Aaron Boster, MD

[00:30:26] Meghan Beier, PhD: Now that you’ve heard from Ashley about her experience of being diagnosed with multiple sclerosis. Let’s hear from Dr. Boster, who answers the question, what is MS?

[00:30:38] Aaron Boster, MD: So in order to understand, MS. I want to start by thinking about the immune system. All right. So the immune system are a bunch of little white blood cells, which are made of the bone marrow. And when they grow up, they become soldiers. They go tool around the human body and they identify, um, our own cells and they wave and say hi, and then they identify foreign invaders.

And when they see a foreign invader, they make a memory of it and then they lay waste to it. And it keep a memory of that foreign invader. So the second time you get chickenpox, you don’t manifest spots on your body because your body clears it. Now sometimes unfortunately, um, the immune system makes an error in judgement.

And through a series of weird events, it can identify part of your body as being a foreign invader. So once it does that, it can’t unlearn that and you know, auto-immune conditions are very common. So if the immune system picks on the pancreas, we call that disease, diabetes mellitus. And if the immune system picks on the joints, we call that disease rheumatoid arthritis.

Multiple sclerosis is an autoimmune condition where the immune system inappropriately attacks the holiest of Holies, the super computer that runs the body. And the super highway. You know, the spinal cord that takes all the information from the brain down to your feet and back up. And it manifests really kind of in two ways, people can have discrete episodes of neurological dysfunction where God forbid they lose sight in an eye, or they can’t feel their leg or their hand is clumsy.

And we call these relapses or flare ups or attacks. And it’s a time period where a naughty autoreactive immune cell crossed from the bloodstream into the blood-brain barrier and attack the part of the brain or spinal cord and caused it to short circuit. Now there’s a second way that you can have a pathology in MS, unfortunately, and that’s a term which has recently been termed as PIRA progression, which is independent from any relapse. And this is a situation where there’s a slow burn, where people slowly accumulate neurological disability over time. I always like to point out that that’s in the untreated state and we don’t do untreated MS. At least not in my shop.

[00:32:35] Meghan Beier, PhD: Great. And you know, there’s lots of theories or, I I’ve heard a lot of theories about what causes MS. And I’ve also heard that we don’t really know what causes MS. So can you talk a little bit about that?

[00:32:48] Aaron Boster, MD: Yes, I think you’re right in both states. So, so there’s a lot of theories and we don’t have the definitive answer. I will share with you like the party line, the best that we have today. Um, and so the idea is that. There’s a genetic predisposition. So for example, you and I are pasty white folks that would trace our ancestry roughly back to Northern or Western Europe, very likely.

And folks that trace their ancestry back to that part of the world, tend to share genes. And I don’t mean BlueJeans and, and that includes the genes for, um, our immune response. And so there tends to be a haplotype, a genetic variant amongst folks from Europe, which would predispose them to be more likely to experience a form of auto-immunity compared to a different group of people.

Now, very clearly, that’s not enough to cause MS or everyone in Ohio would have MS. But the idea is that that is probably a predisposition, which would kind of stack the genetic genetically against you. And there’s a belief that there are environmental factors, which can augment that risk profile. So for example, we’ve learned that children who are morbidly obese, double the likelihood of developing MS.

Uh, and so there’s an entire literature about inactivity and obesity early on pre-puberty we’ve also learned, for example, that low levels of vitamin D pre-puberty increased the risk of develop MS. And lastly, and maybe most importantly, exposure to tobacco smoke, including secondhand smoke significantly increases the child’s risk to get MS.

And so, as you can imagine, um, someone growing up with that gene background may be exposed to secondhand smoke and may not have a high level of vitamin D or maybe inactive. And they’ve increased the risk to develop MS. Now, clearly that’s not enough. Otherwise, you know, a bunch of overweight kids in Ohio would all have MS.

And they don’t. We then believe that there’s a problem where your immune system sees a bad guy. It sees a virus. And typically we think of either EBV or rarely we might consider chlamydia, but let’s talk about the kissing sickness. So you get EBV, mono, and your immune system does its best job to build an arsenal to beat up mono.

