Showing posts with label Health. Show all posts
Showing posts with label Health. Show all posts

Friday, 8 February 2019

Real-life healthy dinners (for real people with real busy lives)

This fall, I had gotten away from my regular core-strengthening routine (nighttime planks, pushups, and abdominal exercises, on the carpet as the kids are going to sleep). At about the same time, I increased the consecutive hours spent sitting at my desk, typing away. Weakened core plus prolonged time seated at an ergonomically challenging workspace equals exacerbation of my chronic low back pain.

This situation is exceedingly common. I have both short-term and long-term solutions. For now, I get up and stand when my Fitbit buzzes (which is every 20 minutes). At least once an hour, I do toe-touches, side and back bends. I’m also adding in really quick and easy in-office core strengthening exercises. As a matter of fact, my nurse practitioners and I just practiced our chair squats, one-legged chair stands, and desk planks, as we sit here at our computers for hours at a time. Try this core workout you can do right in your office.
Next, find a way to ease the pain (ideally without medication)

Some days and nights, the throbbing pain is so bad it’s distracting, and I get irritable. What helps me are simple, holistic, evidence-based measures: ice packs alternating with heating pads, massage, gentle stretching including yoga poses, and deep breathing. These and other non-pharmacologic modalities such as tai chi, acupuncture, biofeedback, and spinal manipulation are supported by evidence and included in the updated guidelines for management of chronic low back pain.

I also use topical products that are sold over the counter: salves, usually containing menthol and camphor, and patches, usually 4% lidocaine. Salves can be massaged in to painful areas, and I feel that they are benign and truly soothe (though they have not been well-studied). Key is to keep these products away from children (camphor can be toxic to kids) and also out of your eyes (it can sting). Lidocaine patches are “numbing” and are great for focal pain, as well as widely available and inexpensive.

If I have to, I’ll take a non-steroidal anti-inflammatory drug like naproxen (two 220-mg tablets with food and fluids). I had to take this one day, to get through my clinic. I didn’t think patients would understand my getting up, stretching, and touching my toes during their visit! (NSAIDs are not without risk and their use should be limited. The elderly, people with a history of or risk factors for heart attacks and strokes, as well as those with kidney problems or a history of gastritis or ulcers should really avoid using these medications.) Studies suggest that muscle relaxants can also be helpful for some people.
Do what you can to keep it from flaring up again

I have done physical therapy in the past, which included guided stretching, lower back stabilization, and motor control exercises. The idea is to learn the exercises that work for you and keep doing them. Back before I had kids, I took formal yoga and Pilates classes at the gym. (Yes, I remember those days…) Nowadays, I rely on my home yoga and core exercises, with some of the moves I learned from physical therapy mixed in, all of which I really, really need to practice nightly. My routine takes all of five to 10 minutes, and also helps me to relax into sleep.

I’m two weeks into this latest bout of pain, and I find that any long car ride or day at work sets me back. I’m plugging away at it, as I know that almost all back pain goes away with time. Some called it the Katie Couric effect. Soon after her husband died of colon cancer in 1998, the journalist and television personality had a televised colonoscopy to promote the test. Rates of screening colonoscopies soared for at least a year. Or, call it the Angelina Jolie effect. In 2013, the actress wrote an editorial in the New York Times about the tests she had for genes (called BRCA) linked with breast and ovarian cancer, and how the positive result led her to have a double mastectomy. Soon after, rates of BRCA testing jumped.

Whatever you call it, the effect is real. When it comes to matters of health, celebrities can have an enormous impact.
It’s good when celebrities do good

The impulse to take a challenging or tragic medical experience and turn it into something that helps others is commendable. It may be easier to keep such matters private or avoid talking about them in public. But time and again, we see celebrities joining forces with health-promoting organizations, speaking out, and sharing their stories to help others avoid what they’ve experienced. Many have credited Katie Couric with removing the embarrassment associated with colonoscopy and showing how easy it is.
Is there a downside?

