Speaker 1: Hello, this is the Itchy and Bitchy Podcast because being
itchy is bitchy and our medical system sucks. I'm doctor
Keith Nolica, a vetnary, allergist and dermatologist, and.
Speaker 2: I'm Stephen Miller, a doctor of nursing practice and a
que care nurse practitioner.
Speaker 1: Send us your questions at ask at itch not dot com.
We love you, but we're not your doctors. The information
we discuss is not direct medical advice. Please talk to
your provider who is the expert on your care. The
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us on Amazon. Don't forget to send us your questions
to ask at dot com. Welcome back. As always, we
hope that you are safe and well. How are you doing,
doctor Miller.
Speaker 2: I'm doing fantastic.
Speaker 1: So you are safe and well today, maybean excellent? Okay.
So I was perusing some information on the internet, which
I'm provene to do, and I found this situation that
I thought I would ask you about, because you are,
in fact a cardiologist is that right.
Speaker 2: I am a cardiology doctor of nursing practice.
Speaker 1: So day to day you do cardiology kind of.
Speaker 2: Stuff a lot for twenty six years.
Speaker 1: Lots of hearts lot. OK. So I found this situation
where this mom it'saw on the internet, you can look
it up. Her name is Amber, she was twenty six
years old, so seems like she's doing great. Everything's wonderful.
She gets pregnant, which is twenty six you know it's
about time you get pregnant, and she has a wonderful, happy,
healthy baby. Everything looks like it's going well. And then
within a few days and a few weeks she starts
feeling sickly and developing kind of these vague symptoms. So finally,
after a while, she ends up in the hospital and
gets worked up for both hypertension, cardiac issues, and liver disease,
and she ends up dying. So she had a baby
and then she died. So what is that? A thing?
Can that happen?
Speaker 2: It can happen. And as a matter of fact, one
of the issues with normal state of pregnancy is when
you have sort of symptoms like shortness of breath and
swollen feet and fatigue and dizzyness, A lot of these
symptoms are symptoms normal to pregnancy. However, there when those
symptoms are progressive and worse, then women can develop postpartum cardiomyopathy,
which is a type of heart failure that develops at
the last month of pregnancy, pregnancy, and within the first
five months after delivery. It is a condition where the
heart muscle weakens down and cannot pump efficiently to meet
the demands of the body and women who do not.
This can happen among women who have not had a
history of heart problems before. It is prevalent in about
one in two thousand pregnancies worldwide, and Black women are
more at risk than others, at about four times the
risk for developing compared to their white cohort so can
be devastating.
Speaker 1: So I'm a little bit of the contrarian conspiracy theorist
of this duet here, and so I just can't believe
that a twenty six year old woman would die nowadays
from this postpart condition. So why at age twenty six
was she not diagnosed sooner and had better therapy like
what happens? I know. One of the issues with like
black women is that the quality of care. Sometimes they
get is not always completely up to full standards. Is
that kind of part of what's going on that she
may have been ignored in this situation or what happened.
Speaker 2: Certainly, I think social determinants of health play into the
risk among African American women as well as proper prenatal care,
but also even among young women. I think sometimes they
expect to be shorter breath, or they expect to be swollen,
and maybe the follow ups. I don't know the details
of this case, but I think follow up is important
in getting proper evaluation to see if symptoms are out
of out of balance with normal pregnancy.
Speaker 1: So kind of a first time pregnancy don't really know
to expect maybe, and you might think that it's just
a normal fatigue or swelling that's going on, and so
either you ignore it or your providers may have ignored it.
Speaker 2: Yeah, and the cause is not fully understood. There are
several proposed mechanisms. One can be hormonal changes related to
pregnancy and breastfeeding that's tied back to prolactin and byproducts
of prolactin, and then you get damage to blood vessels
to the heart. And then there's also some thought that
there may be some genetic predisposition, but what we know
is that those who are at higher risk are women
who have had a history of hypertension or preclampsy during pregnancy,
women who have multiple births or twins, women over the
age of thirty, Black women, and then women with a
history of anemia, where women are having children past their
thirty and so I think it's certainly something to be
aware of.