Except it makes an error in judgment. And with that genetic predisposition and those, [00:35:00] those environmental changes, it, it builds an arsenal which identifies your brain as being EBV or a foreign invader. And once that mistake is set up, it can’t be undone. So that’s the leading idea. Um, and it’s not perfect, but it’s a works in progress. As my mentor used to say,

[00:35:17] Meghan Beier, PhD: Right. Yeah. I’ve heard all of those things too. And I think that’s a really great explanation. Um, I’ve also heard that it’s very challenging sometimes. Maybe not always, but sometimes to diagnose MS. And so what does it take to diagnose somebody with MS?

[00:35:33] Aaron Boster, MD: So there’s no blood test for MS to your point, much to my chagrin, that would make my job way too easy. Maybe now there are five elements to an MS diagnosis. If I use patient friendly language. And I have five fingers in my left hand. So as long as they go through every finger, I’ll never forget any. So let’s do that now.

So the first one is your story. And we call that the medical history. Cause it sounds highfalutin, but it’s stuff you tell me. And really what I’m listening for is one of two things. I’m either listening for a story of attacks. We are. And I’m listening to an event that fits the typical description. Sub acute onset lasts a couple of weeks.

It gets better, blah, blah, blah. So I’m listening for a history like that, or I’m listening for a history of progression of an insidious decline over time. So that’s the first element. The second element is the examination. So when we have you do all the funky tests that neurologist have you done. What we’re really doing is we’re trying to see if we can buttress what you tell us with findings on exam.

For example, if you tell me that you were kind of walking, like you were drunk, but you weren’t. And then I walk with you. I would look for unsteadiness of gait, which would support what you just told me. third thing is the MRI and MRIs are our very best diagnostic biomarker. And so we are, our diagnostic criteria have increasingly utilized MRI because it allows us to diagnose much, much faster.

The earlier the diagnosis, the faster the treatment, the better outcomes and the theory and the MRI typically involves a scan of the brain and of the cervical spine. And we’re looking for spots. The real word is brain damage, but neurologists kind of hide it by calling it something which is nonsensical. Um, and we’re looking for brain damage in certain locations.

So there’s these special locations that we look for. And then number four is a spinal tap. Now most patients, in my opinion, do not require a spinal tap for diagnosis, but there are times where the spinal tap can make the difference. Um, I had a case like that today, actually. And so in some people it’s very appropriate to obtain CSF, to look for essentially an overly active immune response in the central compartment.

And then number five is my favorite. Hey, Aaron, prove it’s nothing else. Um, and there’s actually a very large list of things that mimic MS. We call that the differential diagnosis, if you will. And so the onus is on me to make sure I’m not missing something else. So, so those are the five things that we look for when trying to make a diagnosis.

[00:37:53] Meghan Beier, PhD: Can you share what some of those mimics are? I mean, it is a very long list, so you don’t have to go through all of them, but maybe some common ones.

[00:38:01] Aaron Boster, MD: Yeah, for sure. So, uh, you know, I’d like to kind of think about it in, in buckets. So there’s a bucket of infections that you probably don’t have that can mimic on us. And these are things like HIV, syphilis, tuberculosis, things like that, varicella. So it’s very common that an MS neurologist may get a battery of infections. You didn’t think you have those infections, but we don’t want to think we want to know. So that’s the first thing.

The second category are metabolic conditions. And so sometimes low levels of B12, for example, can cause neurological issues or a weird thyroid can cause neurological issues.

Interestingly, diabetes can sometimes mimic MS, even though they’re very, very different conditions. And the third category would be sort of other connective tissue autoimmune conditions. So for example, lupus can sometimes look like MS. Sjogren’s can sometimes look like MS. Now, there are other categories that we look at, but, but those are the big buckets that most MS neurologists are going to be thinking about when trying to work someone up. And the way that we’re going to sort that out. Number one is by history. Number two is by MRI and number three are by laboratories testing that we’ll get through the blood to kind of cross things off our list.

[00:39:11] Meghan Beier, PhD: And can you share a little bit, you know, sometimes I have patients who come in and they say I had my first symptom years ago and I didn’t get diagnosed until, a couple months ago. Why does that happen sometimes?

