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Speaker 1: Hello, this is the Itchy and Bitchy Podcast because being

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itchy is bitchy and our medical system sucks. I'm doctor

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Keith Nolica, a vetnary, allergist and dermatologist, and.

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Speaker 2: I'm Stephen Miller, a doctor of nursing practice and a

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que care nurse practitioner.

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Speaker 1: Send us your questions at ask at itch not dot com.

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We love you, but we're not your doctors. The information

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we discuss is not direct medical advice. Please talk to

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your provider who is the expert on your care. The

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Itchy and BITCHI podcast is sponsored by doc Itchy Medical

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Pets supplements designed to optimize your pet's health with the

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latest veterinary medical research. Visit docchi dot com or find

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us on Amazon. Don't forget to send us your questions

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to ask at dot com. Welcome back. As always, we

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hope that you are safe and well. How are you doing,

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doctor Miller.

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Speaker 2: I'm doing fantastic.

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Speaker 1: So you are safe and well today, maybean excellent? Okay.

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So I was perusing some information on the internet, which

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I'm provene to do, and I found this situation that

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I thought I would ask you about, because you are,

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in fact a cardiologist is that right.

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Speaker 2: I am a cardiology doctor of nursing practice.

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Speaker 1: So day to day you do cardiology kind of.

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Speaker 2: Stuff a lot for twenty six years.

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Speaker 1: Lots of hearts lot. OK. So I found this situation

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where this mom it'saw on the internet, you can look

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it up. Her name is Amber, she was twenty six

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years old, so seems like she's doing great. Everything's wonderful.

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She gets pregnant, which is twenty six you know it's

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about time you get pregnant, and she has a wonderful, happy,

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healthy baby. Everything looks like it's going well. And then

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within a few days and a few weeks she starts

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feeling sickly and developing kind of these vague symptoms. So finally,

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after a while, she ends up in the hospital and

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gets worked up for both hypertension, cardiac issues, and liver disease,

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and she ends up dying. So she had a baby

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and then she died. So what is that? A thing?

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Can that happen?

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Speaker 2: It can happen. And as a matter of fact, one

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of the issues with normal state of pregnancy is when

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you have sort of symptoms like shortness of breath and

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swollen feet and fatigue and dizzyness, A lot of these

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symptoms are symptoms normal to pregnancy. However, there when those

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symptoms are progressive and worse, then women can develop postpartum cardiomyopathy,

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which is a type of heart failure that develops at

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the last month of pregnancy, pregnancy, and within the first

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five months after delivery. It is a condition where the

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heart muscle weakens down and cannot pump efficiently to meet

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the demands of the body and women who do not.

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This can happen among women who have not had a

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history of heart problems before. It is prevalent in about

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one in two thousand pregnancies worldwide, and Black women are

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more at risk than others, at about four times the

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risk for developing compared to their white cohort so can

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be devastating.

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Speaker 1: So I'm a little bit of the contrarian conspiracy theorist

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of this duet here, and so I just can't believe

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that a twenty six year old woman would die nowadays

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from this postpart condition. So why at age twenty six

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was she not diagnosed sooner and had better therapy like

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what happens? I know. One of the issues with like

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black women is that the quality of care. Sometimes they

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get is not always completely up to full standards. Is

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that kind of part of what's going on that she

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may have been ignored in this situation or what happened.

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Speaker 2: Certainly, I think social determinants of health play into the

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risk among African American women as well as proper prenatal care,

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but also even among young women. I think sometimes they

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expect to be shorter breath, or they expect to be swollen,

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and maybe the follow ups. I don't know the details

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of this case, but I think follow up is important

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in getting proper evaluation to see if symptoms are out

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of out of balance with normal pregnancy.

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Speaker 1: So kind of a first time pregnancy don't really know

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to expect maybe, and you might think that it's just

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a normal fatigue or swelling that's going on, and so

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either you ignore it or your providers may have ignored it.

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Speaker 2: Yeah, and the cause is not fully understood. There are

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several proposed mechanisms. One can be hormonal changes related to

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pregnancy and breastfeeding that's tied back to prolactin and byproducts

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of prolactin, and then you get damage to blood vessels

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to the heart. And then there's also some thought that

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there may be some genetic predisposition, but what we know

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is that those who are at higher risk are women

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who have had a history of hypertension or preclampsy during pregnancy,

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women who have multiple births or twins, women over the

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age of thirty, Black women, and then women with a

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history of anemia, where women are having children past their

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thirty and so I think it's certainly something to be

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aware of.

