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Medscape
22-05-2025
- Health
- Medscape
Episode 2: HS, Microbiomes, and Whole-Body Healing
This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider. Ginette A. Okoye, MD: Hello. I am Dr Ginette Okoye. Welcome to the Medscape InDiscussion podcast series on hidradenitis suppurativa (HS). Today we'll discuss the gut and skin microbiome and how they relate to HS with our guest, Dr Tamia Harris-Tryon. Dr Harris-Tryon is an associate professor in the departments of dermatology and immunology at UT Southwestern Medical Center in Dallas, Texas. Her research focuses on how the immune system, the microbiome, and the skin barrier all work together or sometimes against each other in chronic skin conditions such as HS. Thank you for joining us today, Dr Harris-Tryon, and welcome to the Medscape InDiscussion podcast. Tamia Harris-Tryon, MD, PhD: Thanks so much, Ginette. Okoye: I have been excited for this conversation today because certainly there's increasing interest in the role of the gut and skin microbiome and skin diseases, and this interest isn't just among healthcare professionals — it's among our patients, too. Our patients are taking probiotics, especially those who are more interested in holistic care and those who are on antibiotics. I would love for us to try to empower dermatologists and other healthcare providers to understand the science here so we can help our patients make informed decisions about this aspect of their care. Thank you for being willing to guide us through that conversation. Why don't we start by you telling us your connection to HS? Harris-Tryon: My connection to HS pre-dates my connection to the microbiome. I trained at Hopkins in dermatology. Dr Okoye was my attending, and we saw a lot of patients with HS in the practice there. I think what struck me is how much suffering there was and how little knowledge there was concerning what was causing all these festering wounds in the armpit. We were putting people on biologics, but only one third of people were responding to them. These are some of the best medicines we have. Some people would respond, but even then, I would call the response partial. People weren't going back to their normal lives and a normal high quality of life. They were still suffering. It became clear that we needed to learn significantly more about HS and try to make a difference in our patients' lives. Okoye: Absolutely. I agree with that. Do you see patients with HS now? And how do you work in your research on the microbiome into your care of these patients? Harris-Tryon: I spend about 80% of my time running my basic science lab. The focus is on the skin microbiome and the immune system. But when I am in clinic, I see patients at both our public hospital and also in my private practice. I see patients with HS, and when I see those patients with HS, what I want to impart to them is that this is a whole-body condition, and that if we can do things to strengthen their immune system through modifying behaviors in their life, we can make a meaningful impact in their disease. Every medicine I prescribe — I still prescribe a lot of medicines — they'll all work significantly better if we can also make some changes in lifestyle management, smoking cessation, nutrition practices, and increasing physical activity in their daily lives. If we can do those things all together in concert and take an integrated approach to their health, we'll make significant gains and get people, hopefully, into durable remission with their HS, and they can go back to a high quality of life every day. Okoye: I love that goal. You mentioned an integrative approach. How do you manage that with your patients? Harris-Tryon: The way that I approach a lot of integrative health questions now with my patients with HS is to help them understand that the skin microbiome is out of balance. In HS, bacteria are growing and existing in people's armpits and groins, buttocks, and under the breast, which we never see in patients who don't have HS. The lens that I take toward it is, how do we get that balance restored? One of the first things we talk about is diet. Diet is such a hot-button issue. It can be so sensitive for people. I focus more on things we can add back into the diet. And then some major things that we need to take away. The one major thing I say that we should reduce is high-sugar foods. In medicine, we also often call these 'high glycemic index foods' — sweetened juices, sodas, things like that, and sweetened tea here in the south. We love our sweet tea. To partner with my patients, I often say we don't have to get rid of those entirely. Cut back sugary drinks to maybe once a day if you're having them many, many times a day. And then if you're having a sweetened drink once every day, maybe cut them back to once a week. We talk about risk reduction, and sugar is the first place I start. In partnering with that, too, when people are thinking about diet, they're often thinking about restriction. I also try to emphasize that we can add some yummy things back in. What's your favorite vegetable that you enjoy eating? Maybe being intentional about adding those to the diet every day. If they're already there every day, maybe we can add them to every meal. And placing sweet drinks as a dessert and as a treat after a meal, not as the main focus of your nutrition, and understanding that skin and nutrition go hand in hand. The last piece is also fats in the diet. Modern diets are sometimes low in fats. I emphasize that the skin is the largest organ of the human body. It needs a lot of fats to function optimally. Making sure you get those nutrients is going to make a good impact in the skin. Okoye: It must be a different conversation to have a quote-unquote diet conversation with a patient, where you're saying, you can have more fat. I think that's a nice way of having what could be a fraught conversation. Your nutrition recommendations are related to your thoughts and research about the microbiome. Let's take a step back and teach us a little bit about the microbiome and how it relates to those recommendations. Harris-Tryon: I was fortunate to do my postdoctoral fellowship in a gut microbiome lab here at UT Southwestern, Lora Hooper's lab. If you're in a gut microbiome lab, you start to realize that microbiome in the gut and nutrients in the diet, they go hand in hand. Every time you consume something, your body's going to do some of the work of digesting that food and extracting the nutrients from that food. But the microbes are also doing their part. The easiest example is fiber in the diet. If you have any plant-based food, you have a salad today, or even if you have wilted spinach today, cooked vegetables, our body can't digest all of that spinach. We just don't have the enzymes to do that. And that's not bad. It doesn't limit us because in our small intestine and the large intestine, we have a series of microbes that can do the digestion for us. They can digest plant polysaccharides, the big fiber molecules. There are species of bacteria that do that work very well, way better than we do. When you give those microbes the food that they need, they grow and expand. The populations that digest fiber expand. It turns out that the microbes that digest fiber make all sorts of small molecules that are highly beneficial for our immune system, our brain, and our skin. Those things working together in concert help strengthen our immune system and help it help strengthen our skin barrier. Okoye: These bacteria, do they exist from birth, or do they change depending on what you eat throughout your lifetime? Can you change them? Can you adjust your