, classically was in the big cities where they'd see this. It wouldn't be out in the country. So we know not only our genetics in play, but the environment is as well as the early life exposures. We find that people that have the least amount of allergies actually live on farms and are exposed to the most species of animals. There's a great study with the Amish and the Hutterites, which are very similar lifestyles. Everyone knows how the Amish live, you know, right next to their animals and things like that.
Dr. Ayars (54:12):
Whereas the Hutterites actually practice differently where they have industrialized farming. So they're not as close to the animals. So the Amish have, I think a seven-fold increase in asthma as opposed to that genetically like almost identical population. So we know that early exposure along with genetics, so what predisposes people to allergies. And that's why we've seen such an increase over the past hundred, hundred years or so. So I find that fascinating, it's called a hygiene hypothesis. So you have to be genetically predisposed, but early life exposures also play a major role as to whether you're going to develop allergies or not.
Dr. Pelman (54:46):
But then we want to get peanut exposure early.
Dr. Ayars (54:51):
No, it is, it's fascinating. There's a lot of interplay with this. You know, again, antibiotics are some of the greatest inventions in human history, but you know, we get early antibiotics in life and you know, that does change your gut flora. Or, you know, the makeup of the things in your gut that are associated with immunity. So I find it fascinating that not only genetics but early life exposures kind of shape your immune system and predispose you to allergies depending on your early exposures.
Dr. Pelman (55:18):
Yeah. We'll make a plug for an earlier episode. Listen to the episode, part two on your microbiome. Dr. Rampur, any other final thoughts?
Dr. Rampur (55:28):
I think we touched upon everything. Thank you for the great questions, but I just want to add something that I commonly see in clinics. It's called chronic idiopathic urticaria*. Idiopathic, meaning nobody knows why it's happening. And urticaria means hives. Hives that come and go randomly without a clear trigger. And a lot of my patients believe that they're allergic to pretty much everything. They stop eating. Some of them get horrified and they're itchy and hivey all the time. And I would like to say that this is mainly an immunological condition. Basically mast cells become twitchy and they start releasing histamine randomly without a clear trigger. It can happen anytime during their life. And they're typically treated with anti-histamines and no need to get concerned about allergies if it's happening repeatedly without a clear trigger. And they can also be triggered by heat or temperature changes, alcohol, pain medications. And I've seen people go on a cleaning spree, they changed their diet, change all their products. They spent hundreds of dollars cleaning their vents and everything, but nothing really helps. It's an internal phenomenon.
*Chronic Idiopathic Urticaria: https://allergyasthmanetwork.org/health-a-z/chronic-idiopathic-urticaria-ciu/
Dr. Pelman (56:36):
Interesting. Well, I'm sure we could spend hours going over other immunologic and allergic phenomena, but I think we've covered a lot of basics for people. And thank you so much for staying late in the office and allowing us to go through some of the basics here. Thank you so much.
Dr. Ayars (56:54):
Thanks for having us.
Dr. Rampur (56:54):
Thank you for having us.
Dr. Pelman (56:58):
This completes another episode of The Original Guide to Men's Health podcast. We wish to thank all guests who volunteered their time and knowledge. The information presented is the opinion of the speakers. The show's recordings are engineered and edited by Sean Fox. Episode titles and descriptions, as well as editing assistance, are provided by Dr. Kathleen O'Connor, Ph.D. Music for our show is San Juan Bell's, written and performed by Dr. David Whiting. The podcast is sponsored and published by the Washington State Urology Society. The Original Guide to Men's Health is an original publication of the Washington State Urology Society. Reproduction and use without the express written consent of the society is prohibited. For more information about men's health and previous episodes, as well as additional recommended resources, visit us online at https://theoriginalguidetomenshealth.org/. This is Dr. Richard Pellman thanking you for listening and reminding you to take care of yourself.
American
Academy of Allergy, Asthma, and Immunology (AAAAI). Covers symptoms and treatment for a wide range of allergies and
asthma.
American
College of Allergy, Asthma, and Immunology (ACAAI). Lots of useful information on what allergies and asthma are,
diagnosis and treatment.
Allergy
Free Skin Products safe for contact dermatitis allergies.
The Original Guide to Men’s Health Podcast,
Episode 13. Gut Health: Part B—Gut Microbiome
(Part B starts at the 40 minute 30 second mark). Early life exposure to foods and allergens can influence a person’s
- lifetime gut microbiome and allergy risk.
Episode Summary:
The end of life is devastatingly hard, and difficult to navigate, for those grieving a loss, as well as the friends, family & colleagues of people grieving. We don't know what to do, what not to do, or how to cope. Dr. Jennifer Levin, a traumatic grief counselor, talks us through understanding, coping with, and even growing with grief.
Guest:
Jennifer R. Levin, Ph.D., MPH, MFT. Trauma and grief therapist, marriage and family counselor, with extensive experience in counseling and education on trauma, death and dying, bereavement, and loss.
During This Episode We Discuss:
- There are different categories of grief experience: Natural, Traumatic, Anticipatory, Disenfranchised, Complicated, Prolonged, Delayed, Chronic, etc.
- Everyone grieves differently. It varies within a grief category, within a family experiencing loss, and over time. This is so important to remember, to avoid judgment and hurt. The ‘stages of grief’ that you may be familiar with are not discussed in this episode—grief is more complex than the stages suggest.
- There are many common themes in grieving, thus support groups provide critical communities.
- We cover how a dying or grieving person's community can help them. And equally important, what NOT to do.
- Organize your critical documents and affairs (see resources below), and clue someone in on where to find this information. This is something grievers say they are very grateful for.
Quotes (Tweetables):
“…how an individual grieves is going to depend on their age; their cultural beliefs or practices; their religion; the relationship they have to a person who died; the intensity of the relationship; the history they've had of how many other people they've lost; their life stressors; their comfort with grief or with people who are sick; their personality.”
Dr. Levin
“ ….not everybody's grief gets along and there are many different grieving styles that occur within the family.”
Dr. Levin
“…I say all the time to clients, ‘Grief has no timeline. It works on its own timeline."
Dr. Levin
“…I always wanted to write a book—‘What to Do After all the Lasagna’s are All Gone’…”, when “..the individual left grieving feels very alone, very isolated and has a difficult time re-entering the world.”
Dr. Levin
Recommended Resources:
- AARP Advanced Directives Legal forms and guides for planning your end of life care, by USA state.
- Five Wishes Discussion guides and forms on advanced care planning, for people to let loved ones know their wishes in advance of an expected or unexpected trauma or death. Helps people talk about end-of-life wishes with their family.
- From Grief to Growth, Online resource (Traumatic Grief resources, Covid-19 and Grief resources, free mini-course) and support website by our podcast guest, Dr. Jennifer R. Levin.
- Religious organizations provide support groups and resources for those experiencing loss.
- Hospitals usually provide support groups and resources for those experiencing loss.
- Link to Dr. Levin’s C/V/ Bio
- Untethered: Healing the Pain from a Sudden Death, A Podcast
Episode Transcript:
Speaker 1 (00:00):
The Original Guide to Men’s Health is moving to a monthly release schedule. We will be releasing new episode’s the first Wednesday of each month. We really appreciate you listening, and we hope you enjoy this episode.
Speaker 2 (00:17):
[inaudible]
Dr. Pelman (00:18):
Whatever you do, whatever you enjoy, you need your health. Welcome to The Original Guide to Men's Health, a podcast designed for men of all ages to learn about and access good health. This guide shares knowledge on how to be and stay healthy, maintenance and prevention strategies, along with reviews of conditions and issues affecting wellness are explored. Please join me, your host, Dr. Richard Pelman, as I interview renowned experts who will provide you with timely, relevant, and vital information so that you can embark on a journey towards better health.
Dr. Pelman (01:07):
On this episode of The Original Guide to Men's Health, we'll be reviewing grief, grieving, and end of life. You may be wondering why on a men's health episode, we're looking towards grief and grieving. But it is part of life, particularly in this pandemic where unexpected events happen suddenly. I think it's reasonable for us to discuss these issues that are important and are part of the life cycle. To help guide us through this, we are going to be interviewing our guest, Dr. Jennifer Levin. Dr. Levin specializes in working with adolescents, teens, and adults experiencing traumatic grief and sudden loss. In 2000, Dr. Levin received her doctorate from UCLA School of Public Health. And in 2014, she earned her master’s in a clinical psychology program from Pepperdine University. She is a recognized fellow in thanatology, the study of death, dying and bereavement from the Association of Death Education and Counseling.
Dr. Pelman (02:13):
Professionally, Jennifer has served as the executive director of Hospice of Pasadena and has taught at several California universities. She provides continuing education, training, and consulting mobile grief services to schools, community-based organizations, experienced bereavement and loss. She is a licensed marriage and family therapist with a private practice in Pasadena, California, where she works with clients living with chronic and terminal disease, bereavement, traumatic death, and post-traumatic growth. Dr. Levin, welcome. Thank you for taking the time to meet with us, and I know most people don't like to preview the end of life or grief grieving. But as I've learned, it's important for people to come prepared or be prepared or have resources. So take us through grief. First of all, a little bit of your experience of why it's important to understand this issue, that one time or another will impact us all.
Dr. Levin (03:16):
Absolutely. Well, I just want to start off with a basic understanding of what grief is and grief is actually a natural response that we all grow through when we lose someone or something that we love. And in this case, we're talking about someone who has died and it's not a pathological response. It is like I said, it's very natural and it's not a problem that we need to fix. It's nothing that's wrong with us. And when we think about grief, we commonly focus on the emotional response that an individual goes through. But in reality, it's so much more than that. There's a huge physical component that goes through. And we also experience cognitive reactions, behavioral, social, cultural, spiritual, and a large existential component that's all part of the grieving process as well.
Dr. Pelman (04:21):
So there are different types of grief that we as humans experience and categories are fairly varied and different. Do you want to just kind of go through the different categories that we might look at is the overall grief experience in the human condition?
Dr. Levin (04:40):
Yeah.
Dr. Levin (04:41):
Most people think that all grief is the same and actually it's not. A lot of it has to do with the way that an individual died. There's what we tend to think of as natural grief. And this is often expected grief when somebody dies due to old age or the end stage of a disease such as cancer* or failing health. There's something called anticipatory grief, and this is when you anticipate a death of a loved one. Someone you know who's going to be coming to the end of their life in a short period of time, even as long as a year or longer than that sometimes. And with anticipatory grief, we have all of these micro losses that occur along the way. And so it's just loss after loss, after loss and the person who is watching a loved one dies also begins to wonder during this time what their life is going to be like when they're gone.
*Cancer: https://www.cancer.gov/about-cancer/understanding/what-is-cancer
Dr. Levin (05:52):
So they're anticipating the grieving process. There's something called disenfranchised grief, and this can include not being given certain grieving rights by family members or even society who chooses not to recognize that you're grieving a loss. Or you may be experiencing what we call an ambiguous loss, which is a loss in which you never seem to get answers to how a loved one died or the circumstances resulting in their death, which also makes it very difficult to grieve. There is grief such as complicated grief, prolonged grief, delayed grief, chronic grief, cumulative grief, and other forms of grief as well. Personally, I specialize in traumatic grief, which is one of those forms of complicated grief and where an individual experiences a sudden and unexpected loss often in a traumatic manner. And the griever is usually impacted by symptoms of trauma and grief at the same time, which can make the grieving process extremely difficult.