Speaker 1: Yeah, one of a veterinarian. One of the big just
kind of obvious factors is that when you have a
pregnancy and you gain a significant amount of weight, and
part of that was the baby, part of its placenta,
part of its fluids, and that's it's normal. Part of
the pregnancy is that the demand on the heart actually
increases really substantially. So I kind of joke with my
kids that you know, it's a parasitic relationship, but it
really actually is. So the mother has to provide much
more cardiac output than if they weren't pregnant, and if
they have any kind of underlining stress or predisposing cardiac
or blood vessel disease, that can trigger potentially an event.
So a little bit more on the statistics. I did
look this up because it's just I couldn't believe the
story and what's going on. And so some of the
data that's out there that of maternal deaths, thirty percent
can be attributed to cardiac or hypertension type related disorders.
High pertension is about fifteen percent of those issues. A
cardiac issue like cardiomyopathy, where the heart muscle weakens, the
heart enlarges and can't produce enough blood flow out of
the heart, could be up to about four percent of
those deaths. And then it definitely is age related. So
this amber was twenty six years old, which is part
of the reason I just couldn't believe it. As a
twenty six year old, you know, young healthy woman who's
supposed to be in perfect age, you know child bearing age,
has this problem. But it turns out that seven percent
of twenty five year olds can be affected by this,
and then as you get older it gets worse. So
at age thirty average, it could be up to ten
percent of pregnant mothers. Around age thirty seven thirty eight,
it could be up to seventeen percent. If you're forty,
it could be up to twenty five percent of pregnancies.
And if you're over forty five, which you mentioned, more
and more women having children older and older. It can
be over thirty percent of pregnancies can have cardiac or
hypertension related issues. That just seems really crazy high to me.
Speaker 2: If you look at the curves, you can see that,
you know, the chances of getting pregnant, the chances of
staying pregnant.
Speaker 1: Decline a bit.
Speaker 2: Into the thirties and forties, and so I think just
being aware and getting good obstetric and pediatric care during
pregnancy and postpartum time frame is really really important.
Speaker 1: So what would be some treatments for this? So we're
not obviously here, we're not your doctors. We love you,
but talk to your own provider. But if a woman
like this Amber, twenty six year old was diagnosed and
caught early, what would be some therapies and would those
treatments potentially affect the baby?
Speaker 2: Yeah, so treatments are pretty much heart figure guidelined driven,
So medications that help the heart pump more efficiently, like
beta blocker therapy, salt and fluid restriction. Of course, close
monitoring a milcrdial function with an echo cardiogram, and then
in severe cases, some women have had to have heart
pump devices to improve functioning of the milcardium.
Speaker 1: So that would continue to provide blood flow to the mother,
but then also the infant, the preborn.
Speaker 2: One of the challenges of it is that some of
the heart failure medications are not safe during pregnancy and breastfeeding,
and so that's why it's really important that your care
team or your providers choose medications that are safe for
your situation.
Speaker 1: So it can get really complex very quickly. Yeah, okay,
so what happens to the babies in these situations to
you have an idea of.
Speaker 2: Yeah, so the biggest risk if it's during pregnancy, would
be premature birth, and then low birth weight or low
for gestational age type of situation, or even rare but
still birth. So these are very big complications. Hypertension, you know,
in any state is lethal and so we have to
be proactive early on in life to get treatment for hypertension.
Speaker 1: So it turns out with Amber, her baby actually did fine,
so it was born did well. Unfortunately Amber did not,
and that's a very sad situation. But the statistics are
that about ten percent of these babies are born prematurely,
but they can go on to live happy, healthy, normal lives.
And so it's really the mother that's at risk, especially
if they're not followed and diagnosed and caught and treated early.
Speaker 2: Yes, So the risk to the mother would be things
like heart failure requiring hospitalization or congestive heart failure, and
then blood clots dBTP in severe cases of course, the
pump failure requiring heart transplant or alvat, and then of
course very rare cases which result in death.