microbiome? Harris-Tryon: It's been shown in mouse studies and human studies, large population studies from all over the globe, that what you eat will drive your microbiome. Some of the original studies were done in groups of human populations that shift their diet significantly with seasons. During the seasons when you had a high fiber-rich diet, your gut microbiome expands to be full of microbes that digest that food. During the seasons when you don't eat that same nutrient, those microbes go down, and the microbes that metabolize what you are now eating will go up. We know that's true, and it happens over weeks, not over months. It can happen even faster, too. If you change your diet and microbial communities, we expect to see a shift in the gut. To answer your second question, babies are somewhat sterile at birth. Their skin microbiome gets colonized by their method of delivery. If you're born vaginally vs by C-section, the baby's gut gets populated again. If you are getting breast milk, that's going to tune you to have a certain microbiome. Formulas, which we've tuned over time to be a lot like breast milk, are going to have an impact on the microbes that respond to that nutrient early in life. Okoye: Are there data showing the types of microbes that tend to occur in patients with HS in terms of the gut and the skin? Harris-Tryon: Yes, there have been some papers. It hasn't been entirely definitive what microbes are associated with HS in the gut, but we know that there are decreases in fiber-fermenting microbes. We know that in the populations that tend to get HS, we see fewer of those fiber-fermenting bacteria. Okoye: So that's what's driving your recommendation to increase fiber, vegetable, and fruit intake in patients with HS. Harris-Tryon: Yes, increasing vegetables and fruits and lowering the sugars. Every single interaction you have in your life will have a tuning effect on the microbiome. For example, we know that our HS patients smoke more. We know that there are specific species, such as Porphyromonas species, that are more associated with smoking. These links are known. It's diet, and also other exposures such as smoking, that have a big impact on the oral microbiome. Microbes that grow in your mouth will also impact microbes that end up in your gut. Okoye: How does a high sugar diet affect the microbiome? Harris-Tryon: I think it's twofold. If you have a high-sugar diet, you also probably have a low-fiber diet. It's the two things together. We don't exactly know the mechanisms, but if you have high sugars, you'll get high amounts of insulin. We know as dermatologists that we see a lot of rashes that come downstream of that. My lab is trying to dissect some of these questions right now on the bench. What exactly is changing? I have less data for that, and fewer direct links to the microbiome. That is part of my practice as a physician and clinical experience. If I lower those sugars, patients do better. Okoye: And there are lots of other good reasons to decrease sugar in the diet anyway. Harris-Tryon: I emphasize that to my patients for acne and HS, this is the organ we can see. But all these changes, we have decades of medical literature saying that this is good for your heart, your liver, your kidneys. It's very affirming for me as a physician to be able to motivate people to make whole-health system changes to their life that impact the organ they can see every day, which is their skin. Okoye: When you talk to patients in a nonjudgmental, relationship-affirming way, they will often identify those foods themselves as foods that tend to flare their disease. This is fantastic. I think it will help inform some of our conversations with patients, so we are not just arbitrarily saying decrease sugar, increase fiber, have more fruits and vegetables, but we can explain to them why. Especially if they are showing interest in more integrative care or they're asking about dietary changes or probiotics. Harris-Tryon: I've had so many patients who say, my HS was terrible. I decided to drop my soda consumption every single day and my skin cleared up. When they come with those stories, it's very affirming to me that this practice is something people get a lot of benefit from. Okoye: I think it's important to note that this is part of the practice. So yes, we can still treat with antibiotics, we could still treat with biologics, but why not also incorporate this into our care? It'll help the patient's overall health. When I think about foods, I always think about the impact of public health factors that we know impact food choices. What are your thoughts on public health interventions or systemic interventions that we, as a field, should think about for patients with HS when it comes to their microbiome? Harris-Tryon: I think on a systems basis, this is critically important. We have a lot of data on what makes populations thrive and healthier. This includes access to nutrient-dense foods that are affordable and accessible. They've done some studies to show that it's not necessarily more expensive to have a diet that has nutrient-dense foods, but access is an issue. How do people access the grocery store? How do you physically get to that grocery store so that you can get the groceries that you need? That's a major issue here in Dallas. Our food pantries are helping to fill some of that gap with a lot of education and a lot of access to food. 'Food is medicine' programs are allowing physicians to shift their practice so that you can start prescribing foods, so that we can write prescriptions for foods that we know are nutrient-dense and fiber-rich, that can have an impact on health. I think that's a major one. I was fortunate to be at this meeting last week, talking about heart health. The American Heart Association has talked about all of these different metrics that help with hypertension. Many of those help with other things too that we see in dermatology. Making sure our patients know that sleep and stress are going to modify their immune system and gut microbiome, and disease. Allowing people to live in walkable, safe communities so that they can get the exercise that they need and the steps that they need, because that is also a component of how you optimize metabolism, which ends up having a big impact, a positive impact, on skin. All these issues are systems issues. They're public health issues. Addressing them will help with HS. Again, to come back to smoking, whatever we can do to encourage smoking cessation is also going to allow all the medicines we prescribe for HS to work better. It is so clear that patients who smoke are at a higher risk of developing HS. All these are big public health interventions we can make to have an impact on our patients. Okoye: So, at a systems level, zooming out, there is work to be done. Clearly, you already led with the things that we could do one-on-one with patients to help them and ultimately their families. Because often we see women of childbearing age with HS. They may be preparing food for their children and their family. We could have an exponential impact that way. Harris-Tryon: One other thing I try to encourage my patients to do is to use less packaged foods; they're foods of convenience. They are part of everyone's diet, but I think it's just being conscious of that. Foods that are shelf-stable, by definition, are missing some nutrients that we need to make them shelf-stable. Some nutrients we need aren't shelf-stable. I have that conversation as well with my patients. Okoye: What are your thoughts on probiotics? Do you think they have a role in the management of HS and other inflammatory conditions? Harris-Tryon: We talked about my stepwise approach. First, cut