Dr. Pelman (07:12):
So as we view these different types of grief reactions, the behavior, and sort of the way that people will respond to you, or you respond to them may be different. For instance, as you talked about anticipatory grief, someone has a prognosis, a loved one that we all know will eventually end in death. So you have time to prepare versus the traumatic grief where it's very short-lived and there isn't that time. So there's going to be a different interface in each of those. Do you want to go through a little bit with each of those of what actual grieving would look like? So, you know, people sort of have different approaches to this.
Dr. Levin (07:58):
Sure. Let's say an individual has cancer and there's the diagnosis, there's the treatment. Well, it depends, you know, cancer is a different beast as well. There's so many different types of cancer. You know many times there's treatment and, you know, it looks like things may go well for a while. And then unfortunately with some types of cancer, that cancer comes back and there gets to be a point where there's nothing else that can be done medically, end of life is going to occur from the disease. And an individual has time to spend with their family. And this is where anticipatory grief comes on, but they get weaker, they get sicker, they lose things. They lose the ability perhaps to walk or to eat, or to do certain things that they used to be able to do. But during that time, there's time to maybe express wishes, to say goodbye, to see people and get things in order.
Dr. Levin (08:58):
And this can be very painful watching all of these changes occur, but at the same time it also gives, it gives the individual who's dying the opportunity to get a lot accomplished. As I said, with the individuals that I work with, they may wake up on a Tuesday morning and I get into a car accident on their way to work. Or they may go out for a walk and have a heart problem and not come home from their walk. Or a suicide may occur during the day. And it's very, very hard for family members and loved ones to, you know, see a person in the morning and then by the end of the day that they're gone. So there's disbelief, there's numbness, there's shock. There's all of these different factors that come into play, not to say that those things don't occur to a lesser extent in the other types of loss. Unfortunately in traumatic grief, many individuals may see the accident occur or the traumatic loss occur or may find their loved ones. And then there's actual symptoms of trauma: hypervigilance, rumination of something they wish they hadn't seen over and over, flashbacks. And there's actual symptoms of trauma that occur as well that actually need to be addressed and resolved in addition to the actual grief or dealing with the loss of their loved one on top of the trauma.
Dr. Pelman (10:40):
So when we have a individual who has a sort of sudden event, and those that are left are totally unexpecting that to have occurred in their lives. When you encounter people who have been dealing with traumatic grief, what are some of the, well, first of all, unique features to that type of bereavement? And how can people, first of all, other family members, everybody's affected differently, friends, acquaintances, coworkers help that person or those people?
Dr. Levin (11:21):
Well, let me start off. You said, “What are some of the unique features?” And again, this is like right afterwards in the beginning of the grieving process, one of the things that's important to know is not only has their world been turned upside down. And again, this is for somebody who's experienced the sudden and unexpected loss. But in the beginning, it no longer feels safe. Everything that they thought to be true of their world no longer exists. For example, I use the example of somebody going out for a walk. We expect that when a loved one goes out for a walk or goes in a car to drive and get groceries, but doesn't get home. We expect that when people go out for a walk, they come home. We expect that when people go driving to go pick up groceries, they come home. And when those things don't happen, the assumptions that we have about how the world works no longer hold.
Dr. Levin (12:22):
And so the world no longer feels like a safe place. So in the beginning, one of the most important things to do is to help an individual feel safe again in the world. And some of the things that can be helpful for that is re-establishing routine and structure, simple things like eating meals at a regular time, being surrounded by loved ones, daily routines. I know I just mentioned that really strong self care, doing anything that establishes a little bit of normalcy at a time that is absolutely not normal whatsoever. But just doing things that make your world feel a little bit safe again. After a traumatic loss, you're numb, you're in shock. You're, you know, in denial. Your body and your mind hasn't caught up with what has just happened. And so having family and friends who are very supportive and understanding what you're going through while your body is adjusting to this trauma at that time is very important while your mind is just catching up with what has happened. Having people who can help you just picking up the kids, getting some groceries, walking the dog, doing the tasks that all of a sudden you're not able to do at that particular moment as you're just trying to function, you know, just to eat, sleep, just do those basic things.
Dr. Pelman (13:59):
And for those who surround the individual who's in this grief process or the family or, you know, close friends, coworkers who are all grieving, there are varied reactions from some people who just don't deal with death very well and may turn away. So the family, the spouse, child, or coworker, or friend may wonder why somebody they know fairly well has just disappeared in their life. And there's other people who are trying to be supportive and not unwelcome, but be a little more forceful than the person is ready for. So how do people gauge and what should people do? And how do we view those two extremes?
Dr. Levin (14:45):
Something that my clients probably struggle with immensely is reactions from family and friends. You know in our society we are so uncomfortable at large with the topic of death and dying. And we're so uncomfortable being in the presence of others who are grieving. And so many times when our friends and families who are grieving need us the most, we're so uncomfortable. We don't know what to do. So we don't do anything at all. So we do turn away. We don't call because we don't know what to say. When in fact people need us the most, they don't need much from us. They need our presence. They don't need us to fix anything because there's absolutely nothing to be fixed. I think some of the things that my clients will say are the worst things that you could do are to say things like, you know, “He or she is in a better place,” or, “It was God's plan.” Other comments such as, “If you need anything, just call me.”
Dr. Levin (15:54):
Those are comments I hear over and over again as being so unhelpful. Comments or things that are very, very helpful are to drop off meals; come over and water the lawn; pick up kids from school; just do things that need to be done. Because when people are grieving, they're fatigued, they're tired, they're overwhelmed, they're disoriented at times. And again, a lot of what I'm talking about is right in the beginning stages. And we can talk a little bit more about what long-term grief looks like, but often we're out of sorts. And so having people just do things for us without having to ask is such a relief or such a welcome gift. I know one woman said, you know, everybody comes over and grieving during the pandemic has also been a very difficult thing for many people because of the social distancing, because of the isolation where normally we would congregate that hasn't been such an opportunity for many people. But one woman talked about, you know, people came over, they fixed my fence, they mowed my lawn, they took the trash out, and just how helpful that was for her without having to come up with a list or having to ask people to do certain things. But just being there, being present, not having to let people know what you need. Cause like I said, a lot of times people who are really in the midst or the depths of grief don't really know what that is.
Dr. Pelman (17:35):
So it would be something to sort of ask as not immediate family or very close friend, but you know, somebody you're well acquainted with and I'm certain that many people feel they're going to be too intrusive to come in and do many of those things, which would be welcomed. So how does somebody who's not immediately within the nuclear family or absolutely so close that it's not an issue approach somebody who's grieving to find out where the boundaries are? What's the easiest way for them to do that?
Dr. Levin (18:06):
That's a great question. Usually closer member of the family will arrange a meal train or a will be organizing tasks that can be helped. So if you're not in that inner circle, ask around and find out who is organizing it. Or, you know, Instacart or whatever, will deliver groceries or deliver food. I mean, if you can't, you know, get in and do those real close things, there's always things that you can just have delivered or sent or a note, things like that.
Dr. Pelman (18:45):
And then let's look at the actual close nuclear family or very close friends, immediate relationships. We'll take the person who is grieving to the point where they're not functioning. And then the opposite, the person who continues on, goes to work, does all the things and doesn't seem to have even stopped for a moment to ponder what happened. People will look at both of those and think they're extremes, but we're all different. So how do you address those two polar opposite types of approaches to grieving?
Dr. Levin (19:19):
So let's talk a minute about what grieving actually looks like among different people. Grief is so unique. It's such, I mean, it's like a snowflake, no one will grieve alike. Everyone has different patterns. Everybody handles grief differently. There's grieving styles across genders. Research by Kenneth Doka has shown that men are more likely to be instrumental. They like to grieve or it's helpful for them to grieve doing tasks, instrumental tasks, doing things around the house, fixing things where women are more intuitive. They like to talk. They like to express their feelings. Of course, how an individual grieves is going to depend on their age; their cultural beliefs or practices; their religion; the relationship they have to a person who died; the intensity of the relationship; the history they've had of how many other people they've lost; their life stressors; their comfort with grief or with people who are sick; their personality.
Dr. Levin (20:28):
So many different things. You use the example of someone who goes to work. Some people do not want to express their feelings. They unfortunately sweep it under the rug and they feel if they go to work, it'll distract them. If they pretend everything is normal, then it didn't happen or they're going to be able to function better that way. Usually these are people who will experience what would be called delayed grief and maybe 2, 3, 4 years later, they may experience illness. They may experience a mental health struggle and it will come up and catch up with them later. Some people do become non-functional like you said. They may become extremely depressed. They may stay in bed. Many of my clients, especially with a traumatic loss, you know, if there has been a suicide, an overdose, a car accident where several family members have died, they do become non-functional.
Dr. Levin (21:35):
Luckily it usually lasts, you know, a period of anywhere three months to six months to nine months. Everyone is completely different. And hopefully there's a lot of family support and love and care, and people who come and help with a lot of the daily functions to help somebody be able to get back on their feet. It's just different for every single person. So grief is going to be very, very different. It's very common to see people feeling overwhelmed, to have a lack of interest, to not want to go on with their life early on without the person that they loved. You see this so often when spousal loss, I mean, people who've been married 30, 40, 50, 60 years who's grown up with a spouse and done everything with the person, their partner, all of a sudden doesn't know how to exist without their loved one. Doesn't know who they are.
Dr. Levin (22:36):
They've lost their identity. You see yearning and sadness and crying and loneliness. All of those things are very, very common. But one thing I share with clients is it's not always going to be this way. It does get better over time. It doesn't go away, but there's a lot of tools that we work on in therapy and with social support and friends. So it does get better. We talked about, you know, it's very common to feel like it's difficult to fit in with friends. It's a very known reality that there's a tremendous amount of support, right? After a loved one dies. I always wanted to write a book, what to do after the lasagnas are all gone. You know, everybody crowds around and gives a tremendous amount of support after the funerals. But then life goes on. People get back to their normal routines.
Dr. Levin (23:42):
And the individual left grieving feels very alone, very isolated and has a difficult sometimes time reentering the world. Again, those who've been grieving during the last 18 months have been really struggling during COVID because it's been very difficult to re-engage during the world, or into the world. And many times they feel that other people don't understand what they're going through. So grieving is very different, very unique for every single person. Individuals who are grieving are also faced with what we call triggers. Sometimes I call them grief attacks, or it's a name often used throughout grief professionals. These can be sights and smells and sounds. Sometimes the dates are anniversaries or special events that come on without warning and just kind of hits you like a load of bricks or a wave. And you can be doing really well one moment. And then you're just flooded with a grief emotion. And there are many ways that we help individuals cope with these memories or just bouts of extreme grief and sadness that are very normal, very natural, and just helping people work through those triggers that just bring up intense feelings of sadness that are all just part of the grieving experience. So I don't know if that answers your question about how unique the grieving experience is. It's probably one of the most unique experiences with many, many commonalities.