[00:39:23] Aaron Boster, MD: So, um, it happens for a multitude of reasons and we like to start by sharing we’ve gotten better. First of all, the diagnostic criteria, when I started in this game involved all clinical measures and when we invented the MRI, we were able to speed up diagnosis three times faster. So some of the people that you’re talking to may have suffered from a historic, you know, poor criteria.

But, but there’s other reasons. So. When you slur your speech one night and your significant other says, Hey, you’re starting to speech. You do whatever you red blooded American does. You just go to bed and hope that when you wake up, it’s better. And [00:40:00] if it’s better, you’ll ignore it. Even if your speech was slurred for a couple of days in your twenties or thirties, there’s a high likelihood that if it got better, you would just go about life.

And so I’m not trying to make a disparaging comment about humans, but, but natural behaviors. Okay, well, that’s better now. So I’m not going to go seek the attention of a doc. And very often, it’s not until we start talking about MS. They say, oh my gosh. Oh wow. When I was 30, I couldn’t see. And I didn’t know what it was and it got better and I ignored it. Or they didn’t ignore it, but they came to the attention of a doctor and they weren’t able to make the diagnosis.

And so that’s, that’s a major factor. Now there are other factors. Um, there’s, there’s even, for example, Um, ethnic minority communities, there’s systemic racism where doctors are not as attentive to African-Americans as they are to Caucasians. Um, and so we have to fight against things like that. You know, the bottom line is I always like to remind people, it’s your brain and it’s your body and you don’t get a second one, particularly not a second brain.

If something is wackadoodle, we should figure it out. You know? And, and although it’s not easy to diagnose MS. It is. Quantifiable in many respects. And so I asked you if you’re listening to this podcast and you have some weird neurological thing, holler out a neurologist and let us work you up so we can try to figure it out.

[00:41:18] Meghan Beier, PhD: Great. That’s great advice. Um, can you talk a little bit about clinically isolated syndrome, radiologically isolated syndrome? You said we’ve gotten better at diagnosing MS. Does that mean those things have gone away or do, are those still viable categories?

[00:41:33] Aaron Boster, MD: That was an excellent, uh, second part of your question. Let’s break that down or unpack it a little bit. So when someone has, an optic neuritis as an example on the first event, which is de myelinating and inflammatory involving the central compartment, there’s a question on the table. Could that go on to become multiple sclerosis?

And we’ve gotten savvy. We know that if you have certain MRI characteristics, and if you have certain lumbar puncture characteristics that you may be more likely to be, uh, headed towards MS or not. So just by way of example, if you have optic neuritis and your spinal fluid is normal and your brain MRI is normal, you’ve got about a 20% chance, a one in five chance over the next 20 years of developing MS.

If however, you have spots on your brain MRI, that look like MS, that risk goes up to 80, 85% just based on that MRI. So, so whatever the situation may be, when you have that first clinical event, we call it something specific. We call it a clinically isolated syndrome. Now I used to joke that, you know, there’s a similarity between the clinically isolated syndrome and the tooth fairy, and that neither actually exists. And, you know, very often when we’re dealing with clinically isolated syndrome we’re then following someone for years with annual MRIs, with examinations and so on and so forth, because we’re looking for, for the next event that would qualify them for diagnosis. Now you brought up one of my favorite categories in MS.

And that’s R I S we’re radiographically isolated syndrome. Clinically isolated syndrome is when you have the first clinical event. Radiographically isolated syndrome occurs before that, when you get an MRI for some other reason, and in the modern era, you get an MRI. If you sneeze, or if you’re accessibly flatulent or there’s a numerous reasons why a doc might say, let’s get a scan, right?

So you stick your head in the scanner and lo and behold, you have spots that look like MS. And then you take a very careful history, no history of MS. Then you do a extensive neuro exam, no things on exam. And the thought is we might’ve caught it on the MRI before it presented clinically. Now think about it for a second.