There are a number of ways celebrity pronouncements on matters of health can go wrong. For example, the information can be faulty or confusing. The forays of Jenny McCarthy (who claimed vaccines cause autism) and Gwyneth Paltrow (who recommended vaginal steams to “cleanse the uterus”) into matters of health and illness are examples of influence most doctors would consider unhelpful or even dangerous.

When I heard about Katie Couric’s colonoscopy, I thought it was brave and certainly a unique way to get her message across. But as well-intended as it may have been, she was 43 years old at the time. Since guidelines suggest people begin routine screening at age 50, I wondered if she was a good candidate for the test. Unless she had symptoms (such as intestinal bleeding), a strong family history of early colon cancer, or some other special circumstance that put her at higher than average risk for colon cancer, her colonoscopy could be considered unnecessary testing. And that could have led others to have unnecessary testing as well.

A recent study raises a similar concern about Angelina Jolie’s BRCA testing. It found that in the weeks after her editorial was published, testing increased by more than 60% (at an estimated cost of $13.5 million). However, mastectomy rates actually fell over the next two to six months, leading the authors to suggest that most of the additional women who had testing had negative results and therefore may have been poor candidates for testing in the first place. Of note, the study did not confirm whether those having the BRCA test had risk factors (especially a family history of early breast or ovarian cancer) that would make the test appropriate. Critics of the study have suggested that mastectomy rates within six months of testing is not an adequate measure of whether the tests were appropriate. Still, the point is worth considering. When a celebrity recommends a medical test or treatment, the audience is not limited to those who are most likely to benefit.
The bottom line

For any medical test or treatment, ask whether it’s likely to be helpful. The answer may be straightforward. For example, a well-studied and well-accepted screening test may be recommended based only on your age and gender. But in many cases, the answer may rely on a considerable amount of judgement based on how likely it is that you have a particular condition, the ability of the test to detect it, and the impact of the test result on treatment decisions. For example, if a person has knee pain that’s mild and well-controlled with exercises, it may make little sense to have an MRI, as the results are highly unlikely to affect treatment. Every once in a while, I’ll have a terrible shift in the emergency department (ED) in which I have to pronounce yet another young person dead from an opioid overdose. I typically have to call their parents, who usually express sorrow but not surprise at the horrific news, as we all know how deadly opioid use disorder can be. But more frequently, the overdose patients I care for survive. Typically, they were found unresponsive by a friend or family member — 911 is called, the person is given the reversal agent naloxone, and is brought to the ED where my colleagues and I take over.
How naloxone works

Here’s the problem: Naloxone is, in many respects, a wonder drug. It inhibits the opioid receptor in the brain (so it blocks the effect of an opioid) and, if there is an opioid already present, naloxone can knock it off a receptor. So, if a person overdoses on an opioid such as heroin, the naloxone pushes the heroin away and blocks the receptor but does not activate it, so the person can recover from their overdose. However, since its time of action is fairly short — shorter than the effect of many of the opioids people use — we watch patients for a few hours in the ED until we’re sure the opioids have completely cleared their system. Basically, we want to make sure that they don’t overdose again. After they sober, we offer to have them speak to a social worker (most refuse), or provide a list of detox facilities, and then they quietly leave the ED.

This status quo bothers me. In particular, I’m concerned that although naloxone is now readily available — carried by police, firefighters, basic life support ambulances, and even bystanders —overdose deaths continue to climb. I want to talk frankly with the patient who overdoses and survives, and specifically let them know their risk of dying should they not get treatment. I also want to make the case that better treatment options after an overdose are needed.