Dr. Pelman (25:31):
So a number of things, obviously everyone is different and everybody's reaction is different. When you mentioned an author, Kenneth, you say that again or spell it.
Dr. Levin (25:42):
His last name is D-O-K-A.
Dr. Pelman (25:45):
And he explores a lot of what we just reviewed?
Dr. Levin (25:49):
He’s done a lot of research, but he was one of the first people who looked at gender differences in grieving.
Dr. Pelman (25:56):
So let's, again, look at those polar opposites. The person who doesn't seem least bit affected, you know, goes to the funeral, is at the gatherings, goes to work, comes back. If there's family members, maybe they're not that close. Maybe they are, or friends. What should they do, if anything?
Dr. Levin (26:16):
You know, if someone's not that affected, I would be very curious about the relationship they had with the individual who had died. You know, in terms of, you know, was it a parent that there was a falling out with 10, 15 years ago? I would hate to say, or be hard-pressed to say that somebody is not affected. It would just be whether or not they're choosing to acknowledge it, or they're just reentering their world right away as a way to distract themselves from what's happened. Right.
Dr. Pelman (26:49):
Okay. Let's say that they're just choosing to not be affected and you know, said sometimes it comes back. Is it the place of somebody within the family to offer them the fact that perhaps they should get some counseling? And take the opposite, the person who seems so affected, they can't get back on track. That person would be more obvious. The person people say, “Hey, counseling may be good for you.”
Dr. Levin (27:16):
Yeah, everybody does grieve differently. And a lot of times I'll work with families. And one of the things that I will say is not everybody's grief gets along and there's many different grieving styles that occur within the family. And often family members don't like to be judged by one another in terms of who's grieving one way or another way are judged to be grieving right or wrong. Usually there's a lot of critiques among family members as to whether or I've encountered many critiques among family members about whether one person is grieving an appropriate manner or another. But in reality, it's unique for everybody.
Dr. Pelman (28:03):
Again, the person who is so withdrawn and not able to perhaps get to work, take care of themselves, get out, they seem to become isolated. That would seem very obvious. When friends or family or coworkers recognize this as an issue, how should they approach somebody?
Dr. Levin (28:22):
Just by, you know, noticing and say, you know, I noticed that you're really struggling since so-and-so, you know, has died. Have you thought about joining a support group? Have you thought about talking to somebody? There's also some wonderful books. A lot of religious organizations will offer support through a church or a synagogue or another religious institution. So a lot of different ways to get grief support there's online programs and groups. A lot of the support groups nowadays are online due to COVID, but there's, you know, in-person groups, there's online groups, there's in-person therapy, there's online therapy, you know, or many people talking with their friends is sufficient. And then there's the benefit of going to see a counselor. Going to see a counselor does not mean that you're not handling your grief well. Some people just like to process the loss and the things that are associated with a loss, whereas other people will find they're having significant problems in terms of parts of the relationship that were never worked through, or they're having physical problems that have started stomach aches or headaches.
Dr. Levin (29:53):
They're not sleeping since a death has reoccurred. They're having nightmares. They're replaying situations that they saw in their head associated with the death. So people might engage in therapy for all sorts of reasons. I lead a spousal grief group and they find it participants will talk about how they find it, just so helpful to hear how other people are handling their loss. What are they doing about the loneliness? What are they doing about cleaning out closets and rituals around anniversaries and milestones? And so, it could just be a wonderful place to get support. So again, seeking support doesn't mean that there's anything wrong whatsoever. It could just be a wonderful resource or it could be an excellent avenue. If you are struggling with something specific related to your grief.
Dr. Pelman (30:58):
I know that many of the hospitals offer a group grieving opportunity for people to attend sessions. It doesn't have to be immediate after somebody has passed away. It can be a year or two, even longer?
Dr. Levin (31:14):
Yes. I've had participants in groups five to 10 years afterwards, and I've had people, you know, reach out and call me the day it's happened. And again, those are in more of the traumatic situations, but I say all the time to clients grief has no timeline. It works on its own timeline. And as soon as you set a timeline on grief is this as soon as it's going to backfire on you.
Dr. Pelman (31:43):
And if we looked at the, I think it was anticipatory, we were talking about individuals who have a very poor prognosis that will at some point end in death. Tell me a little bit about, first of all, for that individual, the people who have received that very bad piece of news, go through some trauma right away. Everybody does. I mean, as a physician, we've had to talk to patients about a prognosis. Some are shorter than others, but what would you advise to the person who just received some bad news?
Dr. Levin (32:21):
There's a lot going through somebody's head who's just received news like that. I spoke to a woman last week who thought she was doing well and was just told she had a three month prognosis, and she was incredibly overwhelmed and confused and angry and sad. And to be honest, all I could do at that point was just listen and give her the space to absorb everything that she heard. There wasn't really anything I could tell her at that moment.
Dr. Pelman (33:01):
There seem to be stages in dying, obviously. And hospice situations are very well set up for that individual and the family to come to terms with sort of the end of life, that last turn of events that will lead to death. When I asked this question, I was thinking more in terms of, I just received the news, you know, reaching out for support. Obviously the physician, family, friends, some people would want to tell people, other people don't like anybody knowing what's happening. So again, we have polar opposite reactions cause we're all different. So how do you, for that first part, that initial just got some bad news, how would you advise individuals? And then we'll talk about the family and those around that individually.
Dr. Levin (33:50):
Yeah, absolutely. So first just give the individual some time to process what they heard. You know, what's the first thing that comes to their mind, help them identify what are their biggest fears, the biggest concerns that they want to address in the amount of time. You know, I am a huge supporter of hospice. I think it's an absolutely wonderful organization. I used to be a director of a hospice 20 years ago, and it's something that I'm highly supportive of. And of course, you know, the goal of hospice is that everybody has a dignified death and a death without pain and able, it’s actually been a while since I've looked at the actual goals that hospice would say, so I apologize if I'm miscommunicating them. But you know, not everybody still reaches the acceptance and is okay or comes to terms with their death. Many people still die, unfortunately, feeling cheated and angry. But you know, to ask, you know, and actually I’ll be speaking with this woman later tonight, what is it that she wants to accomplish? What is it that's important to her and what is it that she feels that she needs to do? And helping her in any way that I can accomplish those things, who does she want to talk to? What does she need to do to get her affairs in order? You know, just making those things happen to her so that she can not have the regrets. Is there anything that we can accomplish so that she doesn't have the regrets that are there any regrets that we can eliminate?
Dr. Pelman (35:36):
And then for those that surround the individual, you know, for the person who doesn't wish to be isolated, yet many people don't want to bother that person or intrude on somebody at this time. So what's a general rule for people feeling comfortable about how far they can intrude or not intrude? Or, you know, how can they help? And, you know, again, we kind of started with this at the beginning, but now we're in a very particular situation. Somebody who, you know, well enough mentions to you that they just were told they had X amount of time or a terminal diagnosis.
Dr. Levin (36:09):
Well, and again, I'm going to speak about this particular case. She has so little control of the remainder of her life. And so it's going to be about what does she want with her friends and her family and how does she want help from them. And it's not really going to be about what her family and friends can do for her. It's what does she want from them. Because at the end of life, she's lost all control over what's going to happen to the remainder of her life. And so making sure she has as much control about the last decisions that she has available, while at the same point acknowledging that it's so important that the people who love her have a chance to express how they feel. And if she does or does not want, you know, visitors or things like that, finding a way that's acceptable for her to be able to receive their support. Whether it's in a written way or a video or whatever, it's all going to be about what she's comfortable with and what's okay for her.
Dr. Pelman (37:30):
So if say a friend, not somebody that they see all the time, but here's from maybe one of the other family members that this is happening. What's the safe way for them to approach this person? They may feel hesitant to do so. And yet still on the other side, if they don't, after the person passes, feel some guilt that they didn't. So, you know, it's a human condition and kind of give some advice just in general. And of course we're all different. So nobody holds you to absolutes.
Dr. Levin (37:59):
Yeah. And you know, you're touching on such an important issue that I train my staff on because oftentimes there's something called the Ring Theory*. And I wish I had it in front of me to show you. There was an article in the LA times about it. There's a series of rings. So if you imagine a dart board. Okay, so the person who's grieving or who's dying is in the very middle. Okay. And according to the Ring Theory, you put comfort in and you dump out. So the person who is grieving or the person who's dying is in the very middle and it all centers around their needs, and everybody else is external. So it's all about what they want and what they need. So the friend who may or may not be that close, what they want or need is peripheral. It doesn't matter as much as what the person in the middle wants or needs. And so they may have a need to express condolences, to express grief, sadness, or sorrow. They can only dump out their guilt or their sadness that they didn't get to do that to people who were more peripheral than they are. They can't dump in their sadness that they didn't get an opportunity to do that. Does that make sense?
*Ring Theory: https://www.latimes.com/opinion/op-ed/la-xpm-2013-apr-07-la-oe-0407-silk-ring-theory-20130407-story.html
Dr. Pelman (39:35):
Yeah.
Dr. Pelman (39:36):
You know, I think for the individuals who were hesitant, you know, because maybe they're close, but not there every day, but they heard this not from the individual. They want to approach individual, to be honest and say, I'm not good at this, but I do want to. Would that be acceptable?
Dr. Levin (39:53):
Yeah. I mean, but they need to talk to people and say, gosh, I feel really bad that I wasn't able to do this. I'm not good at that. They need to talk to people on the outside of the circle, not to people on the inside who are more impacted by it. So they can write a note and send letters or condolences. But with their frustration about their inability that they didn't get a chance to say goodbye or that they, you know, feel bad that, you know, they weren't there for the person, that has to go out towards the outer part of the circle and not the inner part.
Dr. Pelman (40:38):
And, you know, while the person is still with us and they want to approach that person, can they take that approach? Yes.
Dr. Levin (40:45):
The person in the middle of the circle gets to do whatever they want.
Dr. Pelman (40:49):
So you want to approach the dying person and you know, your acquaintance? You can't.
Dr. Levin (40:55):
Unless they give you permission
Dr. Pelman (40:58):
And how would you even? You know, they're out and about and you run into them and you've heard.
Dr. Levin (41:05):
You know, hi, how are you? And if they say, “Fine. I'm doing great,” then you leave it at that. If they say, “Actually I'm not doing well, I have X, Y, and Z,” then you can go there because otherwise, you know, what happens is the person in the middle begins to take care of everybody else. And that's what's exhausting for the person in the middle.
Dr. Pelman (41:31):
And then, well, we have just the opportunity to explore not somebody who's received a diagnosis, but just somebody who's preparing their family for an event that may occur in a number of years or sooner based on age or just statistics. I was recently at a celebration of life for a friend who was in his mid to later eighties. And, you know, his family expressed two things. One is he had told his daughters that he was, and his grandchildren, that when he passed he had a great life. And they can be sad, but they shouldn't feel that he was deprived of anything. And that was very helpful for them to just know that he had had that fulfilling life. The other was, he was very meticulous because his work required it and he had a book and he made sure they all knew where the notebook and it was organized book of accounts. You know, from financial to wishes, to desires, to property, to what to do. And obviously some of this runs into estate planning for those that can take care of the states and have the means to look after wills, but just to have a book where everything is organized with such relief to the family. So for those who are doing well, but eventualities it just seemed like a nice thing to do for those who remain.