Speaker 1: Yeah, and then I would imagine too that if it's
a much more severe case, they might take the baby
early premature and put the baby in the NIC unit
as long as it's at the age of viability. And
then that now removes the limitations of what kind of
medications and therapies the mother can go through because the
baby's an independent individual getting its own care in a
separate unit. Okay, what happens to the mothers after they
deliver the baby and what's their recovery? Are they doomed
forever or do they do well with treatment? What happens well?
Speaker 2: I think the good news is that many mothers do
cover About fifty percent of women to recover normal heart
function within about six months and up to seventy two
percent recover within five years, and recovery is most likely
in women whose heart function was only mildly reduced. So
you can get a situation where you get the strength
of the heart that decreases into the mid forties or
low forties, which is a mildly reduced ejection fraction or
a percent of blood pumped out by the heart. But
if you get a severe reduction in lecentrical function down
to twenty percent, those people, those women you know, may
take a longer time span to recover.
Speaker 1: Okay, So let's translate laid that into English a little bit.
So forty So he's talking about cardiac injection fraction, how
much blood the heart pumps out with each pump, and
what is.
Speaker 2: Normal Normal is fifty five to seventy percent.
Speaker 1: Okay, So then they can go down to forty, which
is mild tho.
Speaker 2: Normal would be fifty to fifty five, and then mid
range would be forty to forty nine.
Speaker 1: So that's not critical, not quickly, but that if they
drop down to twenty percent normally fifty, that's pretty dramatic.
So okay, So that's the amount of blood that the
heart pumps out with each pump. They have a number
called the ejection fraction, so that's what that number is,
so so good news. So generally they can go on
and recover and do well with therapy and then do
they need monitoring for the rest of their life.
Speaker 2: Yeah, so it is important to follow with a cardiologist
after pregnancy and even during recovery, and then really for
postponum cardiom op with. The best care team for these
women is their obstetrician, they're cardiologists, and then other providers
as needed.
Speaker 1: And then what about the second pregnancy, So if this
was their first pregnancy and then they want to go
on and have another baby, what's the risk factor associated
with that?
Speaker 2: Yeah, it can happen again, and it's up to one
in five make experience a reoccurrence.
Speaker 1: So twenty percent. So we were like at four or
five percent before, I think maybe seven percent. And then
now with the second pregnancy, if you had problems with
the first one, you've almost doubled or even tripled your risk.
Speaker 2: And clearly if heart messile has not recovered after the
first pregnancy, then of course your risk is even higher.
Speaker 1: So all right, anything else to add, doc.
Speaker 2: I think, just talk to your cardiologist to end your
obstetrician and be a strong advocate for your care for
you and your child.
Speaker 1: All right, we're going to take a quick break, and
when we come back, we're going to have our very
short legit or bullshit section where I challenge doctor Miller
with some interesting fun trends in facts and he tries
to tell me if they're legit or if they're bullshit.
Welcome back. I hope you're well and safe after that
short break or how are you feeling, Doc Miller? Great,
you're well and safe. Yes, that was a very short break,
so hopefully nothing bad happened. Okay, so this is our
legit or bullshit. So I get these ideas from various places. Friends,
We're having cocktails with friends the other night and they
say something or I hear something. I try not to
be on tiktook or social media Facebook, those things, but
sometimes I am, and then I do. Actually have a
lot of clients that come into my veterinary clinic and
will ask me these questions or about these trends, even
though most of these trends are human based. For some reason,
they trust me or I have no idea why they're
asking me. But anyway, Okay, So the first trend, are
you ready to doc? Yeah, okay, so you're going to
tell me if this is a legit or a bullshit
kind of thing. Okay, here we go. So cortisol face.
So this is a trend that's happening that all of
these typically young people gen Z kids usually post pubescent,
so age fifteen to about twenty five, think that they
have cortisol face, which basically means that their face is
getting kind of more roundish and puffy and swollen and
cortisol face. So people with cushions disease have too much
cortisol in their system, and they actually do have a
lot of symptoms like weight gain, they get a pot
bellied appearance, they have muscle redistribution, and they do get
a very round moon face. But so these are twenty
year olds that think that they're the shape change of
their faces from cortisol and they're calling it cortisol face.
