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Sleep Apnea (Transcript)
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>>ANNOUNCER: "SECOND OPINION" IS BROUGHT TO YOU BY BLUE CROSS/BLUE SHIELD, ACCEPTED IN ALL 50 STATES. BLUE CROSS/BLUE SHIELD -- LIVE FEARLESS.

 

>>ANNOUNCER: "SECOND OPINION" IS PRODUCED IN CONJUNCTION WITH U.R. MEDICINE, PART OF UNIVERSITY OF ROCHESTER MEDICAL CENTER, ROCHESTER, NEW YORK.

 

>>DR. PETER SALGO: THIS IS "SECOND OPINION." I'M YOUR HOST, DR. PETER SALGO. THIS WEEK, MYTH OR MEDICINE -- "EVERY CHILD WHO SNORES NEEDS A TONSILLECTOMY."

 

>>DR. HEIDI CONNOLLY: PROBABLY ABOUT 8% TO 10% OF PRESCHOOL-AGE CHILDREN SNORE.

 

>>DR. PETER SALGO: AND SPECIAL GUEST CAROL HAGE WALL IS HERE. SHE HAD SOME SCARY SYMPTOMS. THEY DROVE HER TO THE DOCTOR. AND THEY BROUGHT HER HERE TODAY.

 

>>CAROL HAGE WALL: I WAS ADVISED BY MY DOCTOR TO HAVE A BRAIN SCAN TO BE SURE THAT I DIDN'T HAVE SOME KIND OF A SEIZURE, AND I WENT THROUGH ALL OF THOSE THINGS, AND I DIDN'T HAVE ANY OF THOSE THINGS.

 

>>DR. PETER SALGO: THANKS SO MUCH FOR BEING HERE, CAROL.

 

>>CAROL HAGE WALL: YOU'RE VERY WELCOME.

 

>>DR. PETER SALGO: NICE OF YOU TO JOIN US AND SHARE YOUR STORY. I KNOW YOU'VE GOT A LOT TO TELL US, BUT WHAT I'D LIKE TO DO FIRST IS INTRODUCE YOU TO YOUR "SECOND OPINION" PANEL. THESE DOCTORS ARE GOING TO BE HERE FOR YOU ALL THE WAY THROUGH, AND AT THE END OF THE CASE, YOU'LL HAVE A CHANCE TO ASK THEM ANY QUESTIONS YOU WANT AND GET YOUR OWN SECOND OPINION. FIRST, DR. LISA HARRIS FROM OUR LADY OF LOURDES MEMORIAL HOSPITAL. AND DR. MICHAEL YURCHESHEN FROM THE UNIVERSITY OF ROCHESTER MEDICAL CENTER. YOU GUYS BETTER BE READY. I'VE GOT A FEELING SHE'S GOT SOME DOOZIES FOR YOU BY THE END OF TODAY. CAROL, LET'S START YOUR STORY. A FEW YEARS AGO, TAKE US BACK. AS THEY SAY IN THE AVIATION BUSINESS, "THERE YOU WERE, MINDING YOUR OWN BUSINESS, WHEN..."

 

>>CAROL HAGE WALL: WHEN I WAS DRIVING MY FORD EXPLORER DOWN THE ROAD AND FOUND MYSELF TURNED OVER IN A DITCH. SOMEBODY PULLED ME OUT, AND I WAS OKAY, THANK GOODNESS, BUT --

 

>>DR. PETER SALGO: THERE YOU WERE, AND YOU FOUND YOURSELF IN A CAR, UPSIDE DOWN IN A DITCH!

 

>>CAROL HAGE WALL: YES.

 

>>DR. PETER SALGO: YOU HAD NO MEMORY OF ANY OF THAT?

 

>>CAROL HAGE WALL: NO IDEA HOW I GOT THERE. I MEAN, I KNEW THAT I HAD BEEN DRIVING ON THAT ROAD, AND THERE I WAS, UPSIDE DOWN. SOMEBODY ASKED IF I FELL ASLEEP, AND I SAID, "I DON'T THINK SO, BUT..."

 

>>DR. PETER SALGO: WERE YOU BADLY HURT AT ALL?

 

>>CAROL HAGE WALL: NO, I REALLY WASN'T. I WAS ADVISED BY MY DOCTOR TO HAVE A BRAIN SCAN TO BE SURE THAT I DIDN'T HAVE SOME KIND OF A SEIZURE, AND I WENT THROUGH ALL OF THOSE THINGS, AND I DIDN'T HAVE ANY OF THOSE THINGS.

 

>>DR. PETER SALGO: OKAY, SO I WANT TO STOP HERE FOR A MOMENT AND GO TO THE PANEL, BECAUSE HERE'S A WOMAN WHO'S DRIVING ALONG, HAS AN ACCIDENT OF WHICH SHE HAS NO RECALL.

 

>>DR. LISA HARRIS: WHAT TIME OF DAY WAS IT WHEN YOU HAD YOUR ACCIDENT?

 

>>CAROL HAGE WALL: IT WAS ABOUT 4:00 OR 4:30 IN THE AFTERNOON.

 

>>DR. LISA HARRIS: DO YOU REMEMBER BEING SLEEPY AT ALL WHEN YOU WERE DRIVING?

 

>>CAROL HAGE WALL: NOT REALLY, BUT THAT IS THE TIME OF DAY, I LATER FIGURED OUT, THAT I KIND OF DO GET TIRED, BUT I DON'T RECALL THAT AT THE TIME.

 

>>DR. PETER SALGO: WHAT WOULD YOU BE THINKING, WITHOUT ANY PRIOR KNOWLEDGE?

 

>>DR. MICHAEL YURCHESHEN: I'M A NEUROLOGIST, AND THAT'S MY BASIC TRAINING, AND SO WE WORRY ABOUT THINGS THAT CAN HAPPEN SUDDENLY THAT WOULD CAUSE A LOSS OF CONSCIOUSNESS, SO SEIZURE, FOR INSTANCE, SO I WOULD BE ASKING YOU IF ANYTHING LIKE THIS HAD HAPPENED IN THE PAST, NOT WITH THE CAR ACCIDENT, BUT LOSS OF CONSCIOUSNESS OR EVEN SOMETHING MORE SUBTLE, LIKE A RISING FEELING IN YOUR STOMACH OR A FUNNY SMELL.