Dr. Levin (43:03):
What a gift. You know, as I mentioned, I work with so many people who have dealt with an unexpected death and unfortunately some of them on the younger side, you know, thirties and forties and fifties, who never thought that this would happen so early. Who not only, you know, are dealing with the fact that their loved one unexpectedly died, but all of a sudden they have to figure out how to bury them, where to bury them. They have no idea whether it's passwords to anything. There was no organization to anything. And it's an absolute nightmare. It's an absolute nightmare of paperwork, of bank accounts and it doesn't end. And it is such, I hate to use the word “Burden,” but there's no other way to put it on the person. You know, especially I had just a slew of men in their forties having heart attacks, you know, unexpected heart disease that nobody knew about.
Dr. Levin (44:03):
And, you know, women in their forties with young kids or, you know, kids in middle school, early high school, all of the sudden figuring, having to, you know, be single moms, all of a sudden having no idea how to find things out. And it was just the most stressful thing on them ever. And so I encourage everyone, everyone to get organized, no matter what age you are. I encourage everyone to complete forms such as an advanced directive*. I encourage everyone to have all of their passwords and whatever in a notebook. And speaking from personal experience, I not only is it hard to do these things, but it's hard to be the receiver of this information. You know, my dad many times has showed me this is where all this information is. I don't even want to hear that. And even though it's all organized, I know where it is, but we don't want to talk about it and we don't want to receive it. But it is so important because life can turn on a dime. And so the individual you were talking about gave his family a true, true gift.
*Advance directives: https://medlineplus.gov/advancedirectives.html
Dr. Pelman (45:19):
So Dr. Levin, what does healing from grief actually look like?
Dr. Levin (45:23):
So that's a really great question. People ask all the time, am I ever gonna get over this? Or is my grief ever gonna go away? And in reality, no, we never really lose or, excuse me, we never fully recover from losing someone we truly loved. We never fully heal, but here's what happens. The hole, literally people talk about a hole in their heart, things grow around the hole. The hole doesn't necessarily get smaller, but instead lots of growth takes place. And there's a couple of ways that I've heard this explained. One is commonly referred to as the Fried Egg Theory*. And if you think about an egg and if you put an egg in a pan and there's the yolk. So if you look at the yolk as the grief, the yolk stays the same, but what happens is the white of the egg gets bigger and bigger and bigger.
*Fried Egg Theory of Grief: https://www.funeralguide.co.uk/help-resources/bereavement-support/the-grieving-process/tonkins-model-of-grief
Dr. Levin (46:36):
And that is the growth that the occurs. So some days, you might feel like you're closer to the yolk or you're stuck in the yolk and the grief hurts really bad. But other days you are so lost in the growth, the white of the egg, which has grown so much, you're super far away from the actual grief. And you forget that the pain is there. Another way I've seen this explained is like a ball in a jar. If you put a golf ball and a really small jar, the golf ball takes up the entire jar. But if you put it in a medium sized jar, the ball is still the same but the jar is bigger, and there's more room and there's more air. And if you put it in a huge jar, again, the ball is still the same, which represents the grief, but the jar is so much bigger. And there's so much more room for expansion and growth that you sometimes don't even notice that the ball is there
Dr. Pelman (47:53):
Is that happens spontaneously to some people?
Dr. Levin (47:57):
Nope. There are this whole thing and, you know, trainings on how to facilitate post traumatic growth and counseling, and how to facilitate growth. I mean, that's the whole idea. And I mean, truly that's my favorite part is to see people come in and say like, “I don't want to live anymore. My life's never going to be good again.” And then to see them go away, you know, 18 months later and talk about, you know, all the new opportunities in their life and the way they see the world differently. And, you know, that just takes place over time.
Dr. Pelman (48:31):
So some of the benefits to actually having counseling, to be in a group, to seek being with others, to have some guidance, is the ability to replace a small jar with a medium jar, to a large jar.
Dr. Levin (48:44):
And it’s just the reframing and seeing beauty in the world again. And, you know, we do a lot of gratitude work. And in terms of the work that I do with my clients who have experienced so much trauma, I rely on a lot of work that was talked about, or that has been studied by doctors Tedeschi and Calhoun in North Carolina. And they coined the term post-traumatic growth*. And this is a concept that's actually been around for a really long time. But basically according to them, after someone has experienced a trauma and they experienced a huge drop in their life as a result of trauma, they can grow in a new way that not only do they go back up to the level in their life of where they were before the trauma, they actually exceed in their life, their wellbeing way above where the trauma occurs.
*Post-traumatic growth: https://www.apa.org/monitor/2016/11/growth-trauma
Dr. Levin (49:52):
And often they experience growth in several new areas. And these areas or domains actually occur in their ability to develop deeper relationships; in their ability to try new things; increased inner strength in their ability to have a greater appreciation for life; or spiritual enhancement. So even though grief is perhaps one of the most painful things we will ever go through in our life, there are very positive things that can occur in terms of growth and healing. This is not exactly what I share with my clients when they come in to see me on the day or the first day. But it is something that I will say I find very fulfilling and helps me in the work that I do.
Dr. Pelman (50:56):
Yes. Well, we'd like to always wrap up episodes with resources and in your world, personally, you have a online program from grief to growth. And so it mentioned what you have is resources that you can think of, that we can also post for our listeners where they can find it on our website as well, but go through some resources for folks.
Dr. Levin (51:24):
Sure. So in terms of what I was just talking about for the advanced directives, AARP has a great spot on their website, AARP Advanced Directives, and they have by state. They have the legal forms that you can download and complete your advanced directives, which is a form where you can assign a healthcare proxy to make medical decisions for you. There's also a site called Five Wishes, which is a discussion in which you can talk about your end of life care wishes are with your family. And the discussion guide is at fivewishes.com. When you do these forms, it's super important that you give it to your family members and your healthcare providers so that can be part of your medical records. So that's important. I developed a online course for individuals who are living with traumatic loss, and it can be found at my website, fromgrieftogrowth.com**, and at it's under courses. And this is an online program. It has eight different modules where you can do it at your own pace and your own timeline. And again, this is geared specifically for individuals who have experienced a sudden and traumatic loss. And it's a series of videos, growing tips and worksheets designed to help you work through some of the issues that we talked about today.
*AARP Advanced directives: https://www.aarp.org/caregiving/financial-legal/free-printable-advance-directives/
**Five Wishes: https://fivewishes.org/Home
***From Grief to Growth: https://fromgrieftogrowth.com/
Dr Pelman (53:04):
And we have listeners around the states and around the world. Your religious affiliation minister, rabbi, the clergy pastor certainly have resources to help and hospitals nearby also have those resources.
Dr Levin
Absolutely.
Dr Pelman
Well, Dr. Jennifer Levin, thank you for joining us in a topic that is uncomfortable for many, many people, but is something that if we do think about and perhaps can help those who we wouldn't be able to speak with because of our discomfort. Maybe this episode will give us some insight as to how to approach folks when we've been hesitant and for family members, some resources and some opportunities, so truly appreciated. And thank you.
Dr Levin
It's my pleasure.
This completes another episode of The Original Guide to Men's Health podcast. We wish to thank all guests who volunteered their time and knowledge. The information presented is the opinion of the speakers. The show's recordings are engineered and edited by Sean Fox. Episode titles and descriptions, as well as editing assistance, are provided by Dr. Kathleen O'Connor, PhD. Music for our show is San Juan Bell's, written and performed by Dr. David Whiting. The podcast is sponsored and published by the Washington State Urology Society. The Original Guide to Men's Health is an original publication of the Washington State Urology Society. Reproduction and use without the express written consent of the society is prohibited. For more information about men's health and previous episodes, as well as additional recommended resources, visit us online at https://theoriginalguidetomenshealth.org/ . This is Dr. Richard Pellman thanking you for listening, and reminding you to take care of yourself.
Dr Pelman (55:14):
Good news. The Original Guide to Men's Health has just finished a brand new website, and you can find it online at the originalguidetomenshealth.com. Also the https://www.wsus.org/podcasts.html. Our website has podcast episodes, resources, links to our brand new social media accounts, which can also be found in the episode description.
Episode Summary:
In this episode, oncologist Dr. Bruce Montgomery covers precision cancer diagnosis and targeted therapies, for prostate and other cancers. Thanks to rapid-sequencing technology and medical advances, cancer care is better able to identify specific genetic alterations causing a cancer, and identify a specific therapy targeted against that cancer variant.
Guest:
R. Bruce Montgomery, M.D. Oncologist, Clinical Director of Genitourinary Oncology at the Fred Hutchinson Cancer Center. He is a Professor of Medicine, Oncology and Urology, University of Washington.
During This Episode We Discuss:
- Precision diagnosis and therapy have changed some people’s lives, by adding years and quality to their lives, and avoiding treatments that would not help them. There is still much to be learned and research is ongoing for many cancer types and treatments.
- DNA sequencing looks for both familial markers of cancer risk (such as BRCA markers) as well as specific DNA changes in tumor tissue. For patients diagnosed with cancer, consult with your provider about whether or when you should be tested for specific variants.
- Listen to another podcast episode on precision medicine for more information on this growing trend in health care—Episode 28: Medical Genetics. Original Guide to Men’s Health Podcast
- September is National Prostate Cancer Awareness Month—see our episode on prostate cancer: Episode 10. Prostate Cancer: A) Detection, Diagnosis and PSA, B) Surveillance and Treatments. Original Guide to Men’s Health Podcast
Quotes (Tweetables):
“This is a new pathway in oncology and cancer therapy.”
Dr. Pelman
“And we have made real advances.”
Dr. Pelman
“I think the beautiful part [is] how much easier it has been to do DNA sequencing, among the other things, over the last several years, [which] has allowed us to make huge advances.”
Dr. Montgomery
“We have made huge strides.”
Dr. Pelman
“Oh, night and day, for sure.”
Dr. Montgomery
Recommended Resources:
- U.S. National Comprehensive Cancer Network Guidelines. Click on the Patient Resources tab and then the tab Guidelines for Patients tab, and then click on prostate or other cancer type for more information. This information is compiled and updated by panels of experts.
- FORCE: Facing Hereditary Cancer Empowered. Information and support resource for people who already know they have certain risk variants of genetic or other biomarkers.
- U.S. National Institutes for Health: The Promise of Precision Medicine
- American Cancer Society: information on Precision Medicine
- Episode 28: Medical Genetics. Original Guide to Men’s Health Podcast
- Your healthcare provider, major medical centers with oncology units
Episode Transcript:
Dr. Richard Pelman (00:00):
The Original Guide to Men’s Health is moving to a monthly release schedule. We will be releasing new episodes the first Wednesday of each month. We really appreciate you listening, and we hope you enjoy this episode.