Our group at Brigham and Women’s Hospital therefore conducted a study, recently presented at the American College of Emergency Physicians national meeting in Washington, DC. In this study, we aimed to define how many patients who were treated with naloxone by an ambulance crew and initially survived were still alive after one year. Even though these patients are typically just observed in the ED hallway, allowed to sober while the ED staff is busy taking care of other patients with life-threatening emergencies like heart attacks, trauma, and strokes, our team hypothesized that the individual sobering in the hallway bed has perhaps one of the highest one-year mortality rates of anyone seen in the department.
Here’s how the study worked — and what we found

To perform the study, we took advantage of a special project in Massachusetts called the “Chapter 55” legislation which, for the first time, linked many previously separate state databases. We connected the Emergency Medical Services (EMS) database with the all-payer claims database and death records database for our study. In brief, we evaluated patients who received naloxone by EMS over a 30-month period. We then looked at death records one year beyond the first time they received naloxone.

During the study period, there were 12,192 naloxone administrations by EMS, which equals over 400 per month. Of these, 6.5% of patients died that same day and 9.3% died within one year. Excluding those who died the same day, about 10% of the patients who initially survived were dead at one year. Even more significant was that 51.4% of those patients died within one month. Also, apart from those who died the same day, about 40% of those who died within one year died outside of the hospital, highlighting the danger of overdosing before medical personnel can reach the victim and the need for bystander naloxone.
What does this mean about preventing deaths from opioid use disorder?

These results are disheartening: an opioid overdose patient who sobers in the hallway, is offered a detox list, and then is discharged has a one-in-10 chance of being dead within a year. And the highest risk is within one month. Naloxone is an important tool in fighting the opioid crisis, but is no solution. Patients who survive opioid overdose should be considered extremely high-risk. I believe that as a society, we should talk seriously about the resources that are available for people who overdose. We should counsel these patients and offer them buprenorphine (a medication used to help treat opioid use disorder) directly from the ED, provide recovery coaches, and create easily accessible treatment sites where they can go for ongoing care.
Read More »

Is there a link between alcohol and skin cancer?

The winter holidays are almost universally experienced as a time of joy, and of familial togetherness. For many they are the highlight of the year, a time of relaxation, gift-giving, spiritual renewal, and reflection on a year of skirmishes fought on behalf of one’s family.

But for people in recovery from substance use disorders, such as from opiates or alcohol, the holidays can be a time of unique and profound stress. Part of this stress is related to the freely flowing alcohol that can be found at many holiday events, and another aspect is often related to complex interactions with family members who can be “triggers” for dark and uncomfortable feelings that can even threaten one’s hard-won sobriety.

If you are in recovery from a substance use disorder, be it drugs or alcohol, and the holidays do cause you emotional distress, it is critical to have plans and strategies in place for dealing with the realities of the holiday season, to minimize any risks to your sobriety. As it is commonly said in recovery parlance, “The first thing you put ahead of your sobriety will be the second thing you lose.” Even if you have to be, for lack of a better word, ruthless, and step on a few toes, it is essential that you guard your recovery as the most precious gift you have, because it is.

It is critical to have a plan in place, in advance of the holidays, to minimize stress and dangerous exposures. While one certainly can’t foresee or predict all contingencies, many can be anticipated and planned for. What are your triggers and flash points? What are the scenarios that have proven dangerous in the past? What kinds of interactions knock you off center? Who can you call if/when you start feeling like you are losing your grip? How are you planning to re-center yourself? Can you envision yourself just walking away from stressful situations?

The first obstacle that often comes up is the holiday office party. I’ve worked with many people in recovery who tell me that coworkers can look at them as if they have a third eye, or as if they have just sprouted wings, if they decline an alcoholic beverage. Many have trouble just being around alcohol, not to mention the unchecked inebriation that can occur at these parties. Some skip these events altogether, if the office politics allow this; others show up briefly, and those who are more comfortable with their sobriety simply say, “I don’t drink.” That usually ends the conversation, unless the person they are conversing with is clueless enough to ask why.

An even more complex scenario can be a holiday family gathering. In addition to the issue of freely available alcohol, many find resentments, conflicts, hostility, guilt, and triggers lurking just below the superficial holiday cheer. I’ve heard it said that your family can push your buttons better than anyone else because they are the ones that put them there.