So is this a legit kind of thing or is
this a bullshit kind of thing? Doc?
Speaker 2: Well, it's sort of bullshit because the normal day to
day stress rarely causes dramatic facial changes, and puffiness clearly
is more common among people who have high in salt
salt intake ers who don't sleep well or are related
to hydration or hormone used or allergies.
Speaker 1: I mean too much strength the night before and having
a hangover.
Speaker 2: Yeah, so true cortisol related changes happen with significant long
term hormonal imbalance, and that's where you get some issues
with Cushing syndrome.
Speaker 1: But this is and how old are Cushing's patients typically, Well.
Speaker 2: It would be more thirties, forties, fifties, Yeah, they're old teenagers.
Speaker 1: Or the puffiness is much more likely to be post
pubescent facial changes that are happening because your hormones have changed,
or you had a rough night the night before, or
you've had too many dorito's, those kinds of things. The
other really risky thing with this is that the opposite
of Cushings or having too much cortisol is a disease
called Addison's disease. This is what President Kennedy had, and
that is actually a life threatening condition. So if you
start taking random therapies or over the counter or thinking
doctor TikTok's the answer, and you're trying to reduce your
cortisol and you end up with Addison's symptoms and disorder.
You can actually die from that. So this is, you know,
the hormone system in the body is designed to be
really intricate, very closely balanced. Cortisol face. Cushing syndrome is
a thing, moon face. But if you're you know, a
sixty year old patient with Cushing's disease, then go talk
to your provider about that. If you're a twenty two
year old kid that just drank four shots at tequila
the night before and ate a bag of Dorito's, you
don't got cortisol face.
Speaker 2: I think long term hormonal imbalance is the key, and
not just a stressful week.
Speaker 1: All right, So legit or bullshit. So probably legit if
you're a sixty year old Cushing's patient, but total bullshit
if you're a twenty two year old college kid drinking
alcohol the night before. Yeah, okay, I agree with that one. Okay.
The next one of my favorite little things that we
deal with because I'm a veterinarian, are parasite cleanses. So
this has been all the rage for about two years now,
where Americans specifically think that they have parasites. Notice how
I said, think you can see where I'm headed with
this they think that they have parasites and they need
to do a parasite cleanse to get rid of their parasites.
So is this legit, Doc Miller, or is this bullshit?
Speaker 2: Well, I mean I think it is bullshit, especially for
people residing in the United States, where the risk we're
having a parasite is very very low.
Speaker 1: Yeah, So in dogs, we deal with round worms, hookworms,
might all sorts of things. Dogs really should be on
a monthly preventative dewormer, but they go in the park
and they eat pooh, and they eat squirrel and rabbit
turds and all sorts of crazy things where parasite exposure
is very very high. Definitely, if you've been hiking, or
you've been visiting third world countries where hygiene and you
know you're in the jungles of Peru, than parasites are
a thing. But if you've pretty much been in the
United States, especially in suburbia, the likelihood that you have
parasites is extremely, extremely low. If you look up the
symptoms for having parasites, you get things like gi upset
and fatigue and anxiety and pretty much just the realm
of being a normal an itching partis an i which
is actually much more likely to be food allergy or
pen worms, which is a thing but you can actually
see those, and lice is a thing. So those are
two common parasites, but we're talking about people that think
that they have gi parasites like roundworms or lungworms or
those things. The other really big problem with this, save
and aian I am very very aware of, is that
the treatments that you might take to cleanse yourself of
parasites actually have a lot of side effects. All of
these deworm or anti parasitics are designed to kill parasites
through the nervous systems, so they work through GABA channels
and various other kind of mechanisms, and especially the older
class of these molecules can be very toxic to humans.