Dr. Richard Pelman (00:18):
Whatever you do, whatever you enjoy, you need your help. Welcome to the Original Guide to Men's Health, a podcast designed for men of all ages to learn about and access good health. This guide shares knowledge on how to be and stay healthy. Maintenance and prevention strategies along with reviews of conditions and issues affecting wellness are explored. Please join me, your host, Dr. Richard Pelman, as I interview renowned experts who will provide you with timely, relevant, and vital information so that you can embark on a journey towards better health.
Dr. Richard Pelman (01:07):
On this episode of the Original Guide to Men’s Health, we will be reviewing precision oncology. Helping guide us through today's episode on precision oncology is Dr. Bruce Montgomery. Dr. Montgomery is a board certified oncologist and clinical director of genitourinary oncology at Fred Hutchinson Cancer Center and the University of Washington Medical Center. He is a University of Washington professor of medicine, oncology, and urology. Dr. Montgomery divides his time between seeing patients at the Fred Hutchinson Cancer Center, prostate cancer specialized area, and research. He is a compassionate, conscientious, skillful physician, a real intellectual when it comes to cancer knowledge, and an outstanding researcher who is now devoting a majority of his research time to clinical trials. Dr. Montgomery earned his medical degree at Duke University. He subsequently undertook his internship and residency in internal medicine at the Brigham and Women's hospital in Boston, Massachusetts, and undertook his hematology-oncology fellowship, medical oncology at the University of Washington. Welcome Dr. Montgomery.
Dr. Bruce Montgomery (02:30):
Dr. Pelman, thank you for having me on. I really appreciate the opportunity to talk to you and to other folks who might be listening.
Dr. Richard Pelman (02:38):
There’s a distinction about precision medicine and precision oncology. So why don't we first start with exactly what are we talking about with precision oncology. Dr. Montgomery, thank you for joining us.
Dr. Bruce Montgomery (02:52):
So precision oncology is defined in different ways by different people. The way I tend to use it is to say, we use a biomarker to help to tell us whether someone is going to benefit from a therapy or not. And by using that biomarker to say, this is definitely the therapy for you, you'll get better outcomes, or for you because your tumor has this marker in it, we know that it won't respond to X, Y, or Z. So the idea being that that's what's called a predictive biomarker. So the ability to design therapy based on the presence of this alteration in the cancer. And so from my perspective, that's the way in which most precision oncology is used. Viewed more broadly it's essentially saying any biomarker that tells us how to use a therapy could be considered precision oncology. I like to use it attached to a very specific intervention.
Dr. Richard Pelman (03:56):
So you know, our audience may have heard over time, the term moonshot. There were federal funds, we were going to conquer cancer. Dr. Lee Hood, who pioneered a lot of this, talked about P4 medicine. He called it predictive, preventive, personalized, and participatory, and we've evolved. This is a new sort of pathway in oncology and cancer therapy. I'm sure that the listener audience is familiar with chemotherapy and the knock against all the chemo was you were dropping an atomic bomb and killing everything. So kind of fill in a little bit about how this is different. You've given us a little definition, but let's keep going there. We're tailoring therapy.
Dr. Bruce Montgomery (04:40):
The moonshot, as you said, the idea behind that was to be able to find the right therapy for the right person at the right time. The idea is that mostly what we're talking about in medical oncology these days is doing largely what's called DNA sequencing, meaning taking the cancer, pulling it apart, looking for alterations that have occurred in the process of development or evolution of the cancer that then make it hopefully more sensitive to very specific therapies, and in the best situation, the therapy is specifically targeting the pathway that is altered. So that's, you know, sort of the most intelligent engineering of how to treat somebody. And by doing that, you hopefully minimize side effects and you optimize outcomes. So that was the whole idea behind the moonshot. So what we do in medical oncology in general is that in patients who have specific malignancies, most of the time, we're looking for very specific targets.
Dr. Bruce Montgomery (05:48):
Some people would argue that every patient with an advanced malignancy should have DNA sequencing done. And there are other people who say that doing any DNA sequencing of any kind is largely irrelevant because it hasn't been shown to improve outcomes. I would say the truth probably lies somewhere in between. That is, from my perspective, there's no question that patients who are dealing with some specific malignancies, if we can find an alteration to which we can match a therapy, those folks benefit. Not only do they have their cancers respond, but they live longer and their quality of life is better. And so I'm happy to talk about specifics. I obviously tend to think more about prostate cancer than anything else, because that's our most common disease that we treat. But, you know, there are many areas that have been, there have been incredible advances made. So for example, when advanced lung cancer, you know, back in the day, what we did was we used platinum chemotherapy to treat everybody. Now, most people who present with an advanced non-small cell lung cancer will have sequencing done. And in some cases, therapy is designed specifically around the alterations that are found in the tumor.
Dr. Richard Pelman (07:07):
Let's go back a little bit. We're talking about sequencing. DNA sequencing. Are we talking about somebody's DNA that you would get for 23-and-Me, or are we looking at the tumor DNA, or are we talking about both?
Dr. Bruce Montgomery (07:21):
The short answer is both for a couple of different reasons. At its simplest, you sequence the tumor DNA and you try to find alterations that are specific to the cancer. The truth is that in a fair number of people, their normal DNA also contains alterations that tell us why the cancer developed. So for example, folks who inherited an alteration, BRCA1 or BRCA2, when you sequence the tumor, you're also sequencing the normal DNA as well. And the idea is that you pick that up along the way. The important thing is when we're doing those sorts of tests on tumor DNA alone, it's important to recognize those folks who did inherit one of those alterations, because that has implications for family. So the short answer is, for many people, sequencing both the normal DNA, what's called germline DNA, and the tumor DNA, which is called somatic DNA, both of those are important things to think about when we're talking about trying to find the right therapy.
Dr. Richard Pelman (08:26):
And when we talk about therapy, most people are familiar with treating cancer with chemotherapy. Is this always just going to be applied to chemo or are there other forms of therapy that this is useful?
Dr. Bruce Montgomery (08:38):
Actually, there are some types of chemotherapy that essentially are targeted therapy. So for example, cancers that contain these BRCA alterations, which are very common in breast, ovarian, pancreatic, and some prostate cancers, platinum-based chemotherapy can be exceptionally effective in those patients. On the other hand, other drugs also target those alterations. So things like, what are called PARP inhibitors, poly ADP ribose polymerase. So those are drugs that are pills that sort of block one of the pathways that the cancer uses to survive despite the fact that it has a tough time repairing DNA damage. And those PARP inhibitors can be exceptionally effective. There are also what are called tyrosine kinase inhibitors. If you think about it very generally, those are like chemotherapy, but they are targeting very specific proteins that are signaling along these pathways that are responsible for cancer, that in many cases can be really, really effective.
Dr. Richard Pelman (09:40):
And you mentioned BRCA, breaking that down for people listening who may not be familiar with it. It was one of the early determinants for breast. Dr. Mary Claire King of the University of Washington found that gene. So just elucidate a little bit more about BRCA.
Dr. Bruce Montgomery (09:59):
As you said, Dr. King was one of the very first people who recognized that there were women who were developing breast cancer at a very early age and there tended to be a pattern of that in the family. She went back, took the DNA from these families, and specifically found that in a subset of folks, there were alterations in this gene that, BRCA sort of stands for breast cancer gene one is what the original gene that they found was. Subsequently there was another gene found involved, and they're both involved in repairing DNA damage to cells, something called BRCA2. Both of those are genes which, when they're inherited by somebody, particularly women, but also men, carry an increased risk of some very specific cancers like breast cancer, ovarian cancer, male breast cancer, in fact, prostate cancer. And that's a very important risk of developing significant prostate cancer down the road.
Dr. Bruce Montgomery (11:01):
Those again are part of what's called DNA repair. So your body has evolved this process of being able to repair DNA damage because damaging DNA is the first step to getting cancer. Your body obviously doesn't want to get cancer that takes you off the road of life. So these genes are involved in repairing that damage from the sun or what you eat or whatever. The issue is if you inherit one of these genes that doesn't work all that well, then parts of your body are more susceptible to actually developing full blown cancer because it can't repair that damage that we all sustain just walking around every day. So that is one of the best defined predispositions to developing cancer. Those alterations, it turns out, can make cancers extremely susceptible to targeted therapies like the PARP inhibitors, some platinum agents, and a few other therapies as well.
Dr. Richard Pelman (11:57):
This is your body's surveillance system. I've always been under the impression that as we age, our surveillance system gets weaker and sometimes just can't do the repairs like it used to, but there's obviously some genetic predispositions towards this as well.
Dr. Bruce Montgomery (12:12):
Absolutely. And as we age, we tend to build up DNA damage and the system for repairing that damage also is not as effective. So you're absolutely right. That is some part of normal aging. But as I said before, you know, if people don't have a good repair system from the very beginning, they can develop cancer at a much earlier age.
Dr. Richard Pelman (12:33):
So we spoke a little bit about some vocabulary issues that we'll be referring to, the difference between somatic and germline. So testing the tumor itself is again called somatic testing. And then when you just get your blood drawn and you look at your DNA, that's germline.
Dr. Bruce Montgomery (12:52):
Yeah. It's just the DNA that you inherited. You know, every chromosome has half from your dad and half from your mom. So you inherit two of those genes. And if you inherit an alteration from one of them, half of your capacity for repairing DNA in all your cells really is compromised. So that's why looking at germline DNA sometimes tells us a lot about the cancer.
Dr. Richard Pelman (13:15):
We spoke a little bit about this in the genetics episode that we did, but I'm sure listeners are going well, should I go out to 23-and-Me and have my germline sequence? Should I have my blood drawn and look for something that makes me susceptible?
Dr. Bruce Montgomery (13:32):
Some of these sort of vendor products that you don't have to go to a doctor to get like 23-and-Me, some of them do include genes that are involved in things like DNA repair. The issue is that they only test a couple of different alterations in those genes. Whereas a dedicated genetic test looks much more deeply and much more completely at those genes and really means something. The main reason I bring that up is that because somebody has done 23-and-Me, that doesn't necessarily give you a complete answer one way or the other. I would say, I don't think that testing your normal DNA for a cancer predisposition makes sense for everybody, for sure, because there are all these alterations in those genes that don't mean anything. We have very specific guidelines and the guidelines change as we do more research and find more alterations that mean something to people.
Dr. Bruce Montgomery (14:28):
But, you know, for example, in folks dealing with prostate cancer, it's a very clear recommendation that folks who are dealing with disease that's gotten out of the prostate, metastasize is what they call it, those men are people who definitely should have germline testing done because that can, you know, help them to find other treatment options and its important for their family if they in fact inherited something. So the short answer is absolutely the right thing for some people, not the right thing for everybody to go doing, and certainly not to go doing and the wrong.
Dr. Richard Pelman (15:03):
And for more information, I'll just refer listeners to the episode on genetics with Dr. Jarvik. It really did give us some background as to what's available and what's not. And there is a national effort if you're accepted that will do your DNA screening. It's a national program, but listen to that episode. So going back to tumors, I'm going to hold off for a second as far as specifics of what kind of cancers and just look at what kind of testing is actually being done. That category of all right, you've got a tumor, we're going to do this somatic testing. What happens? What are we actually looking at?
