Sunday, 3 February 2019

This year’s flu season: Public health catastrophe or par for the course?

There are a range of options for reconstruction following breast cancer surgery. When a mastectomy is performed, reconstruction can be achieved using various forms of implants, or with natural tissue taken from other parts of the body to re-form the breast. Whether or not a woman chooses to pursue breast reconstruction is a very personal choice. Many women experience an excellent quality of life without reconstruction. However, for some women, undergoing reconstruction after a mastectomy can help improve certain aspects of self-image and well-being.
A new option when reconstruction results are disappointing

Unfortunately, despite advances in plastic and reconstructive surgery, the final cosmetic result of breast reconstruction can occasionally be less than satisfying. Women may have contour irregularities (e.g. indentations, bumps, or ripples), asymmetry, or defects in the reconstructed breast resulting in a disappointing cosmetic appearance. For these women, a new option is available to help correct the deformity. This procedure is fat grafting, also called autologous fat transfer or lipo-filling. It involves removing fat tissue from other parts of the body using liposuction techniques, processing the tissue into a liquid, and then injecting it into the site of the reconstruction to help improve contour and appearance. The tissue is usually taken from the thighs, belly, or buttocks.

Actually, fat grafting is not a new procedure. The process has been available for quite some time. However, it was not used often due to concerns about its safety. The good news is that a growing body of data suggests that the procedure is safer than originally thought, especially because of new and improved techniques that have reduced complication rates.

Recent data from the largest clinical trial investigating patient-reported outcomes following fat grafting showed that fat grafting may improve outcomes rated by patients undergoing breast reconstruction. The findings were reported last year in JAMA Surgery. The study was conducted between February 2012 and July 2016 at 11 sites associated with the Mastectomy Reconstruction Outcomes Consortium Study. Eligible patients included women over the age of 18 who had had breast reconstruction after mastectomy and were available to be followed in the study for at least two years. All types of breast reconstruction procedures (implant and natural tissue) were included in the study.

A total of 2,048 women were evaluated across centers in the United States and Canada. The average age of study participants was 49.4 years. The study found that women who required fat grafting to correct deficiencies in their breast reconstruction were able to achieve equal rates of breast satisfaction, psychosocial well-being, and sexual well-being, compared with women who did not require fat grafting, despite the fact that their initial ratings in these areas were lower prior to correcting the deformities.

An interesting question not explored in the study is whether we should use fat grafting to improve cosmetic results after breast conserving cancer surgery (i.e. lumpectomy). This is still an area of controversy due to concerns about fat cells stimulating potential residual cancer cells, and therefore increasing the risk of cancer recurrence. Although the data are not conclusive — and in fact, emerging studies suggest that fat grafting may not impact local recurrence — the potential risk still limits enthusiasm for fat grafting following breast conserving surgery.
What else is important about this study?

This study is the first of its kind to provide patient-reported outcomes about fat grafting, and reflects a growing trend of incorporating patient-reported outcomes into clinical trials. Gaining a better understanding of outcomes from the patients’ perspective helps researchers and clinicians to design and deliver care that truly meets the personal preferences and treatment priorities of women diagnosed with breast cancer.  It’s a new year, the gyms are unusually busy, and many of us started a new physical activity. Several health clubs are offering fun, interactive, and dynamic exercises such as whole-body workouts, functional training, CrossFit, high-intensity interval training, spinning, etc.

Some of these classes are incorporating intense workouts, which was a hot topic in exercise physiology in 2017. There is significant enthusiasm around these programs among my friends, family, and patients. Some of these classes have loud music, lights, and trainers whose job is to push you to a new level. Increasing the intensity of a workout may bring significant health benefits for some; however, lately we are starting to see cases of a potentially life-threatening disease as a result of these activities. It’s called rhabdo.

The other day I saw someone wearing a shirt that said “Pushing until Rhabdo.” That made me cringe. And I realized that, although rare, some people do not understand how serious rhabdo can be.
What is rhabdo?

Rhabdo is short for rhabdomyolysis. This rare condition occurs when muscle cells burst and leak their contents into the bloodstream. This can cause an array of problems including weakness, muscle soreness, and dark or brown urine. The damage can be so severe that it may lead to kidney injury. Intense physical activity is just one of the causes. Others include medication side effects, alcohol use, drug overdose, infections, and trauma/crush injury. Fortunately, most people who have rhabdo do not get sick enough to require hospitalization. But if you develop any of these symptoms after a hard workout, it’s a good idea to set up an appointment with your doctor. A simple blood and urine test could help establish the diagnosis.
How to avoid rhabdo

I know you are probably excited about your new exercise program, and you want to excel. And that’s great. But take it easy, especially if this is a new exercise routine. You want to challenge your body, but avoid extremes. If you are working with a trainer, make sure you tell him/her where you stand in terms of fitness level and health concerns. In addition:

    Drink lots of water. That will help prevent problems and help flush your kidneys.
    Avoid using anti-inflammatory medications such as ibuprofen and naproxen. These drugs may worsen kidney function.
    Avoid drinking alcohol. Alcohol is a diuretic, which means it will make you more dehydrated. You need more fluids in your system, not the opposite.