Some families are considerate enough to hide the alcohol or, better, to go alcohol-free, but often, sadly, there are many people who just can’t enjoy themselves without some type of intoxicant. As addictions can run in families, many in recovery complain about their addicted or alcoholic family members who refuse to get diagnosed or admit their problems, but who drink like fish at all family gatherings.

To deal with stress, some try to limit time at family events. Some bring sober friends. Some skip them altogether. Some plan extra therapy sessions before the holidays to try to smooth things over in advance. Others spend time with their “recovery families” instead, and go to sober events. For example, most cities have holiday recovery-a-thons (24-hour recovery meeting events) for the exact reason that this is such a difficult time for people in recovery. I’ve heard that they can be really fun.

Recovery, if about anything, is about connecting with other people. It is about far more than just the absence of drugs or alcohol. Addiction slowly robs you of your relationships, as you become emotionally obsessed with your drug of choice. With recovery comes a blossoming of human connection, interaction, meaning, and hope. In order to recover, we learn tools to keep ourselves centered, such as humility, compassion, listening skills, and mindfulness. We learn to ask for help, and not try to internalize and fix all of our problems on our own. The holidays present a perfect opportunity to reach into your recovery toolbox and use any and all of these tools. In line with this, don’t forget to check in on your brothers and sisters in recovery during the holiday season. It’s easy enough to pick up the phone, and you will find yourself feeling better as well.

And if you are not in recovery, but you are at an office party and someone declines an offer of an alcoholic beverage, please accept that as the most reasonable choice in the world and move on. If it makes you uncomfortable that they aren’t drinking, you may wish to reflect upon your own relationship to alcohol. Picking a health insurance plan can be maddeningly complicated. It may seem that no matter what you do, you’re picking the wrong plan. Should you go with the one with high monthly premiums that covers just about everything and even pays for medications? Or maybe it’d be best to go with one with lower premiums but that covers fewer expenses. Picking the one that’s best depends on your medical conditions, the medications you take, and, to some degree, your ability to predict future medical expenses. And it only gets more difficult as costs rise and medical care gets more complex.

Enter the “high deductible health plan” (HDHP). While these health insurance plans have relatively low monthly premiums and cover catastrophic illness, they have high deductibles — the out-of-pocket payments charged before the insurance plan kicks in. For example, a typical HDHP might require you to pay out of pocket for health care expenses up to $1,300/year (or $2,600/year for families), in addition to your monthly premiums, before insurance covers most medical expenses.

HDHPs are often chosen by young, healthy people who don’t anticipate the need for a lot of healthcare or medications. Of course, anyone’s healthcare needs can change; a new illness or injury can make what seemed like a good choice at the time even more expensive than traditional healthcare insurance.
Do high deductible health plans lead to more cost-conscious use of healthcare?

It’s long been assumed that having to shoulder more of the financial burden for doctors’ visits or treatments would encourage people with HDHPs to become more cost-conscious and careful about their use of healthcare services. Not so, according to a new study.

Researchers surveyed more than 1,600 people enrolled in an HDHP about their use of healthcare services (such as seeing doctors or filling prescriptions) over the prior year, including efforts to plan ahead and limit their own out-of-pocket expenses.

Here’s what they found:

    Only 40% saved in advance for healthcare expenses.
    Just 25% talked to a healthcare provider about the cost of services.
    Only 14% compared prices of healthcare providers or services in advance of receiving care; a similar proportion compared quality.
    Only 6% tried to negotiate the price of healthcare services with the provider.
    While a minority of people took these measures to lower their healthcare costs, those who did were often successful — about half of the time, they were able to get help receiving a needed service, or paid less for it.

These results suggest that people with HDHPs are not doing all they can to lower their own healthcare expenses.
Not the last word

The results of this study may not apply to everyone. The researchers “over-sampled” people with chronic conditions who have the most to gain by trying to lower their healthcare expenses; about half of the study sample had at least one chronic condition. In addition, more than 80% of the study sample was employed and had an employer-sponsored healthcare plan. Finally, this study relied on self-reported information from an internet-based survey. For people who are healthier, don’t have healthcare benefits at work, or do not have access to the internet, results could have been different.
So what?