 

>>DR. LISA HARRIS: AND SO FOR PRIMARY CARE, WE DO LIKE TO GO TO MORE ORGAN SYSTEMS THAN JUST THE BRAIN. SO WE WOULD ASK ABOUT ANY CHEST PAIN -- IT COULD HAVE BEEN A SUDDEN HEART ATTACK, IN ADDITION TO ALL THE THINGS THAT MIKE MENTIONED FOR THE NEUROLOGIC DISORDERS.

 

>>DR. PETER SALGO: ALL OF THIS WAS NEGATIVE?

 

>>CAROL HAGE WALL: I DIDN'T HAVE ANY OF THOSE SYMPTOMS AT THE TIME.

 

>>DR. LISA HARRIS: AND OF COURSE WE'RE GOING TO ASK ABOUT DRUG AND ALCOHOL USE.

 

>>CAROL HAGE WALL: NAH, I --

 

>>DR. PETER SALGO: "NAH" PRETTY MUCH SUMS THAT UP -- UNTIL LAST JANUARY. THEN WHAT HAPPENED?

 

>>CAROL HAGE WALL: WELL, THEN I WAS DRIVING ALONG AND STOPPED AT A STOP SIGN IN MY HOME TOWN, AND I WAS THE SECOND CAR -- THERE WAS A CAR IN FRONT OF ME -- AND I WAS THERE, AND I THINK IT WAS ACTUALLY ABOUT THE SAME TIME OF DAY, AND I HAD VISITED A FRIEND, I WAS GOING HOME, AND THE NEXT THING I KNEW, SOMEBODY WAS POUNDING ON THE WINDOW OF MY CAR, I MEAN, REALLY POUNDING, AND I APPARENTLY FELL ASLEEP, AND THE GUY SAID, "ARE YOU OKAY?" AND I SAID, "I'M OKAY, I'M GOING TO DRIVE HOME," BUT IT WAS AN AWAKENING.

 

>>DR. PETER SALGO: SO TO SPEAK.

 

>>CAROL HAGE WALL: OH -- [ LAUGHS ]

 

>>DR. PETER SALGO: AND I KNOW, WE TALKED, THAT SOMEWHERE IN THE MIDDLE OF THIS STORY, THERE WAS ANOTHER INCIDENT WHERE YOU HAD IRREGULAR HEARTBEATS. WHAT HAPPENED THERE?

>>CAROL HAGE WALL: I WAS HAVING SOME IRREGULAR HEARTBEAT, AND MY DOCTOR SAID, "WELL, LET'S GO GET THAT CHECKED OUT," I WENT AND HAD A NUCLEAR-TYPE TREADMILL TEST, AND THAT DAY THE YOUNG WOMAN THAT WAS MONITORING ME, SHE SAID, "WHY ARE YOU HERE," AND I TOLD HER SOME OF MY SYMPTOMS, AND SHE SAID, "YOU KNOW, YOU MIGHT WANT TO GET CHECKED FOR SLEEP APNEA." AND I SAID, "EVERYBODY GETS SLEEP APNEA. THAT'S A FAD." AND I DIDN'T DO IT.

 

>>DR. PETER SALGO: IT MAY BE A FAD, BUT IT DOESN'T MEAN YOU DON'T HAVE IT.

 

>>CAROL HAGE WALL: YES.

 

>>DR. PETER SALGO: BUT HERE YOU HAVE ONE INCIDENT WHERE YOU CLEARLY FELL ASLEEP IN THE CAR, ANOTHER INCIDENT WHERE YOU ROLLED THE CAR, AND A THIRD WHERE YOU HAD ARRHYTHMIAS, OR IRREGULAR HEARTBEATS. IS THIS A FAMILIAR STORY?

 

>>DR. LISA HARRIS: IT IS, AND AGAIN, FROM A PRIMARY CARE PERSPECTIVE, WE'RE GOING TO BE LOOKING AT SOME OTHER THINGS -- SOME OF THE OTHER LOW-HANGING FRUIT. SO WE'RE LOOKING AT A THYROID DISORDER, TO MAKE SURE THAT YOUR THYROID GLAND IS NOT UNDERACTIVE, THAT YOU'RE NOT ANEMIC, THAT YOU DON'T HAVE DIABETES OR SOMETHING ELSE THAT COULD CAUSE YOU TO BE FATIGUED, AND THEN WE WANT TO GET A SLEEP HISTORY BEFORE WE START JUMPING INTO --

 

>>DR. PETER SALGO: WHAT IS A SLEEP HISTORY, LISA?

 

>>DR. LISA HARRIS: SO WE ACTUALLY WANT TO ASK THE PATIENT ABOUT THEIR SLEEP HABITS -- WHAT TIME – DO YOU HAVE A REGULAR TIME THAT YOU GO TO BED? DO YOU WAKE UP IN THE MIDDLE OF THE NIGHT? HOW OFTEN DO YOU WAKE UP? DO YOU FIND YOURSELF COUGHING OR SHORT OF BREATH? DO YOU SNORE? AND ON AND ON -- I'M SURE MIKE CAN -- I DON'T WANT TO HOG --

 

>>DR. PETER SALGO: ANYTHING ELSE YOU WANT TO PUT ON THAT LIST?

 

>>DR. MICHAEL YUCHESHEN: YEAH, A LOT OF THIS, THE HISTORY IS CRITICAL, I AGREE. AND A LOT OF IT ALSO DEPENDS ON WHAT YOUR BED PARTNER, IF YOU HAPPEN TO HAVE ONE, CAN CONTRIBUTE, BECAUSE JUST BY THE VERY NATURE, YOU'RE UNCONSCIOUS WHEN YOU'RE SLEEPING.

 

>>DR. PETER SALGO: I'VE ASKED PATIENTS, "DO YOU HAVE SLEEP APNEA," AND THEY ALWAYS SAY, "WELL, I'M ASLEEP."

 

>>CAROL HAGE WALL: AND THEY SAY, "AND I DON'T HEAR MYSELF SNORE."

 

>>DR. PETER SALGO: THAT'S RIGHT, BUT THEY DID ASK YOU TO KEEP A SLEEP LOG. IS THAT WHAT LISA WAS ASKING ABOUT?