Very often at the time of diagnosis, the human being has multiple lesions on their brain. It just didn’t rise to the, to the level where it became clinically relevant. So if you happen to get an MRI because you were sneezing a lot and you see spots that may be something even preclinical. And it turns out that about a third of people with RIS in the next 10 years, going to declare themselves as having MS. Now you, you asked a very enlightened question about if the, if we gotten better, has that gone away? And the answer is partly, I’ll give you an example. Not long time ago, 2016, if you had optic neuritis and an MRI of the brain, which spots that wasn’t enough to make the diagnosis and we’ve, we’ve updated our information.

If you now add positive spinal fluid, that same human now is diagnosed with MS. Whereas in 2016, we would have called them CIS. And that’s not airy fairy. That’s actually based on statistics, the likelihood of going on to have an event. So by virtue of our diagnostic criteria, people that we used to say were at high risk to have MS. Are now properly diagnosed with early MS. And that’s a good thing.

[00:44:42] Meghan Beier, PhD: In the last question you mentioned systematic racism, and I’ve heard that a lot. Many of my black and African-American patients have talked about taking longer to get diagnosed or being misdiagnosed. What can you tell us about who gets MS. And how has that [00:45:00] changed over time? Because I think some of that research has changed

[00:45:03] Aaron Boster, MD: You’re right. You’re right. It certainly has. So, so women tend to develop MS. More often than men. What’s fascinating is in the sixties. It was like 1.5 to one in favor of women. Now it’s three to one. So there’s been an international rise in MS. In women, not in men. And we don’t know. Which is like a very concerning quandary.

So women are a higher likelihood to develop MS than men. And this tends to be a disease of younger folks. So the average age of onset is 30, depending on which paper you read, you know? And so you could have a bell curve, you know, the twenties to the forties as the average age that I see of new onset of symptoms.

Now we used to say that it was a disease predominant of caucasians. And then we would say, but if you’re an ethnic minority, you have a more aggressive disease course. Now I think recently we even challenged that. And it’s starting to become more prevalent and prevalently understood that, in fact, probably the, the prevalence in ethnic minorities is very similar to Caucasians, but the prognosis remains that they have a more aggressive disease course, which to me means we need to be faster at diagnosing so we can get them on high effective therapy quicker.

[00:46:13] Meghan Beier, PhD: You mentioned a few different symptoms, and there’s lots of symptoms that people with MS are effected by. Can you share kind of some of the most common things or maybe even the things that have the biggest impact on people?

[00:46:25] Aaron Boster, MD: Absolutely. I would like to address those separately because I that they’re different actually. So, so if we bucket symptoms, I would bucket them in three big categories. So I would say optic neuritis is a very classic symptom and that’s, you know, the optic nerve goes from your brain to your eyeball and light goes down it in the back of your head where you process vision.

And if you think of the optic nerve as like a two lane road, when it gets inflamed, it’s like a traffic jam. And so light signal going back dies and you don’t see anything. And optic neuritis is a very common initial presentation of MS, it’s also one that brings you to the attention of the doctor because humans who have vision problems attend the doctor.

Not so much, but whenever a human loses vision, they’re very quick to go see a doctor. So that’s one symptom. A second one is a bucket of symptoms, uh, in the setting of transverse myelitis. So Milo is Greek for spinal cord and itis means inflammation. And transverse just tells you that both sides should be affected, although they don’t have to be affected equally.

And some of the very best research and transverse myelitis comes from your institution at Johns Hopkins. And transverse myelitis causes an inflammation of a different highway of a different, so it’s not the optic nerve, it’s the spinal cord. And typically everything below the spinal cord can get beat up.

So you may have numbness or abnormal painful sensations from like the level where it is down. You may have weakness or in coordination of those arms and legs that are affected. And unfortunately the “down theres” can be affected bowel, bladder and sexual function because a lot of those things are housed within the spinal cord.

A third category is other brainstem lesions. So the base of the brain is really high real estate. So it’s not very different than like Manhattan. And it’s very hard to have brain damage in that area, without it becoming clinically manifest. And so the base of the brain has a lot of the functions that runs your face.

So facial sensation and strength and symetry and all these other things, speech, characterization, et cetera. So we can see a brainstem syndrome.

Now, as far as what are the most impactful symptoms, it might not be what you think at first. Because for a very long time, we thought of MS. As a problem that we defined by a walking, which is an error because walking is not the basic determinant of quality of life in humans.