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Speaker 1: Yeah, one of a veterinarian. One of the big just

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kind of obvious factors is that when you have a

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pregnancy and you gain a significant amount of weight, and

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part of that was the baby, part of its placenta,

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part of its fluids, and that's it's normal. Part of

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the pregnancy is that the demand on the heart actually

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increases really substantially. So I kind of joke with my

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kids that you know, it's a parasitic relationship, but it

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really actually is. So the mother has to provide much

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more cardiac output than if they weren't pregnant, and if

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they have any kind of underlining stress or predisposing cardiac

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or blood vessel disease, that can trigger potentially an event.

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So a little bit more on the statistics. I did

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look this up because it's just I couldn't believe the

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story and what's going on. And so some of the

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data that's out there that of maternal deaths, thirty percent

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can be attributed to cardiac or hypertension type related disorders.

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High pertension is about fifteen percent of those issues. A

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cardiac issue like cardiomyopathy, where the heart muscle weakens, the

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heart enlarges and can't produce enough blood flow out of

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the heart, could be up to about four percent of

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those deaths. And then it definitely is age related. So

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this amber was twenty six years old, which is part

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of the reason I just couldn't believe it. As a

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twenty six year old, you know, young healthy woman who's

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supposed to be in perfect age, you know child bearing age,

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has this problem. But it turns out that seven percent

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of twenty five year olds can be affected by this,

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and then as you get older it gets worse. So

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at age thirty average, it could be up to ten

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percent of pregnant mothers. Around age thirty seven thirty eight,

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it could be up to seventeen percent. If you're forty,

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it could be up to twenty five percent of pregnancies.

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And if you're over forty five, which you mentioned, more

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and more women having children older and older. It can

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be over thirty percent of pregnancies can have cardiac or

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hypertension related issues. That just seems really crazy high to me.

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Speaker 2: If you look at the curves, you can see that,

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you know, the chances of getting pregnant, the chances of

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staying pregnant.

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Speaker 1: Decline a bit.

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Speaker 2: Into the thirties and forties, and so I think just

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being aware and getting good obstetric and pediatric care during

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pregnancy and postpartum time frame is really really important.

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Speaker 1: So what would be some treatments for this? So we're

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not obviously here, we're not your doctors. We love you,

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but talk to your own provider. But if a woman

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like this Amber, twenty six year old was diagnosed and

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caught early, what would be some therapies and would those

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treatments potentially affect the baby?

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Speaker 2: Yeah, so treatments are pretty much heart figure guidelined driven,

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So medications that help the heart pump more efficiently, like

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beta blocker therapy, salt and fluid restriction. Of course, close

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monitoring a milcrdial function with an echo cardiogram, and then

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in severe cases, some women have had to have heart

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pump devices to improve functioning of the milcardium.

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Speaker 1: So that would continue to provide blood flow to the mother,

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but then also the infant, the preborn.

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Speaker 2: One of the challenges of it is that some of

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the heart failure medications are not safe during pregnancy and breastfeeding,

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and so that's why it's really important that your care

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team or your providers choose medications that are safe for

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your situation.

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Speaker 1: So it can get really complex very quickly. Yeah, okay,

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so what happens to the babies in these situations to

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you have an idea of.

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Speaker 2: Yeah, so the biggest risk if it's during pregnancy, would

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be premature birth, and then low birth weight or low

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for gestational age type of situation, or even rare but

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still birth. So these are very big complications. Hypertension, you know,

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in any state is lethal and so we have to

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be proactive early on in life to get treatment for hypertension.

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Speaker 1: So it turns out with Amber, her baby actually did fine,

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so it was born did well. Unfortunately Amber did not,

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and that's a very sad situation. But the statistics are

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that about ten percent of these babies are born prematurely,

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but they can go on to live happy, healthy, normal lives.

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And so it's really the mother that's at risk, especially

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if they're not followed and diagnosed and caught and treated early.

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Speaker 2: Yes, So the risk to the mother would be things

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like heart failure requiring hospitalization or congestive heart failure, and

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then blood clots dBTP in severe cases of course, the

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pump failure requiring heart transplant or alvat, and then of

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course very rare cases which result in death.