back on the sugars. Next, focus a lot on what we need to add back those fibers, fats, and healthy proteins. I always say, if people still want to talk about it, then we move on to probiotics. My approach to probiotics is also supported by a lot of other microbiome scientists, who focus on fermented foods. There are so many fermented foods that are ancient in human history, and we know that a lot of the microbes in those foods are beneficial to all aspects of human health. If you take yogurt, probably the most easily and readily available fermented food, it often has Lactobacillus species in it. Those are beneficial microbes. And they make a lot of products that are good for the immune system. They often also have Bifidobacterium species in them. We know that when you're eating the fermented food, in the case of yogurt, you're getting the live microbes. If you turn over any container of yogurt at your grocery store, they will list the live active cultures. They'll actually list the species that are in there. These foods are also approved by the US Food and Drug Administration. We've had them in our history as humans for millennia, so we know they're safe. We know that humans have been eating them with benefit for a long time, and they're also well-controlled. We know what active species are in them. So, for all those reasons, I think it's great to start with a fermented food such as yogurt. You can eat other foods that are ancient, such as kimchi, sauerkraut, kefir, yogurt drinks, all these foods, we know are full of microbes that have now been shown with all of our scientific tools to be very beneficial. But for millennia, humans have been eating them. Okoye: Our ancestors already knew. Are there any other fermented foods we could mention? Harris-Tryon: Ginette, you and I are both from the Caribbean region. My family's from Guyana. We have drinks such as fly, mauby, and ginger beer. Those are just from the region my family happens to be from. I know in West Africa, even their fufu and these other pounded grains, they have to be fermented. My lab is full of people from all over the world, and so I often ask questions about their fermented food practices. Bamboo shoots are often fermented in many parts of the world. Some of the people in my lab point out that dosa dough is fermented. I didn't know that, and I love dosa. The dough is made and then left overnight to ferment. I'm not sure what species are in that. I was saying we should study that in the lab. I do think one thing that microbiome has helped me align with is, how you feel is important. If you eat some of these things and your stomach or your digestion is upset, you don't have to eat things just because they're fermented. I think it is important to center on how you feel after you eat, and that's also what microbiome science has helped me understand. Thinking about the skin, too — if your skin reacts negatively after a few days of something, move away from it. And if your digestion reacts negatively after a few days, move away from it. I can't tolerate a lot of fermented drinks if I drink too much of them. I don't drink too many fermented drinks if they have too much gas in them, too much carbon dioxide. Many other fermented foods, I tolerate well. There have been so many fermented foods throughout human history. Remember to always align with how you feel after you consume something. Okoye: I think that's important to follow up on those recommendations to patients, so they don't feel like they failed. For example, I tried kombucha, and I felt terrible. Okay, then try something else. And I think it's always nice to tell people to think about their people — where are from, and what have they been eating for millennia? Harris-Tryon: Yes. A beneficial diet is the Mediterranean diet. One way that you can understand how the Mediterranean diet might be used differently throughout the world is through the website They've created food pyramids that reflect Mediterranean-style diets, not just from the Mediterranean, but from the African continent, Asia, and the Americas, so that everybody can have access to that. Okoye: This has been fascinating. Do you have any parting words for us? Harris-Tryon: Your skin is telling you something about your health, is probably my parting word. It shouldn't be itchy. It shouldn't be inflamed. It shouldn't be red. It does need care, but that care doesn't always involve a 15-step, highly astringent regimen that's expensive. I think it involves taking care of your body through making mindful choices of what you're ingesting. Get good movement several times a week; the body needs that for its metabolism. As dermatologists, we love a great moisturizer for a reason because the skin needs lipids, both in the diet, and if your skin is dry, you want to add a little bit more lipid to it. If you feel like your skin is oily, then you can shift away from that, too. But I do think trying to find a skin balance where your skin is not inflamed is an important part of health. Okoye: Today, we've talked to Dr Harris Tryon about the gut microbiome in HS. Some key takeaways from my perspective include the fact that what you eat changes your gut microbiome, and that change can happen within days or weeks. And that encouraging our patients to have a higher fiber, lower sugar diet can sway their microbiome toward the types of bugs that we believe are more beneficial for inflammation in the skin. Thank you for joining us. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on Hidradenitis Suppurativa. This is Dr Ginette Okoye for the Medscape InDiscussion podcast. Microbiota and Maintenance of Skin Barrier Function Evaluating Dietary Considerations in Hidradenitis Suppurativa: A Critical Examination of Existing Knowledge Role of Dietary Fiber in the Recovery of the Human Gut Microbiome and Its Metabolome Mediterranean Diet Intervention Alters the Gut Microbiome in Older People Reducing Frailty and Improving Health Status: The NU-AGE 1-Year Dietary Intervention Across Five European Countries Population-Level Gut Microbiome and Its Associations With Environmental Factors and Metabolic Disorders in Southwest China Seasonal Variation in Human Gut Microbiome Composition Dynamics and Stabilization of the Human Gut Microbiome During the First Year of Life Skin and Gut Microbiome in Hidradenitis Suppurativa: A Systematic Review Cigarette Smoking as a Triggering Factor of Hidradenitis Suppurativa Probiotics in Hidradenitis Suppurativa: A Potential Treatment Option? Oldways Cultural Food Traditions
Yahoo
21-05-2025
- Health
- Yahoo
Globally Recognized Expert in Rare Autoimmune Neurologic Diseases, Dr. Benjamin Greenberg, Joins Trethera Scientific Advisory Board