If you experience intense pain and fatigue after your workout, you should call your doctor. Most cases of rhabdo are treated at home simply by increasing fluid intake. If muscle enzyme levels are high, or if there are signs of kidney problems, IV fluids may be needed. In some cases, we have to admit patients to the hospital and even to the ICU for close monitoring and further treatment.
Ramping up safely

Be smart and train your muscles to adapt to new activity. Exercise is better if it is enjoyable and entertaining, and I have to say that some of these classes are incredibly fun. But make sure that you listen to your body. Watch out for trainers who may push you too hard to the point of exhaustion. That should not be your goal when you are first starting a brand-new routine, especially if you haven’t been active for a while. A good trainer should get to know you and will tailor the exercise routine to your level of fitness. Adding a new workout to your day is probably one of the healthiest habits you can incorporate in 2018, but don’t “push until rhabdo.” Instead push slowly but consistently, challenging your body toward wellness and better function. We are fortunate to have a country home in the Catskills where we can escape city life. An eight-year-old neighbor often crosses our meadow or bikes over to stop by for a visit. While I’d like to think I’m the featured attraction, his visits are not just to see me; of much greater interest is our basement with its shelves of toys and games. Particularly appealing to this lad is the sports equipment: hockey sticks, goalie pads, a goal to shoot on, baseball mitts, a batting helmet, a catcher’s mask, soccer balls, and more. Name the sport and it is most likely we have equipment for it, even in different sizes.

I’ve given my young friend a few items: retaping a hockey stick that’s the right size for him, a pair of batting gloves, a cracked bat from a Bat Day at Yankee Stadium. He knows these were things that belonged to my son. Visits have been frequent, offering a chance to go to the basement so we could play some more floor hockey, or perhaps do a review of our inventory again, maybe hoping to catch me in a generous frame of mind. Downstairs amongst the gloves and balls and pads, waiting to be discovered, was The Question. “Where is your son, where is William?”

Knowing that sooner or later The Question that would come up, I had a conversation with his parents. Who explains William’s permanent absence to the young fellow? What is age-appropriate detail? Is there a better time for the discussion?

The Answer is, sadly, that William died from an accidental heroin overdose. At the time my wife and I became aware that William was using heroin, he was 22. He was already seeing a psychotherapist. Over the next two years we added an addiction psychiatrist, outpatient treatment, treatment with Suboxone, inpatient detox, inpatient treatment, outpatient treatment, outpatient detox, treatment with Vivitrol, more outpatient treatment, another inpatient treatment, more outpatient treatment, a revolving door of well over a dozen trips to and from the emergency rooms of at least four different hospitals, an attempt to work with another addiction psychiatrist, Alcoholics Anonymous, Narcotics Anonymous, and a home life fraught with tension, despair, sometimes hope during intermittent periods of sobriety, and always filled with the apprehension of misfortune.

That apprehension became fact when William accidentally overdosed shortly before his 24th birthday. Just four days prior he had gone to a hospital to ask to be admitted to inpatient detox. His insurance company denied the request as “not medically necessary.” Six weeks of comatose and/or heavily medicated hospitalization followed before the ultimate realization that William was consigned to a persistent vegetative state.

When we decided to permanently remove him from a respirator we attempted organ donation. Organ donation in William’s condition required an expedient demise within a tight one-hour time frame once removed from the respirator. William continued on and survived for another 21 hours before breathing his last in our arms. Ultimately, we made an anatomical donation of his body to Columbia University’s College of Physicians and Surgeons.

Once, William was young, curious, engaging, and adventuresome, much like our eight-year-old neighbor. I continue to question, puzzle, and agonize over the path that takes a boy from building with Legos, playing catch, bocce on our lawn, snow forts, an entertaining sense of humor, late night talks, fierce and courageous loyalty to friends, right-on-the-money analysis of people, situations, and numbers, a flash of the pads for a save, and the sweetness, strength, inspiration, and love that was William… to a death certificate that reads death due to “complications of acute heroin intoxication.”

One thing I do know. When my young neighbor asks about William, I have to answer him openly and honestly. There’s more of William to share than some old hockey sticks and baseball bats. William’s story, like that of so many others, has to come out of the basement so that it can be the cautionary tale every growing boy should hear. I got a new doctor last year and at my first exam, he asked the standard, “What do you like to do for fun?” I laughed at him. I said that I have a 6-year-old and 3-year-old, mumbled something about poker games, and then my answer stopped. I’m not complaining, at least not much. I like my family and they require time. I don’t mind giving it, though I also work at home, a personal choice that comes with great benefits. But I can’t completely disappear, so sometimes, it just feels like an unending amount of time. My friends with older kids try to be supportive, saying that my wife, Jenny, and I are in the deepest part of the hole and it will soon get better, but they said that last year, and maybe the year before — I don’t really remember.