So I would say that the biggest impactful symptoms I divide into what I call the “up theres”. And the “down theres”. So the “up theres” are thinking and memory, energy and mood. A constellation that you deal with on a daily basis with your patients as do I. And unfortunately, in the setting of MS. People are twice as likely compared to general population to experience clinical depression. They are twice as likely to experience anxiety compared to general population, some evidence that they have an increased risk of bipolar disorder. Um, and, and so it’s very, very common that people impacted by MS struggle with mood issues. Very, very common. The energy is the biggest symptom in MS.

Hands-down and it’s a fatigue, which their spouse generally does not understand. The best I’ve ever come up with explaining MS fatigue to someone without MS is as follows. Monday, you go to work and you work a great day and you come home and you have dinner with your family, and then you watch TV and then you don’t go to bed.

You stay up all night. Maybe you check out my YouTube channel and you watch half the videos, right? Stay up all night long. You’re exhausted. But, you know, you slap water on your face, take a shower, put on your best face and go to work. And you work all day on Tuesday and you come home from Tuesday and you have dinner with your family, and then you don’t go to bed and you stay up all night and watch the rest of my videos.

Then Wednesday morning, [00:50:00] I’ll come to your house with some coffee and we’ll go for a walk and talk about fatigue. And that’s about the best I’ve come up with to help someone understand the profound and pathologic fatigue that people with MS can experience. It’s actually the leading cause of loss of work because they’re so freaking tired.

Now. Very very closely tied to mood and energy is cog fog, cognitive fatigue, and cognitive impairment affects upwards of 70% of people impacted by MS. And I think it’s one of the leading causes of loss of work and people impacted by MS. And so the”up theres” are very commonly affected and people impacted by MS and oftentimes ignored by doctors much to my chagrin.

Because honey, it looks so good. You know, and if I come in for seven minutes and don’t really actually talk to you and talk at you, you look fantastic. It was great seeing you I’ll see you next time. And I never picked up the fact that you can’t think through a math problem when you’re trying to help your kid doing their homework or that you’re getting lost in your own neighborhood.

Now the second constellation of symptoms, that in my opinion are very impactful or the “down theres.” So the down there’s our bowel, bladder and sexual function. And if you would like to make an adult human really miserable mess up the “down theres.” So incontinence of urine, uh, or urinary retention, leading to frequent urinary tract infections, um, constipation is extremely common amongst people impacted by MS and unfortunately all of the circuitry of sex is in the brain spinal cord. And so it can take a hit and you can have pain during intercourse. You can have inability to achieve an orgasm difficulties with erection or lubrication. There can be a major serious problem. So to me, those are the biggest categories that I want to combat to improve someone’s quality of life.

[00:51:41] Meghan Beier, PhD: Absolutely. I deal with those things all the time, especially as you said, the “down theres,” many times I work with people who aren’t leaving the house anymore and their social life has died because they’re not leaving because they can’t find the closest bathroom. And yeah, so it, it’s such a huge, such a huge impact. And certainly one where I think mental health providers can play a role hand in hand with the neurologist.

[00:52:06] Aaron Boster, MD: The, the relationship that you craft with your patients is unique within the field of medicine. It is an intimate relationship. Within intimate relationships and someone may develop a degree of comfort with you. They don’t share with their spouse or their priest or their doctor. And so I love what you said. Because our goal is to make someone live their very best life, despite having MS.

And if they’re comfortable enough to share with you that they’re scared to leave their home because they’re, they’re scared to be incontinent. What a great service by helping encourage them to talk to their neurologist. I make a very big habit of talking about the “down theres” and the “up theres” with each patient, almost every visit in an attempt at helping them understand that I am sensitive to that, and I will help them. In hopes that it makes them feel more comfortable in sharing, because it’s very embarrassing to talk about this kind of stuff sometimes.

[00:52:54] Meghan Beier, PhD: Yeah, absolutely. I had somebody recently who told me she’s been working with the same neurologist for over 10 years and she never talked to him about her sexual dysfunction. So it’s amazing that you bring that up

[00:53:05] Aaron Boster, MD: And it’s super important. Um, you know, and, and again, I w I want you to have a really good quality life, and if you can’t achieve an orgasm, that’s going to be challenging.