 

>>CAROL HAGE WALL: YES, AND ACTUALLY, MY FAMILY DOCTOR, BEFORE I WENT FOR THE TEST, THE SLEEP APNEA TEST, ASKED ME TO KEEP A SLEEP LOG. AND I DID THAT ON MY iPHONE. THAT'S MY METHOD OF COMMUNICATION. AND IRONICALLY, ONE DAY, WHEN I WAS SEARCHING MY...FOR MY PROGRAM, I CAME UP WITH ANOTHER REFERENCE TO SLEEP APNEA. AND IT WAS THE REFERENCE THAT THE LADY AT THE HOSPITAL WHEN I WAS HAVING THE HEART TEST SAID, "MAYBE YOU SHOULD CHECK ON SLEEP APNEA." WELL, I DIDN'T CHECK ON IT, BUT IT REMINDED ME THAT, YEP, THIS HAS COME UP AGAIN, AND MAYBE I SHOULD PAY ATTENTION.

 

>>DR. PETER SALGO: SO YOU WENT AND GOT A SLEEP STUDY?

 

>>CAROL HAGE WALL: I DID.

 

>>DR. PETER SALGO: WHAT IS A SLEEP STUDY? WHAT DID IT MEAN TO YOU? WHAT DID THEY DO?

 

>>CAROL HAGE WALL: WELL, I SPENT THE NIGHT IN THE SLEEP STUDY CENTER ON THE BED, HOOKED UP TO ALL SORTS OF EQUIPMENT. THE PEOPLE WERE VERY NICE AND EXPLAINED EVERYTHING TO ME THAT WAS HAPPENING, SO IT WAS RELATIVELY COMFORTABLE, IF YOU'RE CONSIDERING THAT YOU'RE HOOKED UP TO ELECTRICITY --

 

>>DR. PETER SALGO: YOU TURNED INTO DOC OCK OUT THERE.

 

>>CAROL HAGE WALL: YES, RIGHT. BUT IT WENT PRETTY WELL.

 

>>DR. PETER SALGO: WHAT IS A SLEEP STUDY? WHAT ARE YOU LOOKING FOR IN A SLEEP STUDY?

 

>>DR. MICHAEL YURCHESHEN: THERE ARE ACTUALLY NOT -- IT'S NOT JUST ONE SLEEP STUDY ANYMORE. THERE ARE SEVERAL VARIETIES. BUT WHAT YOU'RE DESCRIBING IS WHAT WE CALL A DIAGNOSTIC NOCTURNAL POLYSONOGRAM, AND SO --

 

>>DR. PETER SALGO: WANT TO SAY THAT FIVE TIMES FAST?

 

>>DR. MICHAEL YURCHSHEN: NO. [ LAUGHTER] I'D LIKE TO BE ASKED BACK AGAIN SOMETIME. AND SO IT'S A STUDY WHERE, ESSENTIALLY, WE MONITOR PATIENTS' SLEEP. WE MONITOR SLEEP STAGES. WE MONITOR BREATHING, MOVEMENTS, A LITTLE BIT ABOUT HEART RATE AND RHYTHM, AND FROM THAT INFORMATION WE ASSESS MOSTLY BREATHING DISORDERS, LIKE OBSTRUCTIVE SLEEP APNEA.

 

>>DR. PETER SALGO: NOW, PATIENTS ASK ME – AND IT'S A VALID QUESTION -- I'LL ASK IT FOR YOU IF YOU LIKE -- "I'M HOOKED UP TO EVERY WIRE KNOWN TO MAN AND WOMAN. AND I'M HOOKED UP TO ALL SORTS OF OTHER MONITORS, AND I'M BEING WATCHED. AND YOU EXPECT THIS TO BE A NORMAL NIGHT'S SLEEP. WHY IS THIS AT ALL RELEVANT?"

 

>>DR. MICHAEL YURCHESHEN: SO, IT'S A VERY GOOD QUESTION, AND YOU'RE RIGHT, IT IS ASKED A LOT. WE'RE PRIMARILY INTERESTED, IN MOST OF THESE STUDIES, ABOUT WHAT HAPPENS AFTER YOU FALL ASLEEP, AND IT DOES OCCUR WHERE PATIENTS SOMETIMES DON'T SLEEP AT ALL, AND THAT'S A SITUATION WHERE WE MAY NEED TO REPEAT A STUDY, BUT FUNDAMENTALLY, AFTER YOU FALL ASLEEP, JUST PHYSIOLOGY TAKES OVER, AND WE CAN GENERALLY CAPTURE THE TYPES OF INFORMATION THAT WE NEED.

 

>>DR. LISA HARRIS: SO WE'RE NOT REALLY INTERESTED IN WHETHER OR NOT YOU'RE HAVING A NORMAL NIGHT'S SLEEP OR NOT. WE'RE TRYING TO FIND OUT, "WHAT IS THE BRAIN ACTUALLY DOING WHEN YOU FALL ASLEEP?" AND IS THERE SOMETHING THAT'S OCCURRING WHERE THE BRAIN IS TELLING YOU NOT TO BREATHE, OR IF IT'S A RESPIRATORY PROBLEM WHERE YOU CAN'T BREATHE BECAUSE OF OBSTRUCTION.

 

>>DR. PETER SALGO: DID THEY TELL YOU WHAT YOUR SLEEP STUDY SHOWED?

 

>>CAROL HAGE WALL: I WAS BASICALLY TOLD THAT I WAS, LIKE, A MID-RANGE -- I DID NOT HAVE A SERIOUS SLEEP APNEA PROBLEM, BUT THE ONE THING THAT CAME UP WAS THAT WHEN I WAS IN DEEP SLEEP, MY OXYGEN LEVEL WAS VERY LOW.

 

>>DR. PETER SALGO: I HAPPENED TO SEE SOME OF THE REPORT. I KNOW THAT YOUR OXYGEN SATURATION WENT DOWN TO ABOUT 84%.

 

>>CAROL HAGE WALL: AND I UNDERSTOOD THAT WAS A CONCERN. I HAD BEEN HAVING TROUBLE WITH DEPRESSION AS WELL AS THE SLEEPING, AND A LOT OF ANXIETY, AND I KIND OF UNDERSTOOD THAT THAT COULD BE EXPLAINED BY THE OXYGENATION.

 

>>DR. LISA HARRIS: WELL, YOU NEED OXYGEN TO LIVE. [CHUCKLES] IT SUPPLIES ALL OF YOUR ORGANS, AND SLEEP IS WHEN THE BODY REGENERATES ITSELF. SO IF YOU'RE NOT PROVIDING A VITAL NUTRIENT TO THE BODY WHEN YOU'RE ASLEEP, THEN YOU END UP WITH ORGAN DAMAGE.