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Speaker 1: Yeah, and then I would imagine too that if it's

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a much more severe case, they might take the baby

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early premature and put the baby in the NIC unit

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as long as it's at the age of viability. And

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then that now removes the limitations of what kind of

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medications and therapies the mother can go through because the

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baby's an independent individual getting its own care in a

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separate unit. Okay, what happens to the mothers after they

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deliver the baby and what's their recovery? Are they doomed

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forever or do they do well with treatment? What happens well?

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Speaker 2: I think the good news is that many mothers do

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cover About fifty percent of women to recover normal heart

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function within about six months and up to seventy two

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percent recover within five years, and recovery is most likely

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in women whose heart function was only mildly reduced. So

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you can get a situation where you get the strength

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of the heart that decreases into the mid forties or

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low forties, which is a mildly reduced ejection fraction or

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a percent of blood pumped out by the heart. But

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if you get a severe reduction in lecentrical function down

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to twenty percent, those people, those women you know, may

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take a longer time span to recover.

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Speaker 1: Okay, So let's translate laid that into English a little bit.

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So forty So he's talking about cardiac injection fraction, how

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much blood the heart pumps out with each pump, and

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what is.

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Speaker 2: Normal Normal is fifty five to seventy percent.

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Speaker 1: Okay, So then they can go down to forty, which

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is mild tho.

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Speaker 2: Normal would be fifty to fifty five, and then mid

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range would be forty to forty nine.

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Speaker 1: So that's not critical, not quickly, but that if they

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drop down to twenty percent normally fifty, that's pretty dramatic.

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So okay, So that's the amount of blood that the

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heart pumps out with each pump. They have a number

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called the ejection fraction, so that's what that number is,

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so so good news. So generally they can go on

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and recover and do well with therapy and then do

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they need monitoring for the rest of their life.

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Speaker 2: Yeah, so it is important to follow with a cardiologist

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after pregnancy and even during recovery, and then really for

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postponum cardiom op with. The best care team for these

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women is their obstetrician, they're cardiologists, and then other providers

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as needed.

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Speaker 1: And then what about the second pregnancy, So if this

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was their first pregnancy and then they want to go

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on and have another baby, what's the risk factor associated

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with that?

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Speaker 2: Yeah, it can happen again, and it's up to one

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in five make experience a reoccurrence.

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Speaker 1: So twenty percent. So we were like at four or

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five percent before, I think maybe seven percent. And then

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now with the second pregnancy, if you had problems with

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the first one, you've almost doubled or even tripled your risk.

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Speaker 2: And clearly if heart messile has not recovered after the

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first pregnancy, then of course your risk is even higher.

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Speaker 1: So all right, anything else to add, doc.

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Speaker 2: I think, just talk to your cardiologist to end your

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obstetrician and be a strong advocate for your care for

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you and your child.

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Speaker 1: All right, we're going to take a quick break, and

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when we come back, we're going to have our very

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short legit or bullshit section where I challenge doctor Miller

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with some interesting fun trends in facts and he tries

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to tell me if they're legit or if they're bullshit.

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Welcome back. I hope you're well and safe after that

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short break or how are you feeling, Doc Miller? Great,

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you're well and safe. Yes, that was a very short break,

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so hopefully nothing bad happened. Okay, so this is our

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legit or bullshit. So I get these ideas from various places. Friends,

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We're having cocktails with friends the other night and they

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say something or I hear something. I try not to

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be on tiktook or social media Facebook, those things, but

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sometimes I am, and then I do. Actually have a

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lot of clients that come into my veterinary clinic and

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will ask me these questions or about these trends, even

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though most of these trends are human based. For some reason,

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they trust me or I have no idea why they're

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asking me. But anyway, Okay, So the first trend, are

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you ready to doc? Yeah, okay, so you're going to

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tell me if this is a legit or a bullshit

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kind of thing. Okay, here we go. So cortisol face.

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So this is a trend that's happening that all of

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these typically young people gen Z kids usually post pubescent,

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so age fifteen to about twenty five, think that they

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have cortisol face, which basically means that their face is

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getting kind of more roundish and puffy and swollen and

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cortisol face. So people with cushions disease have too much

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cortisol in their system, and they actually do have a

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lot of symptoms like weight gain, they get a pot

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bellied appearance, they have muscle redistribution, and they do get

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a very round moon face. But so these are twenty

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year olds that think that they're the shape change of

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their faces from cortisol and they're calling it cortisol face.