LOS ANGELES, May 21, 2025 (GLOBE NEWSWIRE) -- Trethera Corporation ('Trethera'), a clinical stage biopharmaceutical company developing first-in-class therapies for cancer and autoimmune diseases, announced today the appointment of Benjamin Greenberg, MD, MHS, to its Scientific Advisory Board. Dr. Greenberg will assist in evaluating the clinical development of Trethera's lead asset, TRE-515, in demyelinating autoimmune diseases. A demyelinating disease is any condition that causes damage to the protective covering (myelin sheath) that surrounds nerve fibers. When the myelin sheath is damaged, nerve impulses slow or even stop, causing neurological problems. Dr. Greenberg is an internationally recognized neurologist specializing in rare autoimmune disorders of the central nervous system. He currently serves as Vice Chair of Clinical and Translational Research and Professor of Neurology and Pediatrics at UT Southwestern Medical Center. Dr. Greenberg completed his medical degree at Baylor College of Medicine, followed by an internal medicine internship at Rush–St. Luke's Presbyterian Hospital and a neurology residency at Johns Hopkins Hospital, where he later served as co-director of the Transverse Myelitis Center. Since joining UT Southwestern in 2009, he has founded multiple pioneering programs, including the Transverse Myelitis and Neuromyelitis Optica Program and the Pediatric Demyelinating Disease Program. 'It's fantastic to have Dr. Greenberg join our team,' said Immunology Advisory Board Chairman Dr. Peter M. Clark of UCLA. 'With his addition, we now have an exceptional and purpose-driven team at Trethera with the world's foremost experts from Harvard, Stanford, and UT Southwestern to provide scientific answers as well as enroll patients in our forthcoming neuroimmunology Phase 1 clinical trials to transform patient care.' 'I'm honored to have Dr. Greenberg join the Scientific Advisory Board and support the advancement of TRE-515 as a potential treatment for patients with rare demyelinating diseases,' said Dr. Ken Schultz, Chairman and CEO of Trethera. 'Safe and effective treatments for these neurologic conditions represent a significant unmet need, particularly in pediatric populations, where existing therapies often carry substantial side effects and deliver inconsistent results.' Dr. Greenberg's research and clinical expertise focus on demyelinating and inflammatory disorders such as acute disseminated encephalomyelitis (ADEM), optic neuritis, neuromyelitis optica spectrum disorder (NMOSD), and transverse myelitis. As the principal investigator of major national collaborative studies, he has contributed extensively to the discovery of novel biomarkers and the development of biorepository protocols that support precision diagnostics and treatment strategies. Dr. Greenberg's appointment to the Scientific Advisory Board further strengthens Trethera's commitment to advancing innovative therapies for autoimmune neurologic diseases. Trethera's clinical stage and first-in-class drug, TRE-515, holds FDA Orphan Drug status for both optic neuritis and ADEM. FDA Orphan Drug designation confers substantial advantages, including a faster path to market approval, FDA assistance in designing clinical trials, exemption from the $4M drug approval application fee, and eligibility for seven years of marketing exclusivity. Should the FDA approve TRE-515 for commercial use in ADEM, Trethera would be eligible for a pediatric priority review voucher. TRE-515 is currently being evaluated in a Phase 1 dose escalation solid tumors clinical trial. ADEM is an autoimmune disease, affecting 15,000 patients a year in the United States, with most cases occurring in six to eight year-old children. ADEM can present with fever and difficulty walking that progresses to loss of consciousness, coma, and even death. Optic neuritis typically occurs in adult patients, manifesting with rapid vision loss in one or both eyes, with up to one in four patients never fully recovering their eyesight. Over 100,000 cases of optic neuritis occur annually in the US and have a close association with multiple sclerosis (MS). Figure 1: Representative stained sections of the optic nerve from mice experiencing optic neuritis. Arrows point to regions of leukocyte infiltration. Sources: Cleveland Clinic 2021; Bennett 2019; Yang 2017; Wilhelm 2015 About Trethera Trethera is a clinical stage, privately held, biopharmaceutical company dedicated to pioneering the development of novel treatments for autoimmune diseases and cancers. Founded by prominent UCLA scientists, Trethera is led by experienced management and board members. Trethera's innovative approach to targeting nucleotide metabolism led to the development of TRE-515, an orally administered capsule twice designated by the FDA as an Orphan Drug. TRE-515 is a first-in-class clinical stage drug that inhibits deoxycytidine kinase (dCK), the rate-limiting enzyme in the nucleoside salvage pathway, one of two biosynthetic pathways that generate DNA precursors. It is believed that some forms of cancer may be preferentially dependent on the salvage pathway to support tumor growth, and certain autoimmune diseases might also respond to TRE-515 treatment. Trethera is developing TRE-515 for use as a monotherapy or in combination to precisely target a metabolic vulnerability of cancer or autoimmune diseases that will transform outcomes for patients. For more information, please visit us at or e-mail Investor Relations at ir@ You can also follow Trethera on Facebook and LinkedIn. Note on Forward-Looking Statements All statements other than statements of historical facts included in this press release that address activities, events or developments that Trethera believes or anticipates will or may occur in the future are 'forward-looking statements,' which may often, but not always, be identified by the use of such words as "may," "might," "will," "will likely result," "would," "should," "estimate," "plan," "project," "forecast," "intend," "expect," "anticipate," "believe," "seek," "continue," "target" or the negative of such terms or other similar expressions. Although Trethera has a reasonable basis for the forward-looking statements contained herein, Trethera cautions that such statements are based on current expectations about future events and are subject to risks, uncertainties and factors relating to medical and scientific research, all of which are difficult to predict and many of which are beyond Trethera's control, that may cause actual results to differ materially from those expressed or implied by the forward-looking statements in this press release. These potential risks and uncertainties include, without limitation: the extent to which development of any novel cancer therapies or therapies for autoimmune diseases succeeds; whether Trethera would obtain the necessary regulatory approvals to commence human trials or commercialize TRE-515 or any novel therapies resulting from such research; Trethera successfully implementing its growth strategy, including that relating to its disease therapies; the effects of the global Covid-19 pandemic; changes in economic conditions; competition; and risks and uncertainties applicable to the business of Trethera. The statements in this press release speak only as of the date hereof and Trethera does not undertake any obligation to update, amend or clarify these forward-looking statements whether as a result of new information, future events or otherwise. The Company intends that all forward-looking statements be subject to the safe-harbor provisions of the Private Securities Litigation Reform Act of 1995. A photo accompanying this announcement is available at in to access your portfolio
Medscape
16-05-2025
- Health
- Medscape
Radiofrequency Ablation: A First-Line Treatment Option