Dr. Bruce Montgomery (15:42):
The first thing is you have to decide which tissue to test. You know, you're taking tissue of some kind and the right tissue to test depends on what the setting is. So in some people it's taking a diagnostic biopsy, the tumor tissue that's taken at the very first time a diagnosis is made, that tissue is sent off. You can either send off the, there's something called a block of tissue that has the tumor tissue put into wax, and then it's cut and you can actually send the block itself, or just pieces of the tumor tissue that are cut off onto a slide that is usually sent to what's called a vendor, a company that does the sequencing, the majority of the time. And what they do is they take that stuff off the slide or out of the block, they break down what's in that tissue sample, and then they sequence all the nucleotides in that sample, looking at very specific parts of the DNA.
Dr. Bruce Montgomery (16:35):
They don't sequence the whole DNA, and there's lots and lots of DNA in there, but we really are looking specifically at genes that we know mean something. And so that is usually done over the course of several weeks. You know, sometimes the results can come back very quickly within less than a week, but the majority of the time, that takes somewhere between two and four weeks and then the report comes back to the provider that says, we found these genes that are altered. The alterations have this implication. And hopefully something can be found that can be a benefit to people. And, you know, again, for the right person, doing that testing makes sense. I want to reemphasize before we go further. Not every single person with advanced malignancy is expected to be able to find something. So I don't think that necessarily, you know, although there's this propensity for all of us to, you know, more information is always better for a lot of people doing that, sequencing doesn't really provide any information because we haven't ever found a mutation in that type of cancer that's ever been able to be used to treat them differently. Definitely is part of research we do all that, but not necessarily as part of clinical care.
Dr. Richard Pelman (17:59):
So along that direction, and then I'll go back to next generation sequencing for you to elucidate a bit about that, but in the Emperor of all Maladies, which I think was a wonderful book, one of the greatest treatments that came along came because a researcher happened to be attending a meeting and heard somebody speak and told a colleague that they should meet. It was almost happenstance. And, you know, somebody says, well, how do they know that there's nothing that works for this tumor? How does my oncologist know? We are now networked into work groups so that the information is shared much more readily and that somebody on the east coast is getting information from the west coast and from the midwest. Yes. I mean, just let people know how this works in this day and age rather than happenstance.
Dr. Bruce Montgomery (18:43):
Right. So great points. I think, as we all know in the midst of this pandemic, virtual communication has been critical. We all tend to communicate with each other about new research because that's obviously the cutting edge. That's what we're all trying to find, the newest, greatest thing for the patients we see. That communication takes place through a number of different media and mechanisms. So, you know, publication of journal articles is out there. The vast majority of journals now are electronic. You can access them immediately from anywhere. So publication of those results is critical. We have meetings, they used to be face-to-face and hopefully we'll get back to that soon, but you know, virtual meetings now many times per year. Some of them are subspecialty meetings where the newest, greatest research is being presented. Thousands of people will attend these meetings to see the latest data that's come out of either both clinical trials and in and out of the laboratory that informs the subsequent clinical trials. And then the companies that are involved in doing this research are, both the sequencing and the clinical trials, are just as invested in making sure that everybody knows the results as quickly as possible as all the rest of us are. I would say in this modern age, communication happens so much faster than it used to, and access to the information that can inform the next experiment or the next clinical study or the next treatment is generally much more available than it used to be.
Dr. Richard Pelman (20:19):
And going back to next generation sequencing, or NGS, review that it's targeted and some comments about whether it’s the whole exome or the whole genome, just review that and break it down a little bit.
Dr. Bruce Montgomery (20:35):
We talked about DNA sequencing and the issue is that sequencing all the DNA and somebody's tumor, or even just in their normal DNA, there's a lot of DNA in there that has no impact on things like cancer therapy. So to sequence all of that, it's called Whole Genome Sequencing. That is literally sequencing every nucleotide in somebody's genome. And then there's, what's called Whole Exome, which means just sequencing the part of the DNA that ends up being made into protein, because that's actually what the majority of us are all ourselves made out of, is proteins. And so that's more important. But what's called targeted next generation, so NGS or next generation sequencing, is just the method of very rapidly sequencing DNA very efficiently. What targeted means is that the majority of the time what happens is a company or an investigator just says, okay, these are the genes that mean something for therapy or for predicting response to something more how people are going to do. We're going to sequence that. In most cases, the sequencing is being done many, many times to make sure that it's accurate and that the result is what we think it is. So we take most cases, maybe 50 genes when we're talking about germline testing, or hundreds of genes when we're talking about sequencing the tumor DNA, or somatic testing and sequencing them many, many times to get the answers about what we can find.
Dr. Richard Pelman (22:03):
And is that currently the most popular platform or are there other ways of achieving this?
Dr. Bruce Montgomery (22:10):
From a research standpoint, a lot of people are doing the broader sequencing effort. There are other tests for biomarkers that aren't DNA. So for example, in prostate cancer, there is an RNA test looking for a very specific type of receptor for testosterone called the androgen receptor. There are these variants of the androgen receptor, which are sort of hyperactivated. And the way to detect them is by pulling RNA out of cells that are floating around in the bloodstream. So, you know, there are a broad range of different ways of looking for this for these sorts of biomarkers. The DNA sequencing, again, targeted DNA sequencing that we were talking about is, far and away the most popular and the one that has the most of the drugs attached to it. But there are a range of other approaches as well.
Dr. Richard Pelman (23:02):
So the upshot of course is looking at who should be tested. And maybe we will now kind of talk about some examples because this episode will be launched in September, which is prostate cancer awareness month. And you know a lot about prostate cancer. Let's start there. So a patient or somebody who's listening who knows somebody who has prostate cancer says oh, you have to listen to this episode, you should go get tested. We talked about prostate cancer generally after diagnosis of being clinically localized or metastatic. And certainly there are people we feel are localized, but sometimes there's microscopic disease that's already escaped based on certain risk factors. How high their PSA is and the grade of the tumor. So somebody has been diagnosed with prostate cancer. Who should go out and have their tumor examined or their blood examined.
Dr. Bruce Montgomery (23:58):
So the majority of the utility of doing sequencing of the tumor is for folks who have disease that's clearly out of the prostate because for those folks there are drugs that are either available for use today, or they will be, when they reach the point where that becomes necessary. There are folks who have localized prostate cancer for whom doing that sequencing might be useful. So for example, there are folks who, as I think you know better than anybody because you’re in urology, we've sort of moved some of the tendency to treat everybody to this idea that people can just watch their cancer if it's not really an immediate risk to them. And that's what's called active surveillance. That's an inappropriate approach. I'm sure you've had other folks on talking about this for men who have small volume, low grade cancers that aren't predicted to have a big impact on their outcomes for a long time.
Dr. Bruce Montgomery (24:57):
We know that for example, men who have inherited one of these alterations in genes like BRCA 1 or 2 are at higher risk for developing advanced prostate cancer. Cancer that gets out of the prostate and becomes the thing that threatens them. So what's an area of very active discussion and research right now is, are people who are germline carriers of these alterations, like BRCA 2, are those men who really are appropriate for active surveillance? I think there are folks that come down on both sides of that discussion, but I think certainly many providers who are considering putting men on active surveillance are looking at whether they inherited one of these alterations because from the data that we have, we know that their risk of having something happen that we don't want is higher. So that would be one situation.
Dr. Bruce Montgomery (25:55):
Okay. The other situation for getting sequencing, although the national guidelines say that people who have high risk cancer are appropriate for sequencing, I honestly don't necessarily do that for the majority of men who have disease that can be treated with radiation or surgery because there isn't anything we can do with those results for those men right now. And, you know, you want to have the most up-to-date information when it's relevant for somebody down the road. So I think every man with metastatic prostate cancer should have both the germline tested, meaning the normal DNA, to look for whether they inherited that alteration, or somatic sequencing. And that can be either their prostatectomy specimen, if it's still around, or it can be even a metastasis biopsy. That's actually how we originally found all these alterations in prostate cancer. Or there's something called circulating tumor DNA, where you can actually just draw blood and you can pick up DNA fragments that are floating around in the bloodstream that the tumor has shed and can give you a good sense of what's going on with cancer in real time. And it's pretty easy to access and generally a very good approach.
Dr. Richard Pelman (27:08):
So a patient who is clinically localized, and we talked about guidelines, I suspect you're talking about the National Comprehensive Cancer Network guidelines, which nccn.org patients can find. And if you're looking at prostate cancer, you go to guidelines for patients, if you find the header under nccn.org and you find guidelines for patients, and then you'll see basically every cancer. And if you click on prostate cancer, it's interpretable. You can follow it. And it comes up as a nice little booklet and you can read it. The NCCN guidelines that are not for patients are a little more in depth and that's for practitioners, but that's where we get this information.
Dr. Bruce Montgomery (27:53):
Exactly. Those are expert panels who take all the data into consideration. And sometimes part of it is opinion. That's part of being an expert, right? As the people who do most of the research and do the clinical trials, you know, they generally have the best sense of how both treatment recommendations and evaluations should be done. So that NCCN is a great resource, as you said.
Dr. Richard Pelman (28:19):
And then somebody who's category of tumor is more active or their PSA is higher. The volume of tumor is larger, who should move ahead with treatment and not be in surveillance. We would hope they're clinically localized. We look for any metastatic disease. It's not there. They move ahead with either radiation or surgery, which are the two main modalities at this point. They don't have to worry though that if, you know, there is residual tumor somewhere that was hiding that they didn't have it sequenced initially, because, as you said, it can be from the paraffin block that’s stored, so you can always go back, or from the actual metastasis should that develope.
Dr. Bruce Montgomery (28:59):
Exactly. And we just did some work, not very long ago. One of my colleagues, Dr. Schweitzer and I, and a number of other folks, we went back and we looked at the tumor tissue that was taken at the very beginning, either prostate needle biopsy or the prostatectomy specimen. And, you in folks who had had one of these targetable alterations defined from things like metastasis, we actually show that they agree the vast majority of the time. So it's very reasonable to sequence the prostatectomy specimen or the prostate needle biopsy. If people don't have other easy ways of analyzing tissue.
Dr. Richard Pelman (29:36):
In some instances where there's been radiation, can the radiation change the character of tumor and the metastatic disease?
Dr. Bruce Montgomery (29:43):
With regards to the kind of mutations that we think of, at least as of today, that give people different treatment options. There isn't actually a lot of data that radiation generates those alterations. And therefore you would miss that from the biopsy that preceded the radiation. And there are some things that happen over the course of treatment pressure from hormone therapies and chemotherapy, and those sorts of things, those alterations can evolve. But most of them are not things that we can necessarily use today to treat somebody differently. So even though they might be, they might be different knowing that those are different, doesn't change things. So, you know, knowledge is knowledge for sure. On the other hand, what you want to know about is something that you can use to treat somebody.
Dr. Richard Pelman (30:32):
And we have made real advances.