 

>>DR. PETER SALGO: SO ARE THERE COMMON SYMPTOMS? WAS SHE HAVING A COMMON SYMPTOM OF SLEEP APNEA?

 

>>DR. MICHAEL YURCHESHEN: IF YOU WERE TO PRESENT TO MY OFFICE -- OCCASIONALLY PEOPLE PRESENT AFTER SOMETHING DRAMATIC LIKE THIS, BUT USUALLY IT'S A LONGSTANDING HISTORY OF FEELING SLEEPY DURING THE DAY, LOW ENERGY. SOMETIMES IT'S HARDER TO FIGURE OUT IN PREMENOPAUSAL WOMEN THAN POSTMENOPAUSAL WOMEN. JUST THE SYMPTOMS MAY LOOK A LITTLE BIT DIFFERENT. AND ALSO IN CHILDREN.

 

>>DR. PETER SALGO: DID YOU HAVE ANY SYMPTOMS, ANYTHING --

 

>>CAROL HAGE WALL: WELL, I DID -- I HAD A PERIOD OF BEING DEPRESSED, AND I CAN TELL YOU NOW THAT IT WAS GRADUALLY GETTING A LITTLE BIT WORSE. I WAS TAKING EXTRA VITAMIN D, I WAS WORKING ON EXERCISE, DOING THINGS I THOUGHT WOULD HELP TURN THAT AROUND, AND MY HUSBAND TELLS ME I SNORE. I CAN'T GUARANTEE THAT. [LAUGHTER]

BUT, UM... AND THE ANXIETY LEVEL AND THE DEPRESSION WERE THE MAIN THINGS, AND I WAS SLEEPY DURING THE DAY. BUT I DIDN'T KNOW, IS THAT MY AGE OR WHATEVER, BUT --

 

>>DR. LISA HARRIS: AND THAT'S WHAT OFTEN DRIVES PATIENTS INTO THE OFFICE. IT'S USUALLY THE SPOUSE OR SIGNIFICANT OTHER THAT'S SAYING, THEY'RE FALLING ASLEEP ALL THE TIME, THEY JUST CAN'T STAY AWAKE.

 

>>CAROL HAGE WALL: RIGHT IN THE MIDDLE OF MY FAVORITE TV SHOWS, RIGHT.

 

>>DR. PETER SALGO: THAT MAY BE ABOUT THE TV SHOW TOO, YOU KNOW.

 

>>CAROL HAGE WALL: [ LAUGHS ]

 

>>DR. PETER SALGO: SO WHAT DID THEY RECOMMEND YOU DO?

 

>>CAROL HAGE WALL: WELL, AT THIS POINT, WHEN I WENT TO THE SECOND SLEEP CENTER, HE ACTUALLY SUGGESTED I USE THE SLEEP APNEA MACHINE FOR A WHILE.

 

>>DR. PETER SALGO: A CPAP MACHINE.

 

>>CAROL HAGE WALL: CPAP MACHINE, WHICH I AM DOING. AND I ALREADY FEEL BETTER. I'VE PROBABLY BEEN USING IT, PROBABLY FOR THREE MONTHS, THREE AND A HALF. I WAS DOING SOME TRAVELING, AND I USED IT WHEN I TRAVELED, BUT BASICALLY ABOUT THAT, AND I SEE A DIFFERENCE.

 

>>DR. PETER SALGO: SO WE'RE GOING TO STOP RIGHT HERE, AND WE'LL COME BACK RIGHT AT THIS MOMENT. YOU ALL STAY WHERE YOU ARE. YOU GUYS STAY WHERE YOU ARE. BUT FIRST, HERE'S THIS WEEK'S "MYTH OR MEDICINE."

 

>>NARRATIVE: OBSTRUCTIVE SLEEP APNEA IS A COMMON TYPE OF APNEA IN CHILDREN. IT'S TYPICALLY CAUSED BY AN OBSTRUCTION IN THE AIRWAY, SUCH AS ENLARGED TONSILS. ONE OF THE MANY SYMPTOMS INCLUDE SNORING, AND TREATMENT IS OFTEN THE SURGICAL REMOVAL OF THE TONSILS AND ADENOIDS. SO IF YOUR CHILD SNORES, THEY SHOULD HAVE THEIR TONSILS OUT? IS THIS MYTH OR MEDICINE?

 

>>DR. HEIDI CONNOLLY: "IF YOUR CHILD SNORES, THEY SHOULD HAVE THEIR TONSILS OUT." THAT IS A MYTH, AND I'M GOING TO TELL YOU WHY. I'M HEIDI CONNOLLY, AND I'M THE CHIEF OF THE DIVISION OF PEDIATRIC SLEEP MEDICINE AT THE UNIVERSITY OF ROCHESTER MEDICAL CENTER AND THE GOLISANO CHILDREN'S HOSPITAL AT STRONG. PROBABLY ABOUT 8% TO 10% OF PRESCHOOL-AGE CHILDREN SNORE, BUT ONLY ABOUT 2% ACTUALLY HAVE SLEEP APNEA. SO IF EVERY CHILD WHO SNORED WAS GOING TO HAVE THEIR TONSILS AND ADENOIDS TAKEN OUT JUST BECAUSE THEY WERE SNORING, WE WOULD BE DOING SURGERY THAT'S NOT NECESSARY. TAKING OUT TONSILS AND ADENOIDS IS A RELATIVELY LOW-RISK SURGICAL PROCEDURE, BUT IT'S STILL A SURGICAL PROCEDURE WITH THE ATTENDANT RISKS OF GETTING GENERAL ANESTHESIA, RECOVERY TIME, TIME OFF OF WORK, AND TIME FROM SCHOOL.

 

>>NARRATOR: WHAT IS THE CORRELATION BETWEEN OBESITY IN CHILDREN AND SLEEP APNEA?

 

>>DR. HEIDI CONNOLLY: HAVING OBESITY INCREASES THE RISK OF HAVING OBSTRUCTIVE SLEEP APNEA BECAUSE IT NARROWS THE AIRWAY DUE TO FAT DEPOSITION IN THE TISSUES OF THE UPPER AIRWAY. THE CONVERSE IS ALSO TRUE, THAT HAVING SLEEP APNEA INCREASES THE RISK OF OBESITY BECAUSE OF THE SLEEP DISRUPTION LEADING TO MORE SLEEPINESS AND SEDENTARY BEHAVIORS DURING THE DAYTIME. TREATMENT OF SLEEP APNEA IS KNOWN TO IMPROVE LINEAR GROWTH IN CHILDREN, SO TALLER CHILDREN WHO WEIGH THE SAME ARE MORE THIN, AND IT ALSO HELPS WITH WEIGHT LOSS BECAUSE CHILDREN ARE MORE ENGAGED IN ACTIVITIES DURING THE DAYTIME AND THEREFORE LESS LIKELY TO BE SEDENTARY AND HAVE EXCESS WEIGHT GAIN. AND THAT'S MEDICINE.