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So is this a legit kind of thing or is

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this a bullshit kind of thing? Doc?

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Speaker 2: Well, it's sort of bullshit because the normal day to

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day stress rarely causes dramatic facial changes, and puffiness clearly

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is more common among people who have high in salt

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salt intake ers who don't sleep well or are related

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to hydration or hormone used or allergies.

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Speaker 1: I mean too much strength the night before and having

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a hangover.

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Speaker 2: Yeah, so true cortisol related changes happen with significant long

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term hormonal imbalance, and that's where you get some issues

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with Cushing syndrome.

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Speaker 1: But this is and how old are Cushing's patients typically, Well.

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Speaker 2: It would be more thirties, forties, fifties, Yeah, they're old teenagers.

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Speaker 1: Or the puffiness is much more likely to be post

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pubescent facial changes that are happening because your hormones have changed,

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or you had a rough night the night before, or

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you've had too many dorito's, those kinds of things. The

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other really risky thing with this is that the opposite

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of Cushings or having too much cortisol is a disease

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called Addison's disease. This is what President Kennedy had, and

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that is actually a life threatening condition. So if you

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start taking random therapies or over the counter or thinking

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doctor TikTok's the answer, and you're trying to reduce your

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cortisol and you end up with Addison's symptoms and disorder.

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You can actually die from that. So this is, you know,

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the hormone system in the body is designed to be

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really intricate, very closely balanced. Cortisol face. Cushing syndrome is

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a thing, moon face. But if you're you know, a

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sixty year old patient with Cushing's disease, then go talk

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to your provider about that. If you're a twenty two

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year old kid that just drank four shots at tequila

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the night before and ate a bag of Dorito's, you

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don't got cortisol face.

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Speaker 2: I think long term hormonal imbalance is the key, and

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not just a stressful week.

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Speaker 1: All right, So legit or bullshit. So probably legit if

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you're a sixty year old Cushing's patient, but total bullshit

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if you're a twenty two year old college kid drinking

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alcohol the night before. Yeah, okay, I agree with that one. Okay.

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The next one of my favorite little things that we

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deal with because I'm a veterinarian, are parasite cleanses. So

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this has been all the rage for about two years now,

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where Americans specifically think that they have parasites. Notice how

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I said, think you can see where I'm headed with

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this they think that they have parasites and they need

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to do a parasite cleanse to get rid of their parasites.

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So is this legit, Doc Miller, or is this bullshit?

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Speaker 2: Well, I mean I think it is bullshit, especially for

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people residing in the United States, where the risk we're

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having a parasite is very very low.

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Speaker 1: Yeah, So in dogs, we deal with round worms, hookworms,

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might all sorts of things. Dogs really should be on

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a monthly preventative dewormer, but they go in the park

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and they eat pooh, and they eat squirrel and rabbit

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turds and all sorts of crazy things where parasite exposure

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is very very high. Definitely, if you've been hiking, or

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you've been visiting third world countries where hygiene and you

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know you're in the jungles of Peru, than parasites are

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a thing. But if you've pretty much been in the

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United States, especially in suburbia, the likelihood that you have

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parasites is extremely, extremely low. If you look up the

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symptoms for having parasites, you get things like gi upset

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and fatigue and anxiety and pretty much just the realm

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of being a normal an itching partis an i which

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is actually much more likely to be food allergy or

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pen worms, which is a thing but you can actually

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see those, and lice is a thing. So those are

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two common parasites, but we're talking about people that think

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that they have gi parasites like roundworms or lungworms or

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those things. The other really big problem with this, save

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and aian I am very very aware of, is that

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the treatments that you might take to cleanse yourself of

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parasites actually have a lot of side effects. All of

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these deworm or anti parasitics are designed to kill parasites

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through the nervous systems, so they work through GABA channels

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and various other kind of mechanisms, and especially the older

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class of these molecules can be very toxic to humans.