Dr. Bruce Montgomery (30:35):
Oh my God. Yeah. I mean, I think that, you know, the beautiful part about how much easier it has been to do DNA sequencing among the other things over the last several years has allowed us to make huge advances. I mean when I started in this world, and a little younger than you, not by much, the idea is that we just didn't have options. And then as options came, we treated everybody exactly the same every time. And we are, thank God, evolving out of that approach to one where we can more appropriately personalized therapy for people. And, you know, the research has really been, what's made that possible.
Dr. Richard Pelman (31:18):
There continues to be research. You know, this is ongoing everyday.
Dr. Bruce Montgomery (31:22):
There are many, many people thinking about this every day, trying to find the next great thing. And many people are very focused on the next great thing. That's going to be curative for people who have advanced disease. So the good news is that we continue to improve therapy for men who have disease. That's just in the prostate. We've also made some huge strides in dealing with more advanced disease and people are working everyday too, and continue to move forward on that.
Dr. Richard Pelman (31:52):
And just for someone who's listening, who either has advanced prostate cancer, that's metastasized or knows somebody who does, say their tumor get sequenced, are they still being treated initially for the metastatic disease, with the first-line therapy, which has been to deprive the tumor of male hormone, or are we moving into this very specialized approach?
Dr. Bruce Montgomery (32:18):
First, as of today, outside of research studies, hormone therapy remains the backbone of therapy for men. And, you know, I know that that's something that's been around for many, many years. On the other hand, what we've learned is that by doubling down on that, by even more significantly suppressing the signaling through the hormone axis, we've been able to add years to men's lives by adding other drugs right upfront. And now what's actually happening in the research area is adding these targeted therapies to that combination in men who have just been diagnosed with advanced disease and, you know, looking at whether, you know, when we talked about a little bit earlier, these PARP inhibitors, which were these ways of really leveraging the inability of the cancer to repair DNA damage, we're looking at moving that into that area. And I know that there are studies being done looking at using those drugs for men whose PSA is just rising. And it actually, even before things like surgery.
*PARP1 possesses Poly (ADP-ribose) activity and when activated by DNA damage, adds branched PAR chains to facilitate the recruitment of other repair proteins to promote the repair of DNA single-strand breaks. PARP inhibitors (PARPi) were the first approved cancer drugs that specifically targeted the DNA damage response in BRCA1/2 mutated breast and ovarian cancers. Since then, there has been significant advances in our understanding of the mechanisms behind sensitization of tumors to PARP inhibitors and expansion of the use of PARPi to treat several other cancer types.
[Image Source:PARP Inhibitors: Clinical Relevance, Mechanisms of Action and Tumor Resistance - PubMed (nih.gov)]
Dr. Richard Pelman (33:25):
Going back to a initial screening, we talked about BRCA. How does an individual who's listening know if their mother or sister had breast cancer or ovarian cancer, is it a clue that they should perhaps consider getting tested?
Dr. Bruce Montgomery (33:39):
Family history. Although it isn't completely predictive of whether people carry one of these alterations, you know, a family history of breast, ovarian, pancreatic, or prostate cancer in multiple members of the family. But particularly at younger ages would be reasons for people to be thinking, “oh, you know, I've always worried about this. And you know, now maybe I should talk to my doctor about it,” whether in fact, this is a reason to do that kind of testing. You know, it's important to bring these things up. You know, doctors are obviously trying to do the right thing, but a lot of appointments are 15 minutes and, you know, you gotta get through the things that you're thinking about that day. You know, bringing that up when you talk to your doctor is really critical. So thanks for bringing that up.
Dr. Richard Pelman (34:24):
And then populations that are at risk that come to mind.
Dr. Bruce Montgomery (34:28):
Yeah. So, you know, in terms of germline alterations, beyond the family history part, we know that for example, black or African-American men are at higher risk for significant prostate cancer. As of today, we don't seem to see a significant increase in these germline alterations. In general, the frequency is about the same in the Caucasian population versus other ethnic groups. You know, folks who have an Ashkenazi Jewish background are much higher likelihood of carrying one of these alterations and that something is you should definitely pay attention to that. But I think a lot of the time, it's a matter of asking if there is a family history, seeing if somebody has been tested, sometimes that information actually hasn't been passed on. And there is somebody who family who actually knows that there is an alteration, but, you know, for whatever reason that information didn't make it.
Dr. Richard Pelman (35:27):
Again, genetic counselors are available at most major centers. I'll again, refer people back to our episode on genetics and genetic testing, looking at cancers besides prostate and lung, we spoke a bit about adenocarcinoma. But, for somebody who's listening who has lung, or knows somebody with lung cancer, let's delve into that a little bit.
Dr. Bruce Montgomery (35:48):
I think a lot of the era of molecular medicine or precision oncology started when people recognize that in a subset of adenocarcinoma in the lung, there were these… and I'm going to start using terminology that mean a lot, but epidermal growth factor receptors. There are these proteins that were mutated and they discovered them because, you know, there were people who had never smoked and, you know, were getting diagnosed at a young age and they recognized that these alterations were present in the tumor. And then because they knew about these mutations, they developed very specific therapies that target that mutation in those tumors in a way that can be extraordinarily effective. And we've continued to develop more and more effective drugs for that. Once they actually discovered that these what are called ETFR mutations existed, then they started looking for other mutations, have found a plethora of these mutations that are not very common, but when you start adding up, how many of them there are, and many of them have these targeted therapies attached to them, which can be extraordinarily effective. You know, it has become really the best. Now precision oncology can change people's lives because folks who otherwise would have gotten platinum chemotherapy and had a relatively poor outcomes, are now living many years.
Dr. Richard Pelman (37:15):
So as we look at these tumors and the interpretation of these issues, let's elucidate a little bit more about the findings.
Dr. Bruce Montgomery (37:25):
What usually happens is the tumors get sent off, or the circulating tumor DNA sample gets sent off, and a report comes back to a provider and it says these genes were altered and there are these treatments attached to them. So there are a couple of different aspects to that that are really important for making sure that the provider has thought about, you know, is this something of significance? So first, you know, they need to look at whether that alteration it's definitely obviously there, the question is, is that something that the patient could have inherited? So being able to tell from the report that somebody might've actually gotten that alteration because they inherited it, that is sometimes not very clearly spelled out, but sometimes it is. And it's sometimes on page 25 of a 25 page report. So one thing is, you know, as somebody who's interacting with a provider who just interpreted that result, you know, making sure that the provider thought about whether that alteration was something that may or may not have been inherited.
Dr. Bruce Montgomery (38:32):
So that's one part. The second part is that even this, what is called the circulating tumor DNA, also called the liquid biopsy, which is just a blood draw where we can, again, sort of get the tumor DNA just by doing that simple procedure. The issue is that there is something that is not as widely recognized as I think should be recognized. There's something called Clonal Hematopoiesis of Indeterminate Potential. That is a mouthful. So we call it CHIP. But what it means is that as we age and our bodies absorb that DNA damage that you would actually referring to earlier, our bone marrow function can sometimes not be normal, meaning that some little collections of cells in your bone marrow start to not make perfect cells, shall we say there are mutations in 'em and the bone marrow isn’t functioning? Well, it doesn't mean you're necessarily getting leukemia.
Dr Montogmery (39:31):
We can find these what are called CHIP clones floating around in 10 to 20% of people by the age of seven. Okay. So a good portion of us at the age of 70, have these things floating around. And the thing is some of these alterations happen in genes that are picked up as being something from cancer. And so what happens is this is a very common problem. So for example, again, back to prostate cancer, if we look at a set of patients who had one of these liquid biopsies done, and an alteration was found in a DNA repair gene, for which they might be a candidate for, let's say one of these PARP inhibitors, almost 50% of those alterations are actually not from the cancer they're from this CHIP clone. Okay. So the issue is it's an under-recognized problem that both the provider and being an advocate for yourself, because, you know, saying, and I know this is asking a lot of people, but they should just be aware of it, you know, asking the provider, because if they're giving somebody therapy based on this alteration, in the tumor, in the report, half the time, it's not going to do anything to fight the cancer, and it can be expensive.
Dr. Bruce Montgomery (40:50):
People are being exposed to side effects of therapies that don't work, and then it's delaying treatment that could work. So that would, I want to comment about that.
Dr. Richard Pelman (41:00):
Is there a more specific way to find out if it's actually involved in the tumor?
Dr. Bruce Montgomery (41:04):
Yeah. So the best way to do that is having it done through an assay that does comparison of the tumor DNA to the normal DNA from the blood draw. If some labs can in fact get both of those out of the blood draw, just out of the blood draw that was used to get that read, not to tout our own work, but for example, the lab at the University of Washington, which is a commercial lab, they do that tumor normal sequencing. It's doing both at the same time. And that way you can tell whether it is in fact related to the cancer or not. You can tell sometimes from just looking at the report carefully, for example, if the tumor DNA amount is very high and the amount of this alteration is very low, that really tells you that it's not from the cancer, but from one of these CHIP clones.
Dr. Richard Pelman (41:58):
And sure somebody is thinking that well, if they find these alterations before I have cancer, can't they fix it?
Dr. Bruce Montgomery (42:05):
We do know that if we find this CHIP abnormality in someone, their risk of developing, not every cancer, but specific cancers like leukemia is elevated, but because the frequency of leukemia is very low, even though the risk is elevated, if it were found, I think your provider would want to look at, for example, other blood counts to make sure that your other blood counts are normal, if they are, and you're otherwise doing fine. Although again, the reason you'd be getting this sequencing done most of the time is because you're dealing with a malignancy of some kind. But if there's no evidence that the bone marrow function is being compromised, all you would do is just follow that without actually doing any intervention.
Dr Pelamn (42:51):
Just going back to generalities, then people are wondering, well, can they cure something preventively by fixing the gene?
Dr. Bruce Montgomery (43:00):
Yeah, that is clearly what all of us want to be able to do. So I think for example, there are diseases that are now being treated by using what's called CRISPR* technology, where you can in fact insert or alter genetic material in a way that allows you to restore function. For example, either in bone marrow cells, for folks who are dealing with various types of LCME or sickle cell disease and a number of other diseases, although most of them are not related to cancer right now, I think to a degree, some of these approaches that we're coming to are not that far away from what we did with what is called CAR-T cell therapy, where we basically take somebody cells out and we put constructs into their T cells. So that were hyperactive in their immune system against whatever cancer they're dealing with, mostly leukemias, and that can be curative and Hodgkin's disease and various types of lymphoma.
Biologist Explains One Concept in 5 Levels of Difficulty - CRISPR | WIRED
Dr. Bruce Montgomery (44:10):
That has been a huge step in the direction of finding a cure for people with those diseases. Everyone wants to find a way to make immunotherapy more effective because so far that has been sort of the realization of the hope for cure, for people who are dealing with advanced disease right now, solid tumors beyond things like lymphoma and leukemia. We're still making progress, but we're not there yet. Let's just say so far as immunotherapy goes. Now, I would say a very important aspect of this molecular medicine. Precision oncology part is finding folks who have these cancers that are what are called hyper mutated or mismatch repair deficient. They're not very common, but if by doing the sequencing that is found that immunotherapy can be curative in those people. And that actually is another aspect of this precision oncology effort that can in fact mean a great deal to people. So, but again, it's just a different way of leveraging immunotherapy for the most important outcome, if possible, which is to cure the disease.