I know that I should squeeze in something like listening to music, reading, or doing nothing. It just never tops the priority list. I feel guilty spending time or money on anything that isn’t family-related. Jenny feels the same. We’re not pioneers with this mindset. As Dr. Beth Frates, assistant professor of physical medicine and rehabilitation at Harvard Medical School, says, it’s almost a default. “If you’re not working or taking care of another relative, you’re giving kids 100% of your attention.”
Why taking a break is important (and why it’s so hard)

The problem, she explains (and which isn’t surprising), is that parenting is a drain. It requires CEO-like thinking that happens in the prefrontal cortex, the place for self-control and rational decisions. That takes stamina, and if — check that — when you’re exhausted, you’ll shift into the amygdala, the emotional part of the brain that fights or flights, which is good against a bear attack, not so much against your child. Point is, a break every so often isn’t the worst thing.

Great. I’m still all for it. One question: when and how exactly does this magic happen?

The first step, Frates says, and it’s a big one, is acknowledging that personal time isn’t a luxury. The airplane oxygen mask analogy — put on yours first so you can better help your child — is the classic, but she prefers the idea that you can’t pour from an empty cup; with nothing there, there’s nothing to give.
The practical realities of “me time” — even a little bit can help a lot

If you can accept the concept, it becomes about identifying the daily possibilities. Ideally, she says, it’s a range, from 30 minutes to the occasional 24 hours. At minimum, it’s taking five. Even that might feel undoable, but any type of screen time is a good place to look for time that can be better spent. And if it’s just the five, Frates likes deep breathing. She did it when her kids were young. She’d be in a chair with them in the room. They eventually understood not to bother her. She got her break and they got to witness the habit.

Ultimately, there’s no list of best things to do. The main requirement is that you look forward to whatever it is to get the reward of being fully absorbed, of losing your sense of time, and forgetting that you actually have bills, deadlines, or even children. It sounds simple, and it is to a degree, but if kids are involved, few things are simple. It takes teamwork to pull off. As a supportive partner, “What can I do to help?” is never a bad opening question. Often the person knows; now there’s an opening to brainstorm and strategize. Sometimes, if you know it’s not overstepping, you can take the initiative and buy something like a prepaid yoga classes card. The free time now almost has to happen.
“Me time” done just right

My wife took that route. I recently turned 50 on a Monday, and she woke me the morning before, holding a bottle of sports drink and telling me that this was my present. Where my head was at, I thought, “I have to get another colonoscopy?” She told me that at noon, I was playing tennis with a buddy.

I got to do something that I love — I think I stammered tennis out to the doc as well — with the person I like to hit with the most. But where Jenny crushed it was setting the whole thing up. She knew that if she gave me an open-ended coupon, it wouldn’t have happened. She just told me to go and enjoy myself.

I listened to my wife on this one. For two hours, I didn’t have to watch my language or answer the same question 10 times. My biggest responsibility was hitting a ball back over a net and breaking a sweat. It was great. I felt unburdened. I felt more energized and positive, and, at some point on the drive back, I remembered that I had two children. If you think that there’s a lot of flu going around this winter, you’re absolutely right. Every state except Hawaii is reporting widespread influenza activity, making for a lot of miserable people suffering from classic flu symptoms of cough, fever, headache, stuffy nose, and achy muscles. Hospitals across the United States have been flooded with flu patients. Matters have been made worse by national shortages of IV fluids in the wake of Hurricane Maria.

Are we headed toward a historically bad flu season? It’s too early to tell. This year, it could just be that flu season, which is usually at its worst in February, is peaking early. Even an average flu season is a public health disaster, leading to between 12,000 and 56,000 excess deaths in American adults. There have been several tragic and widely publicized deaths of children this flu season, with at least 30 such cases so far. Unfortunately, this is not that unusual. In the United States, 98 kids died of flu-related complications in the most recent flu season. In recent years, deaths of children from flu in the US have ranged from 35 in 2011–2012, to a peak of 282 in the 2009–2010 flu season. Most children who die after influenza have a high-risk underlying medical problem, such as asthma, cerebral palsy, or heart disease, but 43% were previously healthy.

So far this year, the major flu type is H3N2, a strain of influenza A virus. Last year, the flu vaccine was only around 32% effective against H3N2, while providing much better protection against the other two major flu strains. It’s not too late to get a flu vaccine if you haven’t already. Some protection against flu is better than none. Even if the flu vaccine is not completely protective against H3N2, it can reduce the risk of a life-threatening case. It’s also common for other varieties of virus, such as influenza B, to emerge late in flu season, and the vaccine usually provides better coverage for these other strains.

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