If you have an HDHP, you may be able to cut the costs of your healthcare by taking the results of this study to heart. Not so long ago, many considered talking about the cost of healthcare with their healthcare provider taboo. Those days are long gone. And saving in advance only makes sense, since unforeseen healthcare expenses can be hefty.

While the landscape of American healthcare and payment programs continues to evolve, as long as healthcare costs are high and rising, HDHPs are likely to be a common option. And that means more financial risk than with traditional plans. So it’s important to speak up, ask questions, and recognize that when it comes to healthcare, it’s often possible to save money without sacrificing quality. You know the saying “Don’t go to the grocery store hungry”? The reason is pretty obvious. If you’re famished, you may not make the best food choices. Well, the same applies to holiday parties. If you are truly hungry, have something healthy and filling beforehand, like a beautiful salad. Pressed for time? Eat an apple.

Already there? Look at the appetizers. Is there anything reasonably healthy? Pick up a small plate and choose from the healthier options, like crudités (vegetable slices), shrimp cocktail, even fruit and cheese (no crackers). Avoid fried snacks and processed carbohydrates. Enjoy! Take the edge off your hunger, then walk away from the table.

Are you the host? Serve delicious hors d’oeuvres that also happen to be healthy. Some ideas: make or purchase fresh guacamole, sprinkle with red pepper flakes, and serve as a dip with crisp sweet red pepper slices. Or try red pepper hummus sprinkled with crushed toasted pistachios, served with bright green cucumber rounds. Easy, and easy on the eyes as well!
Stay hydrated

Drink water, and a lot of it, to feel full as well as minimize alcohol intake and its effects. Are you the host? Serve a fancy festive mocktail: sparkling water with cranberries, orange slices, and a sprig of rosemary. Another idea: try lime-infused seltzer with mint (basically a virgin, sugar-free mojito). At a party with an open bar? Ask for a seltzer with a twist of lemon. Feeling bold? Ask for it in a martini glass with extra olives, drink with flourish, and be the envy of everyone, as you stay blissfully (and soberly) hydrated.
Prepare yourself, pace yourself

Know you’ve got a big function coming up? Live the days leading up to it as healthfully as possible. Get your steps in, work out, eat your veggies, shun the fried foods and carbs, and sleep like a baby. The event may be a late night laden with junk food and drinks, but if you walk in feeling fit and proud, you will be less likely to lose control. If you’re feeling good about yourself, you’re more likely to keep to your limits.

Is Aunt Ida bringing her world-famous pecan pie that’s only served once a year and you’re dying for a slice? Then have a slice! If you allow yourself a special indulgence, you’ll be less likely to waste your time (and calorie allotment) on cheap, mass-produced boxed baked goods.
Did you overdo it anyway?

Did you already pig out on pigs in a blanket? Feeling sick on chips and dip? Too many champagne toasts? All is not lost. Take a step back, get a glass of cold water, and go for a walk. Sometimes just removing yourself from the temptation is enough. Never underestimate the power of water. And fresh air is remarkably, well, refreshing.

Is it the next day? Feeling the aftereffects of too much rich food or alcohol, such as headache and nausea? Again, hydrate, hydrate, hydrate. Try to get up and out for a walk, or even a jog. Fresh air and increased blood flow brings oxygen to all the angry cells, and helps flush toxins out.