 

>>NARRATOR: NOT SURE IF IT'S MYTH OR MEDICINE? CONNECT WITH US ONLINE. WE'LL GET TO WORK AND GET YOU A SECOND OPINION.

 

>>DR. PETER SALGO: AND WE'RE BACK WITH CAROL, WHO HAD SOME SCARY MOMENTS THERE. YOU ROLLED YOUR CAR OVER ONCE, YOU HAD SOME IRREGULAR HEARTBEATS, SOMEONE HAD TO WAKE YOU UP WHILE YOU WERE SITTING IN THE CAR. HAD A SLEEP STUDY, THEY TOLD YOU YOU HAD MILD SLEEP APNEA, AND THEY PUT YOU ON SOMETHING CALLED CPAP.

 

>>CAROL HAGE WALL: YES.

 

>>DR. PETER SALGO: WHAT ON EARTH IS CPAP?

 

>>CAROL HAGE WALL: WELL, IT'S A LITTLE MACHINE THAT I HOOK MYSELF UP TO AT NIGHT -- I HAVE A TYPE OF CONNECTION THAT'S A NOSE PAD, WHICH I LIKE BECAUSE IT'S MORE MINOR THAN SOME OF THE OTHER OPTIONS -- AND IT HELPS ME TO BREATHE DURING THE NIGHT BY BOTH AIR IN AND AIR OUT. AND I CAN FEEL IT.

 

>>DR. PETER SALGO: ARE YOU FEELING BETTER IN THE MORNING BECAUSE YOU'RE WEARING CPAP AT NIGHT?

 

>>CAROL HAGE WALL: YES, I'M FEELING BETTER THE WHOLE DAY BECAUSE OF THAT.

 

>>DR. PETER SALGO: SO HOW DOES CPAP WORK?

 

>>DR. LISA HARRIS: WELL, IT STANDS FOR CONTINUOUS POSITIVE AIRWAY PRESSURE, SO IT PROVIDES A CONTINUOUS PRESSURE FLOW OF OXYGEN THROUGH THE NASAL PASSAGES OR THROUGH THE AIRWAY, TO KEEP THINGS OPEN.

 

>>DR. MICHAEL YURCHESHEN: YEAH, SO IT'S NOT SUPPLEMENTAL OXYGEN, WHICH MANY PEOPLE WOULD BE FAMILIAR WITH, BUT IT'S JUST REGULAR ROOM AIR THAT'S BEEN PUT UNDER PRESSURE. THE PRESSURE IS CUSTOMIZED TO THE PATIENT, AND IT JUST SPLINTS THE AIRWAY OPEN SO YOU CAN DO YOUR OWN NATURAL BREATHING.

 

>>DR. PETER SALGO: SO LET ME GET A DEFINITION HERE FOR A MINUTE. IF YOU'RE USING CPAP TO BLOW THE AIRWAY OPEN, THAT IMPLIES THAT AT LEAST PART OF THE PROBLEM IS ANATOMIC -- THAT THE AIRWAY IS RELAXING IN SLEEP IN SOME WAY TO CAUSE IT TO CLOSE DOWN AND PREVENT YOU FROM BREATHING.

 

>>DR. MICHAEL YURCHESHEN: THAT'S EXACTLY RIGHT.

 

>>DR. PETER SALGO: BUT THERE'S ALSO A KIND OF SLEEP APNEA THAT'S CENTRAL, RIGHT, WHERE YOUR BRAIN SIMPLY SAYS, "LA LA LA, I DON'T NEED TO BREATHE"?

 

>>DR. MICHAEL YURCHESHEN: THAT'S CORRECT.

 

>>DR. PETER SALGO: DOES CPAP WORK FOR BOTH OR JUST ONE?

 

>>DR. MICHAEL YURCHESHEN: NO, CPAP IS THE MAINSTAY OF TREATMENT FOR OBSTRUCTIVE SLEEP APNEA.

 

>>DR. PETER SALGO: THAT'S THE FIRST KIND, THE ANATOMIC PROBLEM.

 

>>DR. MICHAEL YURCHSHEN: RIGHT. THERE ARE SIMILAR TYPE MACHINES BUT MORE SOPHISTICATED THAT YOU MIGHT CONSIDER TO USE FOR SOMEBODY WHO HAS CENTRAL SLEEP APNEA.

 

                >>DR. PETER SALGO: OKAY, SO THEORETICALLY, AT LEAST, WHAT YOU HAD WAS OBSTRUCTIVE SLEEP APNEA.

 

>>DR. LISA HARRIS: THERE'S A THIRD THAT'S MIXED.

 

>>DR. PETER SALGO: THE MIXED -- THERE'S ALWAYS A THIRD ONE THAT'S MIXED, BUT THE POINT I'M TRYING TO GET AT IS, IF YOU WERE TO LOOK AT THIS YOUNG WOMAN, YOU WOULD NOT SAY SHE FITS THE CLASSIC DESCRIPTION OF SOMEBODY WITH OBSTRUCTIVE SLEEP APNEA. MOST PEOPLE BELIEVE THAT THEY HAVE THESE RECEDING CHINS AND THICK NECKS AND THEY WEIGH 2 MILLION POUNDS. YOU DON'T, DO YOU?

 

>>CAROL HAGE WALL: NOT LAST TIME I CHECKED.

 

>>DR. PETER SALGO: OH, I'M GLAD. SO CAN YOU TELL FROM PHYSICAL APPEARANCE, IS WHAT I'M ASKING.

 

>>DR. LISA HARRIS: SO THERE ARE SOME PATIENTS, BASED ON PHYSICAL APPEARANCE, THAT YOU WOULD SUSPECT -- SO THE MORBIDLY OBESE PATIENT THAT YOU ALREADY DESCRIBED, YOU WOULD SUSPECT HAS SLEEP APNEA, BUT WE CAN'T TELL JUST FROM LOOKING AT SOMEONE WHETHER OR NOT THEY ARE.