[00:53:13] Meghan Beier, PhD: Yes. Yeah. It’s going to impact you and you know, any partner that you have.

[00:53:17] Aaron Boster, MD: Amen.

[00:53:20] Meghan Beier, PhD: Earlier on you talked about kind of two different categories that you were looking for in that clinical history. And I think some of those tie to the subtypes of MS. But my understanding is that those categories are also not quite as distinct as we would like them to be. And so can you talk a little bit about those subtypes and how they overlap?

[00:53:40] Aaron Boster, MD: Absolutely. Absolutely. So, so human beings like taxonomy, we like to put things in boxes, even if they don’t belong in a box because it makes us feel more comfortable. And so neurologists are good examples of that. And we’re sometimes a little bit nerdy in our heads. And over the years, we’ve come up with a multitude of different ways of trying to describe MS.

And they all suck. The reason I say that. And the reason I use that word is because they do patients a disservice. Because all the phenotypes presently are the equivalent of saying, dare I say, buxom blonde in quotes. Right? So if you are ill appropriate enough to call someone a buxom blonde you’re commenting on two outward features of that human being.

You don’t know what languages they speak, what music they love, you don’t know their politics or their personal history. You just knew two outward things about them that I would submit don’t tell you very much. And that’s about as useful as calling someone at secondary progressive MS, or something like this.

I look forward to a day in the future where we characterize MS properly, with immunologic and genetic discussions. We’re not there yet. And so we’re stuck describing the phenotype. And that’s a very poor surrogate. Now, instead of getting really down a rabbit hole about all these different letters and alphabet soup, [00:55:00] I would rather think about it with you in two categories.

There’s relapsing forms of MS and there’s progressive forms of MS. Period. And the secret is they’re actually the same disease. So relapsing forms of MS are characterized by having a relapse. A flare, an exacerbation, an attack.

If you have MS, and you’ve had a relapse, you have a relapsing form of MS. And we would fold into that term, CIS, RMS, SPMS, blah, blah, blah, blah, blah.

People with relapsing MS are at risk of having further relapses and they’re at risk of progression. And fortunately we have 25 different formulations of drugs approved by the American. That have been shown to slow progression and decrease attacks. Now there’s a second kind of MS. That we see, which is a progressive form of MS.

And this includes both primary progressive MS. And secondary progressive MS. Now the lines are indeed blurred. When I was in training, it was “impossible;” it was “not possible” that someone with PPMS could have an attack. Except they could. And we would see it and we would be like, I don’t know. And we give them steroids and then they get better, but they still have PPMS.

So we’ve become a little bit more honest. And people with primary progressive MS typically don’t have attacks, but they can, and people with secondary progressive on us have a relapsing form of MS that are still at risk of attacks. So at the end of the day, I think that we’ve done a relative disservice by coming up with all this taxonomy without underpinnings that makes sense. Right? Cause they’re not based on pathology. And I think that the farther we move away from that. You know, my patients have MS and I give them medicines to slow the accumulation of neurological disability to prevent attacks and prevent new spots on MRI. And that’s my goal. And that’s my goal if they have PPMS and that’s my goal if they have a relapsing form of MS.

[00:56:56] Meghan Beier, PhD: You talked about attacks and there are “real attacks.” Right? And then there are the kind of exacerbation yeah. Pseudo attacks, right. Those experiences where maybe people are sensitive to heat or things like that. Can you share the difference between those two?

[00:57:13] Aaron Boster, MD: Yes. And just a point of clarification, the two attacks are real, so they’re not, they’re not a, um, a make believe. Or sometimes people misinterpret and they think pseudo means fake. Except it doesn’t mean fake any similar to, but it ain’t. And so a pseudo attack is when a human being has a real neurological problem, but it’s not because of new inflammation in their brain.