Stick to very light foods, like fresh fruit slices and yogurt. Try to avoid over-the-counter pain relievers such as acetaminophen and ibuprofen. These medications when combined with alcohol can cause irritation of the lining of the stomach, as well as liver or kidney damage. The real problem underlying your headache is dehydration, so focus on no-sugar-added beverages like water, coffee, or tea. Ginger tea especially works wonders. Use store-bought ginger tea bags, or make your own from slices of fresh ginger steeped in boiling water. Other soothing (and safe) herb teas include chamomile and mint. Need to be fully functional right away? If you absolutely have to, NSAIDs like ibuprofen will be more effective than acetaminophen. Just use with caution, and make sure you’ve had plenty of nonalcoholic beverages to drink as well as something to eat.
When to seek help

Severe stomach pain or persistent nausea and vomiting after too much alcohol can signal a medical emergency, such as a stomach ulcer or inflammation of the pancreas. If you’re worried, call your doctor.

Are you regularly overeating or drinking too much alcohol? If you have trouble staying in control, and especially if the overindulgence is having a negative impact on your relationships, work, finances, or health, then please talk to a doctor. These can be signs of a possible substance use disorder or eating disorder, which are medical problems that need to be specifically addressed.
And remember

No healthy diet and lifestyle plan is ever “ruined.” You can never overdo it enough to justify giving up on your body. It’s always a good time to start over. You do not need to wait for January first. You’ve only got one body, one life, and you always come first. Take care of yourself this holiday season. Patients are always elated when you can recommend an enjoyable, health-improving, recreational activity. As a runner, my favorite “prescription” while pregnant was exercise! However, more often than not, pleasurable activities are not what’s best for one’s health. But as a dermatologist who specializes in skin cancer, I am generally the bearer of bad news when I tell patients to never get another tan.

This November, alcohol came into the spotlight. The Cancer Prevention Committee of the American Society of Clinical Oncology recommended minimizing drinking alcohol, as it is thought to be a “modifiable risk factor for cancer.” Alcohol is estimated to be responsible for 3.5% of all cancer deaths in the United States.
Does alcohol influence skin cancer risk?

The short answer is that alcohol may be associated with skin cancer.

Several studies have tried to answer this very question with varying results. However, two meta-analyses, which combine results from a number of other studies, found that alcohol intake was associated with the development of basal cell carcinoma and squamous cell carcinoma (the two most common types of skin cancer) and melanoma. One of the studies found that the risk of basal cell carcinoma increased by 7% and squamous cell carcinoma increased by 11% for every 10-gram increase in intake of alcohol in distilled spirit form (or one standard beer or small glass of wine) each day. Another study found a 20% increase in melanoma in drinkers (compared to those who don’t drink alcohol or only drink occasionally) and an increased risk based the amount of alcohol intake, with a 55% increase in risk for those who drink 50-grams of alcohol (or five beers!) per day.
How could alcohol cause skin cancer?

Ultraviolet light causes mutations in DNA and typically our body repairs these alterations. However, one of the byproducts produced when the body metabolizes alcohol can interfere with DNA repair, which can eventually lead to cancer. Alcohol also causes formation of something called reactive oxygen species, which also has the ability to damage DNA. There are other proposed mechanisms, including increasing one’s susceptibility to damage from ultraviolet light and suppressing one’s immune system. Some studies have shown that white wine consumption had a stronger association with skin cancer formation, which may be due to lower levels of antioxidants in white wine.

But before you completely alter your social practices, it is important to recognize a few limitations to these studies. The first is that ultraviolet light is the main factor that increases basal cell carcinoma and squamous cell carcinoma, and alcohol consumption has been associated with behaviors that increase one’s risk of getting a sunburn. So, it is not clear whether alcohol is the cause of the skin cancer or a bystander. In addition, there are other unmeasurable factors that were not accounted for in these studies.
What should you do?

The American Cancer Society recommends limiting alcohol consumption to one drink per day for women and two drinks per day for men. But it is important to consider your underlying risk for developing skin cancer, and to understand how your lifestyle modifications are impacting your health through factors such as sun exposure habits and even ethnicity (a Caucasian’s lifetime risk for melanoma is 1 in 44, whereas an African American’s lifetime risk is only 1 in 1,100).
Read More »

Monday, 4 February 2019

Genetic testing to predict medication side effects

Lately, I’ve been checking the number of steps I take each day. It’s not hard to do. My phone tracks it without me even asking it to. It also tracks the number of flights of stairs I’ve climbed and the number of miles I covered. And there are other options: I could track how often I stand up, how many calories I’ve burned by being active, and how many minutes I’ve engaged in brisk activity.