This transcript has been edited for clarity. Kaniksha Desai, MD: Welcome to the Thyroid Stimulating Podcast . This podcast was created in partnership with the American Thyroid Association to discuss up-to-date diagnosis and management of a wide array of thyroid diseases. I'm your host, Dr Kaniksha Desai, and today we're exploring an exciting and rapidly growing area in the management of hyperthyroidism: the use of radiofrequency ablation (RFA) for treatment. For those of you less familiar with it, RFA is a minimally invasive technique that uses thermal energy to reduce or eliminate targeted thyroid tissue. Although it has been used internationally since the early 2000s, it was FDA approved in the United States in 2018. Initially adopted for the treatment of benign nonfunctioning thyroid nodules, RFA is now gaining traction as a promising option for patients with hyperthyroidism from toxic adenomas. Joining us today is Dr Iram Hussain, associate professor of medicine in the Division of Endocrinology at UT Southwestern Medical Center in Dallas, Texas. She is the president of NASOIE, the North American Society of Interventional Endocrinologists, and she began one of the first endocrinology-led academic RFA practices in the US at UT Southwestern in 2022. Dr Hussain has published extensively on this topic, including expert reviews in Clinical Thyroidology on the latest thermal ablation papers. She has also co-authored the American Thyroid Association's consensus statement on the safe performance, training, and adoption of ablation techniques for benign thyroid nodules, which was published in 2023. We are honored to have her here today to share her experience and expertise with us. In today's episode, we'll dive into how RFA compares to more traditional therapies, such as surgery and radioactive iodine, including potential benefits, such as fewer side effects and a greater likelihood of preserving normal thyroid function rather than leading to permanent hypothyroidism. Thank you, Dr Hussain, for joining us today. Iram Hussain, MD: Thank you so much for having me. I'm thrilled to be here to talk about this exciting area of thyroid care. Desai: I'd like to start off with a personal question. What piqued your interest in RFA, since it's a newer technique? Hussain: My practice primarily consists of patients with thyroid nodules and thyroid cancer. When I was seeing patients in my clinic, many of them had symptoms or they would need some sort of intervention, but they were very reluctant to get surgery. Some of them were afraid of surgery, some of them didn't want a surgical scar, or they were afraid they would have to be on medication for the rest of their life. When I discovered that this new technique was gaining popularity and a training course was available in the United States in 2018, I thought, Oh, I have to go and see what this is about. When I met Dr Jung Hwan Baek, from South Korea, who did the first cases of benign thyroid nodules, I saw that it was very similar to biopsies and fine-needle aspirations that we do in clinic. I thought, We can do this in clinic and this is going to be great for patients. I love procedures, so I got trained and was like, let's set this up. Desai: Thank you. I'm so glad you're here to talk to us about it. Can we start by talking about hyperthyroidism in general for our listeners? What are the different causes of hyperthyroidism and where specifically do toxic adenomas fit in? Hussain: Hyperthyroidism can be caused either by too much production of thyroid hormone or by leakage of preformed thyroid hormone into the systemic circulation, which is usually thyroiditis. Thyroiditis is typically self-limited, but when we're talking about overproduction of thyroid hormone, the most common cause is going to be autoimmune or Graves disease. About 5%-10% of hyperthyroidism is caused by autonomously functioning thyroid nodules. These are nodules that produce thyroid hormone independently of the pituitary's TSH regulation. If there's just one thyroid nodule that's producing too much thyroid hormone, that's a toxic adenoma. If there's more than one, that's a toxic multinodular goiter. Essentially, the nodule just decides to produce hormone on its own, and that leads to suppressed TSH and elevated thyroid hormones. Desai: How do you diagnose a toxic adenoma? Hussain: Typically, you're going to do thyroid function tests first. You can have either subclinical hyperthyroidism, where the TSH is suppressed and you have normal circulating thyroid hormones, or you can have elevated thyroid hormones, which is hyperthyroidism. Then, you are going to do an ultrasound to see if the patient has any nodules. Finally, you're going to do a radioactive iodine uptake and scan. This is going to tell you whether the nodules are producing too much thyroid hormone or if it's the whole gland. Desai: That's very important to distinguish because the treatment options might be slightly different for the different causes of the hyperthyroidism. What are the standard treatment options? Can you go over them for our listeners? Hussain: Traditionally, we've had three options for the treatment of hyperthyroidism. They include antithyroid medications, such as PTU, radioactive iodine therapy, and surgery. Typically, in the case of toxic adenomas or autonomously functioning thyroid nodules, we don't prefer antithyroid medications because these nodules don't go into remission, so people end up being on antithyroid medications for life. In order to get them to definitive therapy, we either choose radioactive iodine or surgery, but both come with disadvantages. Desai: I'm going to have you talk about some of those disadvantages later, but I wanted to switch now to RFA. Can you give us a little bit of background on how it works for thyroid conditions in general and for toxic adenomas? Hussain: RFA is a minimally invasive procedure that uses thermal energy to essentially heat up the cells and cause necrosis. The cells die and then they scar over and shrink, and this shrinks the nodule. It's typically performed under ultrasound guidance using an electrode. It's been used internationally since the early 2000s for benign nodules and it's gaining popularity in the United States now. It's especially effective for solitary hyperfunctioning nodules because it targets a specific area. Desai: When you are ablating it, you just ablate where the nodule is, and then that turns off all the thyroid function that's coming out of there. Hussain: You're essentially going to insert a thin electrode into the nodule and start burning the tissue under ultrasound guidance. The aim is to burn the entire nodule so that there are no viable cells left. This way, the nodule will no longer produce too much thyroid hormone, and your thyroid function tests will normalize. Desai: Can you tell us a little bit about who the ideal candidate for this procedure would be? Hussain: Most of the studies show that this procedure works best in people who have nodules that are less than 12 mL in volume. If they're very big, it might not work in one session. It's particularly attractive for patients who want to avoid surgery or radioactive iodine, or for patients who have many comorbidities that make surgery risky. Also, for patients who are planning pregnancy soon, because after radioactive iodine, you have to typically wait 6-12 months before getting pregnant. And especially for patients who are concerned about becoming hypothyroid, because the risk for hypothyroidism with this procedure is essentially zero. Desai: That's amazing because for some of our other treatment options, including surgery and radioactive iodine, it's not zero. Is there anyone for whom you would not recommend this? Hussain: It's typically not recommended in Graves disease because this is a diffuse disease process rather than a targeted area of excess thyroid production. You also want to avoid it in pregnancy because there are not enough safety data. The procedure uses an alternating current, and the patient has to have grounding pads on their thighs, so there are not enough safety data in pregnancy. You also can't do it in people who have bleeding disorders because that increases the risk for hematomas. Desai: Can you walk us through what the RFA procedure looks like for your patients? Hussain: This is typically going to be an outpatient procedure that you can easily do in the clinic. The patient is lying supine on your exam table, and you ask them to extend their neck. Then you use ultrasound to inject local anesthesia — typically lidocaine — into the skin and the parathyroidal area