 

>>DR. PETER SALGO: BUT WHY, IF YOU WERE OKAY UNTIL THIS POINT IN YOUR LIFE, WOULD YOU NOW DEVELOP SLEEP APNEA? DID ANYONE EVER DISCUSS THAT WITH YOU?

 

>>CAROL HAGE WALL: NO, THEY HAVEN'T. I THOUGHT IT MIGHT HAVE SOMETHING TO DO WITH AGING.

 

>>DR. MICHAEL YURCHESHEN: SO, I MEAN, THOSE WOULD BE QUESTIONS I'D ASK ABOUT. I'D ASK ABOUT WEIGHT CHANGE. AND AS I MENTIONED BEFORE, MENOPAUSE CAN PLAY A ROLE HERE TOO, SO THAT SOME WOMEN WHO DON'T HAVE SLEEP APNEA PRIOR TO MENOPAUSE DO, ONCE THEY GO THROUGH CHANGE OF LIFE.

 

>>DR. PETER SALGO: SO IT MAY BE HORMONAL. IT MAY BE PHYSIOLOGIC. IT COULD BE ANATOMIC, SIMPLY BECAUSE OF WEIGHT. OR THE MOST COMMON CATEGORY -- WE DON'T KNOW.

 

>>CAROL HAGE WALL: RIGHT, AND YOU MENTIONED CHECKING THE THYROID. I'VE BEEN ON THYROID FOR MANY YEARS, BUT I DO HAVE IT CHECKED REGULARLY.

 

>>DR. LISA HARRIS: THYROID DOESN'T CAUSE SLEEP APNEA, BUT IT'S SOMETHING THAT WE WOULD HAVE LOOKED AT, JUST AS PART OF YOUR SYMPTOMS OF FATIGUE.

 

>>CAROL HAGE WALL: CORRECT.

 

>>DR. PETER SALGO: OKAY, SO, OTHER THAN FALLING ASLEEP, WRECKING YOUR CAR, NEEDING A NAP IN THE MIDDLE OF THE DAY, WHAT ARE THE OTHER MEDICAL RISKS ASSOCIATED WITH SLEEP APNEA?

 

>>DR. MICHAEL YURCHESHEN: THERE ARE MANY, AND THIS IS A VERY HOT AREA OF RESEARCH, BUT YOU MENTIONED SOME OF THESE THINGS, TOO – CARDIOVASCULAR RISK AND CARDIAC ARRHYTHMIAS. AND THERE'S A LOT OF EMERGING DATA ABOUT THAT -- THINGS LIKE STROKE RISK, RISK OF HIGH BLOOD PRESSURE, AND THE RISK OF MOOD DISORDERS LIKE DEPRESSION.

 

>>DR. PETER SALGO: NOW, YOU SAID YOU WERE DEPRESSED, RIGHT?

 

>>CAROL HAGE WALL: YES.

 

>>DR. PETER SALGO: SO HOW LONG HAVE YOU BEEN ON THE SLEEP APNEA MACHINE NOW, THE CPAP MACHINE?

 

>>CAROL HAGE WALLL: I THINK ABOUT THREE MONTHS.

               

>>DR. PETER SALGO: AND HAS IT MADE A DIFFERENCE?

 

>>CAROL HAGE WALL: IT'S MADE A HUGE DIFFERENCE. I DON'T -- BEFORE I WAS ON THE MACHINE, I WAS HAVING TROUBLE JUST CONCENTRATING, AND I DO A LOT, I'M A VERY BUSY PERSON, I DO LOTS OF PROJECTS. AND I WAS NOT FUNCTIONING WELL WITH THOSE. I NOW KNOW THAT I FUNCTION BETTER, BECAUSE SOME THINGS I'VE TAKEN ON SINCE THEN. ONE OF THE QUESTIONS THAT WAS ASKED ON THE QUESTIONNAIRE THAT I DID WAS ABOUT LIBIDO, AND I DIDN'T REALI-- I MEAN, I KNEW THAT MY LIBIDO WAS LOW, BUT I FIGURED, "OH, WELL, I'M PUSHING 70-SOMETHING, AND SO -- I'LL TELL YOU, THE SLEEP APNEA MACHINE REVERSED THAT, AND THAT'S KIND OF NICE. [ LAUGHTER ]

 

 

>>PETER SALGO: WE DON'T NEED TO GO MUCH FURTHER ON A FAMILY SHOW, BUT --\

 

>> CAROL HAGE WALLL: I WASN'T GOING TO SAY MUCH MORE, BUT, YOU KNOW, IT WAS DEFINITELY AN ELEMENT THAT I WAS VERY SURPRISED TO SEE MADE A DIFFERENCE, AND I HAVE JUST MORE ENERGY, I'M ABLE TO THINK MORE DIRECTLY, LIKE, I'M A VERY ORGANIZED PERSON, AND I'M THAT PERSON AGAIN. AND IT FEELS GOOD.

 

 

>>PETER SALGO: SO WHAT INTERESTS ME IS WHEN YOU SAY, "I'M THAT PERSON AGAIN," WHICH IMPLIES THAT THERE WAS A CHANGE THAT NOW, IN RETROSPECT, YOU NOTICED. AND DO YOU KNOW WHEN THAT CHANGE OCCURRED?

 

>> CAROL HAGE WALLL: UM...NOT EXACTLY.

 

 

>> DR. LISA HARRIS: AND THAT'S VERY TYPICAL, AND IT SPEAKS EXACTLY TO THE SYMPTOMS THAT WE'RE TALKING ABOUT. IT'S PRETTY MUCH AN INSIDIOUS ONSET, THAT PATIENTS DON'T REALLY NOTICE THE CHANGE.

 

>> PETER SALGO: IT'S GRADUAL AND A LITTLE ONE CHIP AT A TIME.

 

 

>> CAROL HAGE WALLL: ABSOLUTELY.

 

 

>> DR. MICHAEL YURCHESHEN: IN FACT, SOME PATIENTS WILL COME IN AND TELL ME, "I SLEEP FINE, I FEEL FINE DURING THE DAY." AND THEN YOU MAY STILL BE SUSPICIOUS, DIAGNOSE AND TREAT FOR SLEEP APNEA, AND PEOPLE ARE SOMETIMES SURPRISED AT THE DIFFERENCE IT MAKES.