So it’s because old damage kind of came back out to visit them. And I’ll use The example that you had of being overheated. So a really good way to get overheated is to have a urinary tract infection or a fever of some sort. And it raises your core body temperature and old areas of neurological injury short circuit allow me to explain. So we’ll use as a prop this wire. And let’s pretend that this is your, uh, this is your, uh, extension wire for your Christmas lights. Okay. And you have it out and your husband’s using the snowblower and he runs over it and he doesn’t cut it in half, but he cuts it. So he does what any proper husband would do, he just puts duct tape around it and puts it away. And the next year you get it out and you plug in one Christmas light and it’s beautiful. It’s green. It’s very shiny. It looks gorgeous. And then you plug in a bunch of other Christmas lights and the thing short circuits. Because you’ve overloaded the circuit. When he cut it, it’s now damaged.

And it doesn’t work at a hundred percent. It works at 90%, which is good enough for a couple of Christmas lights. But if you try to plug them all, they short circuit, and then when you start to unplug Christmas lights, then it starts up again. This is your optic nerve when you’ve had optic neuritis. So your optic nerve no longer functions at a hundred percent.

Maybe it functions at 80% and under normal circumstances, you’re cool in the gang. You can see just fine. But if you have a urinary tract infection or COVID, and your core body temperature raises. It’s going to cause this to short circuit and you’re going to revisit old injury. Now you really are blind.

You really can’t see, but it’s not a new optic neuritis. It’s an old optic neuritis. That’s coming back out to say hi. And fortunately, when the core body temperature drops, that symptom typically dissipates and goes away. It’s interesting because someone will come to me and say, Aaron, I’m having an attack and I’ll check their urine and they have a raging UTI, and I don’t treat them with steroids. I treat them with antibiotics and the neurological status gets better. So that’s a pseudo attack.

[00:59:27] Meghan Beier, PhD: Right. And for real attacks, how does somebody know if it’s a pseudo attack versus a real attack.

[00:59:34] Aaron Boster, MD: So I think if you’re having an MS attack, then the typical definition is new neurological dysfunction lasting more than 48 hours in the absence of a fever. Why in the absence of a fever? To avoid the pseudo attack concern. Also typical definition suggest a month of disease stability leading up to the attack. Again so that there isn’t some other thing creeping in.

Um, it is complicated though, because you can [01:00:00] have an infection which then triggers an attack.

[01:00:03] Meghan Beier, PhD: Hmm.

[01:00:03] Aaron Boster, MD: How do you sort that out? Well, someone has neurological stuff. You identify an infection and treat it. And the infection is done being treated in the neurological stuff persistents and gets worse. Great. It triggered an attack.

Now we give steroids.

[01:00:15] Meghan Beier, PhD: Okay. That’s super helpful. How does MS progress over time? And I know that’s very different for every individual, and has that progression over time changed with the advent of these new high efficacy drugs?

[01:00:29] Aaron Boster, MD: Your question is profoundly contemporary as there was a paper this week on that topic. So thank you for asking the question. So, so. MS over time. I like to think of it in two categories, the natural history of MS. And then treated it MS. Which is rather different. So the natural history of MS is a very unpleasant experience that I don’t like to participate in.

And the natural history of MS is a very sad story where people lose neurological function, um, and, and just continue to get worse. And that’s really what we saw up into the sixties and seventies and eighties, when we didn’t have therapies. Uh, that’s what my family experienced. My family experienced the natural history of MS because my uncle was fixed in a wheelchair long before the first MS therapy was FDA approved. And when it came out, it was a lottery and my family did not win the lottery. And so we were not eligible to receive therapy.

Treated MS is rather different. And in 2021, as you and I recorded this podcast, we are able to make MS boring. We can’t cure MS, we can make it boring. So, so that’s my goal in clinic is to, yeah, you have MS, but it doesn’t get to pick what you do.

You do. If you want to do a postdoc, you do a postdoc. You want to climb Machu Picchu, you climb Machu Picchu and we don’t let MS pick for you. Now, fortunately, um, in this paper that I just referenced, uh, which came out this week was lovely. And what it showed epidemiologically is that MS is occurring more frequently and it’s less severe. And the paper suggested there were two drivers of that.

The first one is better diagnostic criteria leading to an earlier diagnosis. As I mentioned earlier, earlier diagnosis, earlier application the therapy, better outcome. And the second one is we have drugs. So if you look at the epidemiology in the last twenty-five years, the, the, the experience of MS is much more mild and we believe in large part that’s because of the application of disease modifying therapies.