because the thyroid capsule is where most of the pain is. After that, you insert the electrode into the nodule, keeping an eye on it with your ultrasound. You insert it parallel to the electrode probe and then move it using something called a moving shot technique. You're basically ablating the nodule layer by layer and treating it in sections until the entire nodule is ablated. This usually takes about 30 minutes for a very small nodule, but it can easily take over an hour if it's a very large nodule. Desai: What complications can occur during or after the procedure? Hussain: Because we are burning the nodular tissue, all of the complications are related to heat damage. The recurrent laryngeal nerve typically runs behind the thyroid and the tracheoesophageal groove. If there is heat damage to that nerve, there can be voice changes, and that's the most common complication. Similarly, if you nick a vessel, you could potentially have a hematoma. There could also be damage to other surrounding structures, such as the vessels, the trachea, and the esophagus. There could be skin burns. To avoid all of these, we keep the patient awake. We're talking to the patient throughout, making sure that they're not feeling heat or pain, and we're looking very closely on our ultrasound machine to make sure that we're ablating only the nodule and nothing else. Desai: It sounds like it's pretty intensive for those 30 minutes. Hussain: It definitely requires a large amount of concentration, but it gets easier with practice. I think that most people who do many thyroid procedures are quite comfortable doing it. Desai: What happens if your patient who's now talking to you suddenly can't speak anymore? That can be kind of scary. Hussain: That can be very scary. That means that you've caused some heat damage to the nerve, but you've picked it up very early because you're talking to them continuously. As soon as you notice the voice change, you're going to turn the machine off. Then you're going to wait a few seconds and talk to them to see if the voice is coming back. If it's not coming back, then you're going to take a syringe with a needle and fill it with cold dextrose 5% in water, and inject it right on top of the nerve into the tracheoesophageal groove. Sometimes you need to inject a decent volume. If you're injecting enough fluid and cooling down the nerve fast enough, the voice will gradually come back. It's very scary when it happens, but it's very exciting when the voice comes back and everything's fine. Desai: Do you just continue the procedure then or do you have to do something else from there? Hussain: You can continue the procedure if the patient's comfortable with that. It's happened to me twice, and in both cases, the patients continued the procedure successfully and had good outcomes. Desai: Great. It is completely treatable. If that happens during the procedure, you just take a little break and you try to cool down the nerve. We talked a little bit about the preprocedural workup for hyperthyroidism, but is there anything special that you need to do before you consider RFA treatment in a patient? Hussain: I will typically get their baseline thyroid function tests again, just to make sure they're not very, very hyperthyroid prior to the procedure because you may have to pretreat them with methimazole if that happens. Then I'll typically get platelet levels and an INR and PTT to make sure they don't have any risk of bleeding during the procedure. Of course, in the case of toxic adenomas, you do want to have your ultrasound and your radioactive iodine uptake scan because you want to be targeting the correct area. Desai: Speaking of that, you said the best patients would have one toxic nodule, but can you do this for a multinodular goiter? Hussain: There's not much data for multinodular toxic nodular goiter, but I will say that it's possible if most of the thyroid hormone is coming from one dominant thyroid nodule. Otherwise, the challenge is that you would have to ablate each individual nodule that's making too much thyroid hormone, and this might result in the patient having to undergo more than one procedure, which comes with additional risk, additional cost, etc. Desai: That can be a lot if you have three or four nodules. Hussain: Yes, exactly. Desai: Are patients cured immediately? What is the time lapse for this? Hussain: Typically, they're going to notice a decrease in their thyroid hormone levels over the next few weeks. You can check the patient's thyroid function tests in 4-6 weeks, and you might notice an improvement. Some people have a normalization of their thyroid function tests as early as 6 weeks, but most have it within 3 months. If the thyroid function tests have not normalized by 6 months, it usually means that the procedure wasn't successful and the patient may need a second session. Desai: How often is a second session necessary? Hussain: This depends on the initial characteristics of the nodule. As we discussed previously, nodules that are 10-12 mL in volume or lower respond very well and can typically be treated in one session. However, larger nodules, especially those larger than 30 or 40 mL, typically require more than one session. It really depends on the size. Now, what's really interesting is that although all previous papers say that size is very important, recently a paper was published in Thyroid, in December 2024, which was the Latin American multicenter experience in treating solitary autonomously functioning thyroid nodules. They noticed no difference in size. They had similar success rates with nodules that were less than 30 mL and those that were more than 30 mL, which was very interesting. Desai: Do you think it's because they spent more time treating it or they had more experience treating it? Hussain: I think as RFA gets more popular, people are starting to get better at it. Most of the people treating those nodules are very high-volume RFA practitioners, so they probably have been doing it for a while and they probably used a decent amount of energy on those nodules and used advanced techniques, such as the artery-first technique, and making sure that all the vascularity has been treated. I think experience definitely played a role there. Desai: How much experience do you need? Is there an ideal number of hours or number of treated patients? Hussain: There are a few studies on this, not very many. But typically, the learning curve of RFA is such that you continue to get better for the first 30-40 cases or so. After that, you consolidate your skills, and then there's not much improvement seen once you're past 60-90 cases. That's when you reach your peak. If somebody has done over 60-100 cases, they're probably going to be very good at it. Desai: Do you think that makes a difference in the cure rate? Hussain: I think it does in autonomously functioning thyroid nodules because the main difference between this and benign thyroid nodules is that, in autonomously functioning thyroid nodules, you have to ablate the entire nodule. In a nonfunctioning nodule, even if you leave a margin of unablated tissue, it's not going to start producing thyroid hormone. If you leave unablated tissue in an autonomously functioning thyroid nodule, you have a higher risk for recurrence later on. Desai: Usually, is this in the first 6 months or can it be any time? Hussain: It can typically be any time. It's usually after a year or so. Most people in the first 6 months will normalize their thyroid function unless they had an incomplete ablation. Desai: Do you recommend long-term monitoring for these patients to ensure that they're cured years out? Hussain: I think it would be prudent once they are past