 

 

>>PETER SALGO: ONE QUESTION THAT COMES UP -- IS THERE A DIFFERENCE BETWEEN SLEEP APNEA AND INSOMNIA? BECAUSE BOTH OF THEM MAKE YOU TIRED THE NEXT DAY AND CAN AFFECT YOUR HEALTH AND MENTAL STATUS. HOW DO YOU DISTINGUISH?

 

>>DR. MICHAEL YURCHESHEN: SO INSOMNIA IS, DEFINITIONALLY, IS DIFFICULTY FALLING ASLEEP, STAYING ASLEEP, OR UNREFRESHING SLEEP. AND ALTHOUGH THERE IS SOME OVERLAP BETWEEN SLEEP APNEA AND INSOMNIA, THEY'RE NOT IDENTICAL. YOU CAN HAVE INSOMNIA FOR A VARIETY OF REASONS, SOME OF THEM MEDICAL, SOME OF THEM JUST TRAINING -- YOU'VE ALMOST TRAINED YOURSELF NOT TO SLEEP WELL.

 

>>PETER SALGO: MM-HMM. I MEAN, I WAS SURPRISED TO LEARN, WHEN I LOOKED AT THIS, IF YOU GO TO BED TOO EARLY -- THAT IS TO SAY, YOU HAVE POOR SLEEP HYGIENE, WHICH WOULD INCLUDE GOING TO BED TOO EARLY OR DOING DISTURBING THINGS BEFORE BED, THAT CAN GIVE YOU INSOMNIA.

 

>>DR. LISA HARRIS: THAT'S RIGHT.

 

 

>>PETER SALGO: AND GIVE YOU SYMPTOMS THE NEXT DAY.

 

>>DR. LISA HARRIS: AND THAT'S PART OF ASKING THE SLEEP HISTORY EARLIER ON, TO TRY TO DIFFERENTIATE, IS THIS -- WHAT TYPE OF SLEEP DISORDER ARE WE DEALING WITH?

 

>>PETER SALGO: NOW, FOR A WHILE, THERE WERE A LOT OF OPERATIONS PERFORMED FOR OBSTRUCTIVE -- MECHANICAL -- SLEEP APNEA, WHICH IS A FORM OF WHAT YOU HAD. THEY WENT IN AND DO A RETROPHARYNGEAL PROCEDURE TO TRY TO OPEN UP THE AIRWAY. I SEE LESS OF THAT NOW. IS THAT OUT OF VOGUE?

 

>> DR. MICHAEL YURCHESHEN: WELL, "OUT OF VOGUE" -- IT'S PATIENT-DEPENDENT. SO IF YOU WERE DOING PEDIATRICS, YOU'D SEE A LOT MORE OF IT. YOU'D HARDLY SEE ANY CPAP. IN ADULT PATIENTS, NOT THAT OFTEN. EVERY ONCE IN A WHILE, BUT CPAP IS CLEARLY THE BEST TREATMENT FOR MOST CASES OF SLEEP APNEA.

 

>>PETER SALGO: BUT SHE'S LUCKY YOU'VE GOT JUST THAT LITTLE NASAL CANNULA, RIGHT?

 

>> CAROL HAGE WALLL: YES.

 

 

>>PETER SALGO: DOES IT GET IN YOUR WAY WHEN YOU SLEEP?

 

 

>> CAROL HAGE WALLL: IT DOES, SOME, YES, I WOULD RATHER NOT WEAR IT FROM THE POINT OF VIEW -- FRANKLY, IT GETS IN THE WAY, BECAUSE I FORGET WHERE THE HOSE GOES, AND IT GETS IN THE WAY WHEN I WANT TO SNUGGLE WITH MY HUSBAND, SO, YOU KNOW, BUT I –

 

>>PETER SALGO: AND I THINK YOU'VE ALREADY TOLD US THAT THE SNUGGLING IS INCREASING, SO --

 

>> CAROL HAGE WALLL: YES, YES!

 

 

>> DR. MICHAEL YURCHESHEN: AGGRESSIVE SNUGGLING.

 

 

>>PETER SALGO: AGGRESSIVE SNUGGLING, BUT OTHER PEOPLE WEAR A MASK WITH ELASTIC BANDS BEHIND THEIR -- THIS IS A BIG DEAL. IS THERE ANYTHING ON THE HORIZON THAT WOULD MAKE THAT OBSOLETE?

 

>> DR. MICHAEL YURCHESHEN: JUST TO SPEAK TO THAT ISSUE, YOU KNOW, PATIENT COMFORT IS A PREMIUM. IF IT'S NOT COMFORTABLE, YOU WON'T WEAR IT, AND EVERYONE'S A LITTLE DIFFERENT. THERE ARE OTHER TREATMENT OPTIONS FOR SLEEP APNEA, AND OF THOSE, PROBABLY THE ONE THAT'S MORE COMMON IS SOMETHING CALLED AN ORAL APPLIANCE, WHICH IS SIMPLY A MECHANICAL DEVICE THAT YOU PUT IN YOUR MOUTH TO BRING YOUR JAW FORWARD AND OPEN THE AIRWAY. ON THE HORIZON, FDA APPROVED, AND THIS WILL BE FOR A MINORITY OF PATIENTS, BUT SOME PEOPLE WHO ARE NOT INTERESTED IN USING CPAP, ALMOST LIKE A PACEMAKER FOR THE TONGUE.

 

>>PETER SALGO: I READ THAT.

 

 

>> DR. MICHAEL YURCHESHEN: YES. AND IT'S EXCITING, BUT IT'S NOT GOING TO BE FOR EVERYBODY.

 

>>PETER SALGO: OKAY. NOW, HERE'S THE POINT IN THE SHOW I PROMISED YOU WOULD COME -- IT'S YOUR MOMENT. YOU'VE GOT SLEEP EXPERTS, GREAT DOCTORS HERE. FIRE AWAY, ANY QUESTIONS YOU'VE GOT FOR YOUR SECOND OPINION.

 

>> CAROL HAGE WALLL: WELL, I WAS REALLY INTERESTED IN MORE OF WHAT YOU SAID. I WOULD REALLY RATHER NOT USE THE MACHINE. AND THEY SAY THAT MY LEVEL IS MORE MINOR OF THE APNEA. I WOULD LIKE TO CONTINUE IMPROVING AND HAVE THIS, BUT I WOULD RATHER NOT USE THE MACHINE. AND SO I'M VERY INTERESTED IN WHAT'S DOWN IN THE FUTURE. I'M NOT SURE THAT I WANT A JAW--

 

 

>>DR. LISA HARRIS: I WANT TO JUMP IN ON THAT. THE THINGS THAT ARE DOWN IN THE FUTURE ARE FOR PATIENTS THAT ARE MORE SEVERE.  SO CPAP IS REALLY THE MAINSTAY OF THERAPY FOR PEOPLE WHO ARE MILD TO MODERATE, AND THEN WE MOVE ON FROM THERE.