[01:02:26] Meghan Beier, PhD: That’s great. That’s great. I’m going to switch gears a little bit here, because I’ve asked you a lot about what MS is. Um, but in your experience, if you were referring somebody to a mental health provider, what would you want that mental health provider to know about MS.

[01:02:42] Aaron Boster, MD: Very very important question. Um, and in fact, I hand select my mental health providers who I’ve worked with for years and years because I sent them so many patients. We’ve had so many conversations. They’re typically very savvy. Um, because it’s such a barrier to have to explain to someone what the heck MS is that sometimes it prevents someone from wanting to go to a therapist cause they don’t want to have to tell yet another stranger, their entire story.

So, so having a sensitivity surrounding MS, where you’re not saying, “is that a brain disease?” You know, where it is is, is really respectful and, you know, and, and, and to be expected. I think, I think understanding that people impacted by MS can be cognitively impaired and have cog fog and can have other cognitive deficits is very, very relevant and helping them understand or understanding the degree of fatigue they experience is very relevant. The needs of someone with MS, in the mental health space sometimes can, can, uh, be more intense, um, or they may be needed more often than the general population as a result. And it’s my opinion, that frankly, all adult humans benefit from a therapist. I have benefited greatly over the years from working with therapists.

You guys are very helpful. Thank you. And, and people with MS are people. Except they’re people that are, that are stuck with some things they don’t want. And so. To not be upset about that is to not understand it. And to appreciate that it’s not Okay is an opportunity to then work on it. And, and I think, you know, I would want a mental health professional to understand that, that this is a vibrant human being, trying to do their very best they can, and they just need some help.

Um, you know, I, during the pandemic became, um, much more competent as a psychiatrist because I couldn’t get any psychiatrists to help. And so I now mixed medicines that I never thought I would put together. Um, with success in, in an effort at trying to help patients. And I would submit to you that if there’s a silver lining to the COVID-19 pandemic, it’s what you and I are doing day-to-day, which is telehealth. Because you can deliver care to someone in their living room and arguably maybe more effectively in some respects.

And so, you know, I think that the ability for my patient to connect with a trained therapist, a good listener, someone who cares and will help them process from the comfort of their home is a [01:05:00]gift. Um, and so I have leveraged that to the extent that we can in our practice.

[01:05:05] Meghan Beier, PhD: Absolutely. I 100% agree with the telemedicine part of it. Um, not only did we have a huge influx of people who we started seeing. We see people more consistently for longer and we see more disabled individuals because they couldn’t make it into the clinic. And so now we really are able to meet more people.

[01:05:26] Aaron Boster, MD: That’s very, very special. I’m delighted to hear that. And it’s my strong hope that, um, when the world starts to develop its new normal, that we maintain the benefits of telemedicine for patients, I would be very remiss if that went away.

[01:05:40] Meghan Beier, PhD: I hope so, too. So thank you so much. I really appreciate all your time and expertise. If people want to follow the work that you’re doing and, I know you have a YouTube channel and you have lots of other things going on. Where can people find you?

[01:05:54] Aaron Boster, MD: Oh, so nice of you. You can check out our website at, BosterMS.Com. So B O S T E R M S.com. That’s the Boster Center for Multiple Sclerosis. I do have a YouTube channel. I make YouTube videos every Monday for folks impacted by MS within a goal of kind of upping their game and educating and energizing and empowering.

Um, and so you can find that YouTube channel, it’s my name Aaron Boster, MD. And I do live streams once or twice a month, which are super fun and kind of ask, you know, ask me anything formats. I also have a presence on Facebook and on Twitter and LinkedIn. Again, it’s my name, Aaron Boster, MD. And on those media, I typically will put out the latest and greatest research from the night before, each morning to help people impacted by MS stay up to date. So those are places where you can find me, uh, and, uh, you know, don’t be a stranger. If you’re in the internet, stop by and see.

[01:06:45] Meghan Beier, PhD: Wonderful again. Thank you so much for all your time.

[01:06:48] Aaron Boster, MD: Oh, it’s my pleasure. Have a great day. And thank you again for having me.