the first year to monitor at least yearly. They don't necessarily need to do it with their RFA specialist, but thyroid function tests as part of their annual physical should be sufficient. Desai: Let's talk about RFA compared with other treatment procedures. How does it compare with radioactive iodine and surgery in terms of how effective it is? Hussain: RFA is pretty similar in effectiveness to radioactive iodine. Most of the studies report a success rate of approximately 70%-90%, which is similar to radioactive iodine. Here's the interesting thing: When we talk about the success rate of radioactive iodine, we include patients who are made euthyroid and patients who are made hypothyroid. We, as endocrinologists, know that causing hypothyroidism isn't necessarily a success. Because this procedure causes no hypothyroidism, I prefer it to radioactive iodine. It also shrinks the nodule, so if the patient has compressive symptoms, that also goes away. That doesn't happen with radioactive dividing surgery. Surgery comes with surgical risks. It's a good option for a solitary toxic adenoma, to be honest. The hypothyroidism rate for surgery for a single toxic adenoma, getting a partial thyroidectomy, is only approximately 3%. It's fairly low, but you need a high-volume surgeon to avoid surgical risks. The patient has to go under general anesthesia and they do end up with a scar on their neck. All of those considerations factor into which procedure they might prefer. Desai: Can you compare side effects of RFA vs radioactive iodine and surgery? I know you talked a little bit about it, but are there any main concerns? Hussain: I would definitely say that, with surgery, you're going to be feeling the pain and be out of commission a little bit longer than with RFA. Typically, when we do an RFA, our patients just finish up the procedure and they can walk out the door and go live their life. Radioactive iodine is fairly low risk on the side-effect-profile area. The main thing is that most thyroid disease occurs in women, and most of these women are of childbearing age. Many women don't want radiation exposure when they are trying to plan their families. I think that's a major disadvantage of radioactive iodine. RFA is quick and easy. There's no downtime. You can go to work the next day or the same day if you so choose. It's much easier to recover from this procedure. Desai: It seems like it's a better option than radioactive iodine and surgery. With surgery, you are cured the next day, and then there's a little more time delay for the radioactive iodine and RFA, right? Hussain: Definitely. We counsel patients that the nodule is going to shrink slowly over time. It usually shrinks the most in the first 4-6 weeks. Obviously, the results with surgery are immediate, but it depends on patient preferences here. After surgery, patients typically have to wait for the scar to heal up. They can't lift heavy things, and it interferes with their life quite a bit more. People say that surgery is an easy procedure. As far as surgery goes, it is, but those patients are still discharged on pain medications. All you need is Tylenol after an RFA, if that, so it is much easier to recover from. I give patients the option. I'm not opposed to people choosing surgery if that's what they want, if they want immediate relief. I think it's always nice to have an option. Desai: For patients going to surgery, we often control their hyperthyroidism before surgery with antithyroid medications. We sometimes do that with radioactive iodine if they have severe hyperthyroidism. Can you talk about whether we do that for the RFA procedure? Hussain: There is a small risk of causing thyroiditis due to inflammation because you're burning the cells. We try to keep the patient relatively euthyroid. If somebody's starting out with subclinical hyperthyroidism, we might not necessarily start them on medication beforehand. If they have overt hyperthyroidism, then we're probably going to pretreat them with methimazole and at least get their free T3 and free T4 close to normal before starting the procedure. After we've done the procedure, we might slowly taper off and recheck their thyroid function tests in 4-6 weeks, and then decide to stop the medication to see if they're now euthyroid. Desai: How widely available is this procedure in clinical practice? Hussain: It's becoming more popular and definitely growing in popularity. I want to say that there are probably over 250 physicians in the United States who are now offering RFA. More academic centers are starting to offer it, which is good. When academic centers start to offer it, that means people start to accept it more as standard of care. It's definitely growing, Desai: I know you talked about who the ideal candidate is, but for those of our listeners who would be referring patients, how is it best to identify these patients and where do you send them? Hussain: After you've determined that your patient has a toxic adenoma or a single autonomously functioning thyroid nodule, then you want to look at what size it is. There is a formula to calculate the volume, but if you don't want to do that, then you can look at the maximum diameter. If it's lower than 3-4 cm, they're probably a pretty good candidate for RFA. If it's larger, they can probably still get it, but the practitioner doing the RFA might tell them that they may need more than one session. They can counsel them about that. There's no harm in referring out, getting a second opinion, and having the patient talk to somebody who does RFA to go over their options. Reach out to centers with trained operators, so that could be endocrinology, surgery, or interventional radiology. Our society, the North American Society of Interventional Endocrinologists, has a directory, so you can search by city and send them to the person closest to you for a second opinion. Desai: If someone wants to get trained in this procedure, how would they go about it? Hussain: There are multiple training programs now available. Many of them are in collaboration with some major society meetings and many are done by the company representatives that are providing this technology. I think it is important to observe somebody, who already does RFA in their practice, do it on an actual patient. I think that's very helpful when you're learning, so you can see exactly what the setup is like, how the patient tolerates the procedure, and whether or not you think you can incorporate it into your practice. Desai: There you have it. If you want to get trained in the procedure, it's a relatively easy training. Tell me about reimbursement for this. I know that a CPT code recently came out for RFA, and hopefully now it should be covered more by insurance. Hussain: It was very good news for patients when the CPT code came out on the first of this year, and we've noticed that many patients who previously could not get the procedure because they would have had to pay cash are now wanting to schedule it. We have not had any problems getting it reimbursed thus far. I think that access will only continue to grow. Desai: This is wonderful for our patients as well. You mentioned that the ideal patient has a toxic adenoma, but are there any data on Graves disease? Hussain: I reviewed a paper that was published in Thyroid in June of last year, and it was a really interesting paper because they took over 30 patients with Graves disease and treated them with RFA by essentially ablating both lobes. What they were trying to do is mimic a subtotal thyroidectomy. There was no distinct nodule, so they ablated all the tissue that they could safely ablate and then saw what the outcomes were. They were actually not bad. I