 

>> CAROL HAGE WALLL: I'VE SOMETIMES WONDERED IF IT'S AN OVERCORRECTION, IF I DON'T NEED IT, BECAUSE I HAVEN'T HAD -- BUT YET I'VE SEEN DEFINITE BEHAVIORS IN MY OWN LIFE THAT HAVE IMPROVED. AND I KIND OF DON'T WANT TO NOT DO IT, BECAUSE OF THAT.

 

>> DR. MICHAEL YURCHESHEN: THE THINGS THAT I THINK THAT YOU MIGHT CONSIDER IN THE IMMEDIATE FUTURE -- AND THIS WOULD DEPEND ON EXACTLY WHAT THE STUDY SAID. SOME PEOPLE, YOU KNOW, EVEN A MODEST WEIGHT LOSS CAN BE HELPFUL.

 

>> CAROL HAGE WALL: AND I'VE BEEN TOLD THAT.

 

>> DR. MICHAEL YURCHESHEN: BODY POSITION CAN MAKE A DIFFERENCE. SO SOMETIMES SLEEPING ON THE SIDE VERSUS THE BACK, OR EVEN THE POSITION OF THE HEAD CAN MAKE A DIFFERENCE, ALTHOUGH SOMETIMES IT'S NOT EASY TO TAKE ADVANTAGE OF AT HOME. THERE HAVE BEEN SOME OTHER STUDIES THAT HAVE LOOKED AT OTHER, MORE LIKE TRAINING OR PHYSICAL THERAPY OF THE UPPER AIRWAY. PLAYING AN INSTRUMENT CALLED THE DIDGERIDOO HAS BEEN EXAMINED. AND IT DOES SEEM TO HAVE A BENEFIT.

 

 

>> PETER SALGO: ALL RIGHT, WELL, THANK YOU BOTH VERY MUCH. CAROL, THANK YOU SO MUCH FOR SHARING YOUR STORY WITH US, AND, PANEL, OF COURSE, GREAT THANKS FOR GIVING YOUR SECOND OPINION AND SHARING YOUR EXPERTISE. AND NOW HERE'S THIS WEEK'S "SECOND OPINION 5."

 

 

>> DR. DON GREENBLATT: HELLO, I'M DR. DON GREENBLATT, AND I'M HERE TO SHARE FIVE TIPS TO HELP YOU SLEEP WELL. FIRST THING TO DO IS TO PREPARE YOUR SLEEP ENVIRONMENT. KEEP IT DARK, QUIET, AND COOL. WE GENERALLY SLEEP BEST WHEN OUR BODIES ARE COOLING. AND SLEEP IS DISTURBED BY NOISE AND LIGHT. BY THE WAY, IF YOU CAN'T FALL ASLEEP WITHIN 30 MINUTES, DON'T TOSS AND TURN -- GET UP, GO TO ANOTHER ROOM, DO SOMETHING QUIET. NEXT, AVOID ALCOHOL, CAFFEINE, AND NICOTINE. CAFFEINE AND NICOTINE ARE STIMULANTS AND CAN KEEP YOU AWAKE. FOR MANY PEOPLE, DRINKING COFFEE OR COLA ANY TIME AFTER NOON CAN LEAD TO A RESTLESS NIGHT. ALCOHOL CONSUMED IN THE LATE EVENING CAN CAUSE RESTLESS SLEEP AND NIGHTMARES, AND IT WILL ALSO MAKE SNORING AND APNEA MORE LIKELY. THE THIRD TIP IS TO ESTABLISH A REGULAR SLEEP/WAKE PATTERN, GETTING UP AT CLOSE TO THE SAME TIME EVERY MORNING, AND TO EXPOSE YOURSELF TO BRIGHT LIGHT WHEN YOU GET UP. LIGHT WILL AFFECT OUR BODIES' PRODUCTION OF MELATONIN AND WILL RESET YOUR BODY CLOCK. BRIGHT LIGHT CLOSE TO BEDTIME ON THE OTHER HAND, EVEN FROM A COMPUTER SCREEN OR TV, CAN KEEP YOU AWAKE AND SHOULD BE AVOIDED. WHAT ABOUT EXERCISE AND DIET? AGAIN, WE SLEEP BEST WHEN WE'RE COOLING, SO EXERCISE DONE FOUR TO SIX HOURS BEFORE BED CAN HELP US SLEEP DEEPER. HUNGER IS ALSO A FACTOR. DON'T GO TO BED HUNGRY, BUT YOU ALSO DON'T WANT TO FEEL FULL. IF YOU'RE DIETING, JUST MOVE A FEW CALORIES, PARTICULARLY CARBOHYDRATES, FROM DINNER TO A LIGHT BEDTIME SNACK. LASTLY, REMEMBER THAT BED IS THE PLACE WHERE YOU REST FROM THE DAY'S ACTIVITIES, NOT A PLACE WHERE YOU PLAY ON YOUR PHONE, DO WORK, OR EAT DINNER. THE BED SHOULD BE RESERVED ONLY FOR SLEEP AND SEX. AND THAT'S YOUR "SECOND OPINION 5." SWEET DREAMS.

 

 

>>PETER SALGO: WELL, THANK YOU SO MUCH FOR WATCHING "SECOND OPINION." WE HOPE YOU CONTINUE THE CONVERSATION ON OUR WEBSITE, WHERE YOU CAN COMMENT ON THE SHOW, SEND US YOUR SHOW IDEAS, SHARE YOUR HEALTH STORY WITH US, AND MAYBE WE'LL INVITE YOU TO BE ON THE SHOW. THE WEB ADDRESS IS secondopinion-tv.org. I'M DR. PETER SALGO, AND I'LL SEE YOU NEXT TIME FOR ANOTHER "SECOND OPINION."

 

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>>ANNOUNCER: "SECOND OPINION" IS PRODUCED IN CONJUNCTION WITH U.R. MEDICINE, PART OF UNIVERSITY OF ROCHESTER MEDICAL CENTER, ROCHESTER, NEW YORK.