Even my employer has gotten into the act. As is common in many workplaces, one of our hospital’s wellness programs has organized “walking clubs” with teams comparing and competing with each other based on the number of steps team members take each week. Some companies offer prizes, financial incentives, or reductions in health insurance premiums if an employee participates in such a program.
Why all this monitoring?

Technology we carry around with us — our phones, watches, or other gadgets — allows enormous amounts of data to be collected about us every day. It’s important to keep in mind that there is a purpose to all of this. The point of activity trackers is to become more aware of how much (or how little) activity we’re doing so that we can make positive changes. Since the health benefits of physical activity — and the health risks of being sedentary — are well established, increasing activity is a health priority (or should be) for millions of people. Activity trackers are the first, um, step (sorry, couldn’t resist).
Do activity trackers really improve health?

My guess is that most people take for granted that activity trackers are helpful in promoting more physical activity, but that’s based mostly on assumption. That’s why researchers at Duke-National University of Singapore Medical School designed a study to compare full-time employees who used activity trackers with those who did not. Each of the 800 employees enrolled in the study paid the equivalent of $7 to enroll and then were randomly assigned to one of four groups for one year:

    use of a Fitbit Zip, a popular clip-on activity tracker (with payment of $3/week to continue in the study regardless of the number of steps taken)
    a Fitbit plus a cash incentive ($11 for taking 50,000 to 70,000 steps each week, or $22 for more than 70,000 steps/week)
    a Fitbit plus a payment to a charity (which was larger with increased activity)
    a control group that did not use an activity tracker; this group also received the $3/week for participation regardless of activity levels.

Researchers monitored more than just the number of steps taken. Study participants also had monitoring of more vigorous exercise and physical activity, weight, blood pressure, fitness levels, and they were asked about quality of life as well.

So, what did they find?
First, the good news

The group receiving the cash incentive increased their daily steps compared to the start of the study. This group was more active than the control group at six months, and 88% of them were still using their Fitbits (compared with about 60% of the Fitbit only and charity incentive groups).
Say it isn’t so!

When incentives stopped, only one in 10 study subjects continued to use the Fitbit. And after a year, with incentives stopped, activity levels fell in the groups receiving an incentive compared to when they started. This is disappointing indeed, especially considering that the participants in this study were probably more motivated than most to focus on their activity levels. They went to the effort and expense of enrolling in the study and agreed to put up with all the monitoring. In addition, most people in the real world probably have no direct financial incentives to maintain a certain level of activity each week.

This study follows another one from the University of Pittsburgh that found less weight loss among young adults who used fitness trackers compared to those who didn’t.
What’s next?

As technology evolves and research provides more information about what works (and what doesn’t), I think we’ll see a new generation of devices that are more customized to individual needs and medical conditions. For example, a person with diabetes might monitor physical activity to provide information about how to coordinate insulin injections and meals.

In addition, activity trackers can do more than simply spit out information about how active you’ve been. A good example comes from another recent study in which activity trackers were incorporated into a competitive game, complete with signed commitments to specific activity goals, an elaborate point system, and reliance on team cooperation and rewards. The study found that those using game-based activity trackers were more active and achieved activity goals more often than those using activity trackers without the game. The study lasted only 12 weeks and improvements waned somewhat after it ended, so the long-term impact of such a program is uncertain.

Physical activity trackers have quickly become a multimillion-dollar product category. I don’t see them going away any time soon. But, to actually get people moving and have a positive impact on health, we’ll probably need to use them in more innovative ways. And if they claim to improve your health, we’ll need high-quality research to back that up. As they get older, do men with prostate cancer come to regret the treatment decisions they made? A new study of men diagnosed during the mid-1990s indicates that some of them will.