And I know it's very controversial, but taking ivermectin is
one of the most common parasitic treatments in animals cows, horses, dogs,
works really really great, but at very high doses there's
actually up to a thirty percent of neurologic symptoms like
cortical blindness, where your eyeballs still work, your retina's work,
but your brain doesn't receive the signals, so you are
basically blind, you bump into walls, you can develop muscle
trimmer seizures, all sorts of really kind of scary things.
So if you think you have a parasite, go to
your provider. They now have DNA testing that they can
do on various stool samples, urine samples, fluid samples, mucus samples.
DNA testing is close to ninety nine percent sensitive and specific,
which means it's very very accurate. You definitely want to
be doing a test and not thinking doctor TikTok's home
remedy is the best way to go.
Speaker 2: Yeah, I've seen an increase in people who are doing
this lately, and you know, certainly the treatments can cause
dehydration and electrolyte imbalances and liver issues, and even people
after treatment will look at their stool and they'll say, well,
I actually saw something that looked like a worm, which
actually is most likely probably mucus or food fibers that
they're seeing. And so I would just say that people
should be very cautious and seek the care of their
internist and to get evaluated properly before just going out
to the local horse and feed store and buying some
ivermactin and.
Speaker 1: DNA testing now is amazingly accurate. So really you can
be tested and know very quickly with very high accuracy
if you're positive or negative. Okay, last one, doc, Are
you ready?
Speaker 2: Yeah?
Speaker 1: Okay, So we inherited this podcast from Karen. She's amazing
Karen Nickel, and one of the things she does that
I really learned a lot from her is instead of
just sort of doing disease management, which is the way
medicine was done for hundreds of years, now we're in
a situation where we sort of want optimal management. And
so one of the trends that is along these lines
that may be a little bit misguided is constant blood
glucose monitoring in normal, healthy individuals. And the concept here
is that if you monitor your blood glucose with one
of these devices that you stick on your arm and
it has little needles that go into the skin, then
pretty much on your phone, hour by hour, you know
exactly what your glucose level is, and that's going to
make you be optimal metabolically and you'll live a much longer,
healthier lifespan. Yeah.
Speaker 2: So we're in the time where we have the availability
to do continuous glucose and really continuous glucose monitoring is
indicated for patients with diabetes. And so the issue is, well,
why are people tracking their glucose levels? And there is
a heightened awareness why are healthy people track healthy people? Yeah,
and so they're tracking post prandiole or post meal glucose spikes.
They want to see how foods are affecting their bodies,
and so they want to if they're eating high carbohydrate foods,
they want to see how that affects their legit or bullshit? Well,
I think it's a little bit of both. I think
it's legit. In then it gives us the ability to
be able to track our bodies, especially if we're trying
to maintain certain weights or if we're training athletes.
Speaker 1: Why is it bullshit? Then?
Speaker 2: Well, because there is number one. To be able to
get access to x common freestyle, you've got to be
able to afford it, and certainly insurance will not cover
it unless you have a diagnosis of diabetes or covered
diagnosis for monitoring blood sugar. But then also it's not
what are you doing to treat that's driven by your primary,
by your by your provider. And so but where But
where you can.
Speaker 1: Get into trouble with this though, is that if anytime
you eat a pizza or doritos or a cotton candy,
the body normally is going to have a spike. And
so if you obsess about the results and you try
to micromanage every minute your glucose level, you can actually
end up in trouble with therapy rather than having an
optimal or a healthy metabolic state. So, uh, you can,
you can over monitor, and you can get into trouble
with it too.
Speaker 2: Yeah. So if you, if you are a normal, healthy individual,
your body inherently regulates blood glucose. Glucose spikes are not
inherently harmful. They certainly help us physiologically when our bodies
are stressed or when they're demanding. And then the issue
as well, is the data actionable? Is there anything you're
going to do about it?
Speaker 1: I think is that it's mainly bullshit, but mainly a
little bit legit. That's what I think.
Speaker 2: So I think there are some places where it makes sense,
like if people have pre diabetes, but I would disagree
with you. I think it's about fifty to fifty. Okay,
thank you for joining us. This is the Itchy and
Itchy Podcast. Don't forget to send us your questions to
ask at itchnock dot com.