Dr. Richard Pelman(45:23):
And we've touched on prostate and lung, but there obviously are a number of other cancers and it would be beyond the time that we have to delve into all of them, but all other cancers are being looked at.
Dr. Bruce Montgomery (45:38):
Absolutely. So, even though, as I said at the beginning, I don't think that necessarily everybody with every advanced malignancy should have sequencing done. I know because I work with, you know, very smart people over at the Fred Hutchinson Cancer Center, looking at all those diseases that they're trying to find new targets, new alterations in those malignancies that will be targetable in the near term as we speak. So the research goes on, but many malignancies, you know, it is standard of care to perform this sort of sequencing to find alterations and, you know, asking your provider, if you're dealing with an advanced cancer, whether that's the thing to do, if it hasn't been done, you know, no downside to asking. And I think for many people, it is the right thing. It's just a matter of the right time. Right.
Dr. Richard Pelman (46:30):
Right and then among your own colleagues and other national centers for somebody who's listening, who may not be in Seattle and maybe somewhere else, most major medical centers have major oncology centers or cancer centers. And when is it appropriate to go to a very particular center?
Dr. Bruce Montgomery (46:51):
You know, I think sort of across the spectrum of malignancy, one thing I would say is that, you know, if you're dealing with a significant cancer that hasn't necessarily gotten out of where it started, but you don't feel like the expertise in where you are is necessarily what it might be getting a second opinion, seeing a multidisciplinary care team at a medical center that has that expertise is always a good idea. You may not necessarily have to get your therapy there, but the plan for treatment can oftentimes be developed by review of the pathology, the images that have been taken, those sorts of things. So even at the very onset of the disease being seen at a major medical center, if you have something that isn't, that straightforward is always a good idea from my perspective. And I hope that isn't too self-serving I think in terms of, you know, taking advantage of the research, that's taking place at some of these major medical centers, you know, I think when people are dealing with an advanced malignancy, so metastatic anything, getting an opinion, again, you don't have to make the decision to be treated there, but knowing what your options are and establishing a communication with a provider at one of those centers, so that it may not be the right time now to engage in participation in research, or even just standard of care there, particularly if you live a long distance away, but somewhere along the way, it may be important for you.
Dr Montomery(48:27):
And particularly if you want to take advantage of research and having a contact and having being a known entity within one of those medical centers and only play to your advantage because the research is where the new therapies are coming from and the significant advances are coming from.
Dr. Richard Pelman (48:45):
Right. Are you doing any of this through telemedicine/telehealth?
Dr. Bruce Montgomery (48:49):
So actually a lot of the multidisciplinary care is taking place through what's called telehealth, as you said. So we are in fact, for example, at the University and the Hutchinson, our bladder multidisciplinary clinic offers distance consults and doing that through the pandemic. And we'll continue to do that after the pandemic. And, you know, things are a little bit in flux right now about which states will allow us to do telehealth that aren't the state of Washington, but within the state telehealth consultation is being done much more commonly. And it obviously is much easier. And you can establish whether there's, you know, a great treatment option or a treatment that hadn't been considered that could be available to you locally by having one of those consultations. So thanks for pointing that out. That is definitely something that now and going forward will definitely be a boon for folks who aren't living in New York City you're in Seattle or Houston, for example.
Dr. Richard Pelman (49:51):
Yeah. Just information for listeners. The pandemic allowed us to resolve or lift some of the restrictions on telemedicine, telehealth for the benefit of patients during the pandemic. And we'd like to continue a lot of those so that there are no restrictions. And that's currently legislation both statewide and national that's being looked at well. I always like to wrap up with resources. We talked about the National Comprehensive Cancer Network, other resources that come to mind that you could recommend to people?
Dr Montogmery (50:23):
I think there are a couple. So one is for people who are carriers of one of these alterations, there are organizations out there that are specifically for you. So another resource, which I think can be very important for folks who know that they have an alteration in their normal DNA that has put them at risk for getting cancer is something called force. It's an advocacy group with a lot of resources and it's facing registry cancer, empowered or Force. If you look for that on the web, they've got a lot of information that could be useful from the standpoint of sort of precision oncology. I want to emphasize that the VA has actually become a leader in this area. I play some role in the VA. So this is a little self-serving, but the VA is actually one of the places where precision oncology is really being taken advantage of sequences as much more straightforward to get done.
FORCE - Facing Hereditary Cancer Empowered home page (facingourrisk.org)
Dr. Bruce Montgomery (51:23):
And there are quite a number of studies that are available through the VA. I think from the standpoint of, you know, for folks to be able to find the right information out there, the internet is a wonderful thing. In many regards. I think Dr. Pelman series here is probably one of the better sources. Be careful about what you find out there on the internet, because it isn't curated and the information can be inaccurate at best. So taking advantage of your provider to help you to navigate resources, particularly with regards to research and sequencing and any other resources that they may be available may be able to make available to you is important. You may have had another specific idea in mind beyond just going to a major medical center in terms of resources.
Dr. Richard Pelman (52:16):
Well, the internet, like you said, has opened up a host of opportunities and some people take advantage of people with what they're trying to sell. So again, I think using your provider to help you find legitimate pathways through the internet and, you know, the American Cancer Society, there are many of the NIH resources that you can find regarding your particular tumor. So in wrapping up, I'd like to always leave on a positive note while cancer is always scary. I can tell you personally that from where I started in medicine, beginning of a career to the end, it is a galactic difference. We have made huge strides
Dr. Bruce Montgomery (53:02):
Night and day, for sure, just in time. You and I have been in the field, you know, from 2004 to now, we went from having just hormone therapy to many, many different agents for prostate cancer and hundreds of agents for other malignancies, which are all improving outcomes for people. So more work is being done every day. I have a great deal of optimism just as you do that, now we're going to get to the ultimate situation where we're all out of business, which I wouldn't be too sorry about.
Dr. Richard Pelman (53:32):
Well, Dr. Montgomery, I thank you. This has been just a packed informational session. So Dr. Montgomery, again, thank you so much, enlightening us regarding the advances in precision oncology.
Dr. Bruce Montgomery (53:48):
Thanks for all you're doing to help folks to understand their risks, their health and their options. So thanks for all you're doing. It was my privilege.
Outro (53:58):
Episode Summary:
Some brain functions decline gradually and normally with advancing age in many people. In some cases, more severe cognitive disorders—Alzheimer’s and other conditions that cause dementia—can develop. Dr Bernick, an expert on the aging brain, discusses these conditions, and on a positive note, he highlights that mental and physical exercises can reduce risk factors for cognitive loss.
Guest:
Charles Bernick M.D., MPH. Clinical Professor, Department of Neurology, University of Washington, Seattle WA. Director of Clinical Trials, Memory and Brain Wellness Clinic, University of Washington.
During This Episode We Discuss:
- Defining, comparing, and contrasting normal aging of the brain, dementia, Alzheimer’s, Parkinson’s dementia, and Lewey Body dementia.
- Causes, risk factors, diagnosis, symptom progression, treatment, management, and the current controversy over a newly approved Alzheimer’s drug.
- How prevention critically applies to healthy brain function. The good news is that brain preventive health tactics are no doubt already familiar to you: good sleep (get treated for apnea!), adequate physical and mental activity, social engagement and connection, and a healthy diet.
Quotes (Tweetables):
“In terms of mental exercise, you do get better at what you practice, just as you do physically.”
Dr. Bernick
"If you don’t sleep well, your brain doesn’t do well."
Dr. Pelman
"Yeah, you know it turns out that what people say, that ‘What’s good for the heart is good for the brain’…. is probably true.”
Dr. Bernick
Recommended Resources:
- Luminosity. Website with lots of brain and cognitive exercises.
- Alzheimer’s Association
- Alzheimer’s Disease and Related Dementias, National Institutes of Health. Detailed educational information and resources
- Alzheimer Centers — check your nearest big city
- Seattle and Puget Sound Area: Memory and Brain Wellness Center, University of Washington. Available to anyone in the community.
Episode Transcript:
Coming soon!!
Episode Summary:
Skin is a major organ that serves as a barrier between oneself and the world. It’s amazingly good at its job but needs care. In this episode, learn how skin changes with age and the environment, and how to take care of it, from the teens to the aging years. Dermatologist Dr. Kendra Bergstrom covers many conditions, treatments and preventative strategies.
Guests:
Kendra G. Bergstrom, M.D. University of Washington Medical Center, Roosevelt Dermatology Clinic, Seattle WA.
During This Episode We Discuss:
-
Many specific conditions and their treatments: Acne, eczema, shingles, hives, sunburn, jock itch, rosacea, psoriasis, alopecia, male pattern baldness and hair loss, skin cancer, moles, warts and more.
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Prevention strategies: Different kinds of soaps for different situations; use of sunscreen and SPF clothing (clothes and hats have advantage of being chemical free); cover your ears; see a dermatologist by age 60 for a head-to-toe check; limit sun exposure the same way one limits daily wine consumption.
Quotes (Tweetables):
”…I think of sun kind of like that glass of wine with dinner, it’s ok to get a little bit every day but you don’t want to stack up all your glasses of wine on a Saturday…”
Kendra G. Bergstrom M.D.
“Skin cancer is the thing that keeps us dermatologists up at night..”
Kendra G. Bergstrom M.D.
Recommended Resources:
- Dermnet NZ: All About the Skin https://dermnetnz.org/
- Environmental Working Group on Sunscreens Guide, website aims to help consumers make good choices and avoid sun damage and cancer https://www.ewg.org/sunscreen/about/
- American Academy of Dermatology Association, to find a board certified dermatologist https://www.aad.org/public
- Insurance Lists, to find a dermatologist and conditions covered
Episode Transcript:
Coming soon!!
Episode Summary: In this episode learn how easy it is to develop a daily habit of a virtual, do anywhere, mood-elevating workout. After listening to the podcast, check out these videos from Certified Trainer Lauren Updyke. Episode Guest: Lauren Updyke, MS, American College of Sports Medicine Certified Trainer, Director of the University of Washington Whole U program. During This Episode We Discuss: * The benefits of exercise. Bone health, Cardiovascular health, improve blood pressure, stress reduction, improvement in mental health * Exercise is as essential as breathing * How to start and make it a habit * Different workouts with video links * Fitness, strength training, yoga * How to get motivated to exercise
Quotes (Tweetables): “To start I recommend 15 minutes, and so that 15 minutes is broken up into 5 minutes of cardiovascular, which would be marching in place, jogging in place, jumping jacks, squat jumps, jump rope, anything that gets your heart rate moving. The middle 5 minutes would be strength training, all you need is your body….large muscle groups, an example, pushups, single side - single leg squat, dips, last 5 minutes are for core exercises plank or a crunch. End with stretching. Stretching is key..”
“Variety is key, stay consistent, schedule your exercise.” Lauren Updyke
Recommended Resources: After listening to the podcast, check out these videos from Certified Trainer Lauren Updyke: * Yoga * Mini Fitness * Move More in 2021 * Nike app * Lauren Updyke of @U.W.WholeU
Episode Transcript: Coming soon!!