will say that it worked best in smaller thyroids. If the total volume of the gland was less than 20 mL, those patients tended to go into remission. Patients who had larger glands didn't go into remission that easily or they had recurrence of Graves'. This is not entirely unexpected. When we published our early data in 2021 in the Journal of the Endocrine Society — those cases were done in the United States in 2018, 2019, and 2020, so the very early cases — we noticed that the best outcomes were with nodules that were less than 10 mL. If you have a thyroid that's 20 mL, essentially, one lobe is 10 mL or smaller on each side. Those were the cases that responded best. It's still very early. It's not something that I would recommend except in truly exceptional circumstances. For example: You have a patient with Graves disease and they're allergic to antithyroid medication, so you can't give them that. They have an aversion to radiation exposure, so you can't give them radioactive iodine. They want to avoid hypothyroidism, and they have either strong opposition to a scar or they're not a surgical candidate. In that situation, you could potentially consider this as a treatment option, but we don't have any long-term studies, so it's difficult to say. Desai: How long were the long-term studies for toxic adenomas? Hussain: We have studies for toxic adenomas for up to 5-10 years. It does have a durable response and people stay in remission, so it is a pretty good treatment option. Desai: Do they get other nodules or does that one nodule just go away? Hussain: Most of the studies are for single toxic adenomas, so that nodule just shrinks and becomes really small. Typically, you need about 80% volume reduction in the nodule to have normalization of thyroid function tests. If you have more than 80% volume reduction, the nodule just ends up being a very small nodule on ultrasound at the end of the follow-up time. Desai: What excites you most about the future of RFA in managing thyroid disease? Hussain: I really love that it's so patient centered. As I said before, patients come in and they don't want to be hypothyroid, they don't want a scar, they don't want radiation, and they don't want all these things. This is a way to treat them in such a manner that their nodule shrinks, their thyroid function tests normalize, and their neck looks completely normal. There's no evidence that you ever went in and did anything, so that's really great. Desai: They can have this treated without everyone knowing about it as well. I just want to review for our listeners. We talked about what RFA is and how it offers many more benefits than surgery and radioactive iodine treatment for toxic adenomas. It has an almost 0% rate of hypothyroidism, so patients don't have to take long-term medications of any sort. Can you give us three clinical pearls for our listeners to remember about RFA? Hussain: First, I'd want listeners to know that RFA is a legitimate first-line treatment option for autonomously functioning thyroid nodules. It's not like, oh, you're not a surgical candidate, you can't do this, and only then you can do RFA. It's a first-line treatment option, and if you want to do it, you should go see somebody who can do it for you. Second, I think, personally, that smaller nodules do respond better despite the study that was published out of Latin America, I think it's easier to ablate smaller nodules. If you have a small nodule that's autonomously functioning, you should definitely consider RFA as a treatment option. Finally, if you don't want a scar and/or don't want to be on levothyroxine, then this is the treatment option for you because this is the only treatment option that's going to guarantee that you're not on medication for the rest of your life. Desai: Thank you for joining us today. For our listeners, please stay tuned for next month's episode, which will be on molecular testing for thyroid nodules — are they worth the money? Thank you. Hussain: Thank you so much for having me.
The Guardian
08-03-2025
- Health
- The Guardian
Hantavirus pulmonary syndrome: the infection that killed Betsy Arakawa, Gene Hackman's wife
Authorities said on Friday that actor Gene Hackman died of heart disease days after his wife, Betsy Arakawa, died from hantavirus pulmonary syndrome. But what exactly is this rare illness? Hantavirus pulmonary syndrome is a rare but serious viral disease that can damage the heart, lungs, and other organs. The syndrome progresses quickly and can be fatal, according to the Cleveland Clinic, one of the largest and most respected medical centers in the US. Hantaviruses cause two syndromes, including HPS and hemorrhagic fever with renal syndrome, according to the Centers for Disease Control and Prevention. People can contract HPS by inhaling, eating, drinking, or coming into contact with infected mouse or rat feces, urine, or saliva. Although not all mice and rats carry hantaviruses, some species, including deer mice, white-footed mice, rice rats and cotton rats, are known carriers in North America. 'Between one and eight weeks after that exposure, someone might begin to feel like they have a flu-like illness,' Dr Sonja Bartolome of UT Southwestern Medical Center in Dallas, told the Guardian. In the United States, most cases of HPS occur in states west of the Mississippi River. 'It's mostly in rural areas, because that's where most of the rodents carrying the disease live,' Bartolome said. HPS remains rare in the US despite its severe symptoms. Between 1993 and 2022, there were 864 reported US cases. New Mexico had the highest number over that time, at 122, followed by Colorado at 119. Person-to-person transmission is extremely rare and has only been documented in cases of a hantavirus strain found in Argentina and Chile. Once the hantavirus enters the body, it replicates and spreads, which can cause a severe amount of damage in the lungs. The virus weakens blood vessels and causes leakage and fluid buildup in the air sacs, making breathing difficult. In the heart, it damages the heart muscle and weakens blood vessels while reducing the heart's ability to pump oxygen-rich blood to the body's organs. If untreated, these effects can lead to shock, organ failure, and death. HPS symptoms work in three phases. The first is the incubation phase, lasting up to eight weeks, during which the virus is present in the body but no noticeable symptoms are present. The second phase develops quickly and includes fever, chills, fatigue, muscle aches, stomach pain, nausea, vomiting, diarrhea, rash, dry cough, headache, and dizziness. This stage lasts between two and eight days. About four to 10 days after these initial symptoms, the third and most severe phase begins. This last phase includes internal bleeding, fluid-filled lungs, difficulty breathing, a rapid heartbeat, and chest tightness. These symptoms can be life-threatening and require immediate medical attention. There is no specific treatment or cure, but early medical attention can increase the chance of survival. Patients usually require oxygen therapy, fluid replacement, medications to stabilize blood pressure, antiviral medications like ribavirin, among other care. If patients survive the late-stage symptoms, recovery typically takes a few weeks. Although no vaccine exists for HPS, the Cleveland Clinic recommends taking prevention strategies to help reduce risk. These include avoiding wild rodents, sealing entry points in homes, properly cleaning and disinfecting rodent-contaminated areas, using protective gear when handling droppings, and keeping food securely stored. Sweeping or vacuuming droppings is not recommended because it could release virus particles into the air.