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And I know it's very controversial, but taking ivermectin is

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one of the most common parasitic treatments in animals cows, horses, dogs,

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works really really great, but at very high doses there's

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actually up to a thirty percent of neurologic symptoms like

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cortical blindness, where your eyeballs still work, your retina's work,

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but your brain doesn't receive the signals, so you are

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basically blind, you bump into walls, you can develop muscle

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trimmer seizures, all sorts of really kind of scary things.

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So if you think you have a parasite, go to

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your provider. They now have DNA testing that they can

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do on various stool samples, urine samples, fluid samples, mucus samples.

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DNA testing is close to ninety nine percent sensitive and specific,

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which means it's very very accurate. You definitely want to

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be doing a test and not thinking doctor TikTok's home

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remedy is the best way to go.

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Speaker 2: Yeah, I've seen an increase in people who are doing

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this lately, and you know, certainly the treatments can cause

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dehydration and electrolyte imbalances and liver issues, and even people

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after treatment will look at their stool and they'll say, well,

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I actually saw something that looked like a worm, which

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actually is most likely probably mucus or food fibers that

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they're seeing. And so I would just say that people

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should be very cautious and seek the care of their

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internist and to get evaluated properly before just going out

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to the local horse and feed store and buying some

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ivermactin and.

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Speaker 1: DNA testing now is amazingly accurate. So really you can

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be tested and know very quickly with very high accuracy

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if you're positive or negative. Okay, last one, doc, Are

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you ready?

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Speaker 2: Yeah?

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Speaker 1: Okay, So we inherited this podcast from Karen. She's amazing

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Karen Nickel, and one of the things she does that

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I really learned a lot from her is instead of

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just sort of doing disease management, which is the way

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medicine was done for hundreds of years, now we're in

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a situation where we sort of want optimal management. And

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so one of the trends that is along these lines

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that may be a little bit misguided is constant blood

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glucose monitoring in normal, healthy individuals. And the concept here

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is that if you monitor your blood glucose with one

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of these devices that you stick on your arm and

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it has little needles that go into the skin, then

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pretty much on your phone, hour by hour, you know

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exactly what your glucose level is, and that's going to

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make you be optimal metabolically and you'll live a much longer,

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healthier lifespan. Yeah.

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Speaker 2: So we're in the time where we have the availability

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to do continuous glucose and really continuous glucose monitoring is

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indicated for patients with diabetes. And so the issue is, well,

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why are people tracking their glucose levels? And there is

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a heightened awareness why are healthy people track healthy people? Yeah,

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and so they're tracking post prandiole or post meal glucose spikes.

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They want to see how foods are affecting their bodies,

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and so they want to if they're eating high carbohydrate foods,

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they want to see how that affects their legit or bullshit? Well,

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I think it's a little bit of both. I think

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it's legit. In then it gives us the ability to

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be able to track our bodies, especially if we're trying

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to maintain certain weights or if we're training athletes.

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Speaker 1: Why is it bullshit? Then?

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Speaker 2: Well, because there is number one. To be able to

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get access to x common freestyle, you've got to be

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able to afford it, and certainly insurance will not cover

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it unless you have a diagnosis of diabetes or covered

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diagnosis for monitoring blood sugar. But then also it's not

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what are you doing to treat that's driven by your primary,

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by your by your provider. And so but where But

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where you can.

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Speaker 1: Get into trouble with this though, is that if anytime

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you eat a pizza or doritos or a cotton candy,

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the body normally is going to have a spike. And

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so if you obsess about the results and you try

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to micromanage every minute your glucose level, you can actually

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end up in trouble with therapy rather than having an

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optimal or a healthy metabolic state. So, uh, you can,

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you can over monitor, and you can get into trouble

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with it too.

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Speaker 2: Yeah. So if you, if you are a normal, healthy individual,

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your body inherently regulates blood glucose. Glucose spikes are not

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inherently harmful. They certainly help us physiologically when our bodies

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are stressed or when they're demanding. And then the issue

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as well, is the data actionable? Is there anything you're

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going to do about it?

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Speaker 1: I think is that it's mainly bullshit, but mainly a

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little bit legit. That's what I think.

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Speaker 2: So I think there are some places where it makes sense,

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like if people have pre diabetes, but I would disagree

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with you. I think it's about fifty to fifty. Okay,

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thank you for joining us. This is the Itchy and

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Itchy Podcast. Don't forget to send us your questions to

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ask at itchnock dot com.