Richard Hoffman, a professor of internal medicine and epidemiology at the University of Iowa Carver College of Medicine in Iowa City, led a team that reviewed survey data that men filled out one, two, five, and 15 years after they were treated for prostate cancer. All 934 men included in the study were 75 or younger when diagnosed, each with localized tumors confined to the prostate gland. Approximately 60% of the men had low-risk prostate cancer that was expected to grow slowly, and the others had riskier cancers. Most of the men (89%) were treated with surgery or radiation. The rest were lumped together as having had conservative treatment: either medications to suppress testosterone (a hormone that makes prostate cancer grow faster), or “watchful waiting,” meaning doctors delayed treatment until there was evidence that the cancer was spreading.

Overall, 14.6% of the entire group expressed some treatment regret — 16.6% of the radiation-treated men, 15% of the surgically-treated men, and 8.2% of the men treated conservatively. Among the causes of regret, treatment-related bowel and sexual problems were cited most frequently. Surgically treated men reported the highest rate of significant sexual side effects (39%), while radiation-treated men reported the highest rate of significant bowl problems (15.6%). Remarkably, complaints over urinary incontinence differed little between the groups, ranging from a low of 15.5% for the conservatively-treated men to a high of 17.6% among men treated with radiation.

Results also showed that regret tends to increase with time, suggesting that when initial concerns over surviving prostate cancer wear off, the quality-of-life consequences of treatment become more apparent. Regrets were especially pronounced among men who felt they hadn’t been sufficiently counseled by their doctors before settling on a particular treatment option, and also among men who were preoccupied with changing levels of prostate-specific antigen, a blood test used to monitor cancer’s possible return.

Given these findings, the authors emphasized how important it is that men be counseled adequately and informed of the risks and benefits associated with various treatments. But men should also be reassured that treatment for prostate cancer has improved since the mid-1990s, and that bowel and urinary side effects in particular “don’t occur as frequently now as when the men in this study were diagnosed,” says co-author Peter Albertsen, a professor of surgery and chief of the division of urology at UConn Health in Farmington, Connecticut. Stress accounts for between 60% and 80% of visits to primary care doctors. Chronic stress has been linked to accelerated biological aging, and increased chronic inflammation and oxidative stress, two processes that cause cellular and genetic damage. Scientists refer to chronic, low-grade inflammation in the body as “inflammaging.” Inflammaging has been associated with conditions like diabetes, heart disease, stress, depression, and a weakened immune system.

Several recent studies suggest that yoga could slow the harmful physical effects of stress and inflammaging. There are many different types of biomarkers in the blood that can be used to measure the level of chronic inflammation and stress in the body. Cortisol varies throughout the day based on the circadian rhythm, and a higher baseline level of cortisol is one indicator of high chronic stress. Cortisol becomes less variable throughout the day in people who are chronically stressed, signaling an overactive fight-or-flight or sympathetic nervous system. Another biomarker is brain derived neurotrophic factor (BDNF), a naturally occurring protein in the body that regulates neuroplasticity and promotes brain development. People who have depression, anxiety, or Alzheimer’s disease have been found to have lower levels of BDNF.
Studying yoga’s effects on stress

In an exploratory study published in Oxidative Medicine and Cellular Longevity, researchers found that 12 weeks of yoga slowed cellular aging. The program consisted of 90 minutes of yoga that included physical postures, breathing, and meditation five days a week over 12 weeks. Researchers found indications of lower levels of inflammation and significantly decreased levels of cortisol. The study also found higher levels of BDNF after the yoga program, suggesting that yoga could have potential protective effects for the brain as well.

In another recent study published in Frontiers in Human Neuroscience, researchers found that a three-month yoga retreat reduced inflammation and stress in the body. The yoga retreat incorporated physical postures, controlled breathing practices, and seated meditations. Participants did two hours of sitting meditation, one to two hours of moving practice, and one hour of chanting daily. Levels of protective anti-inflammatory markers increased after the retreat, while harmful pro-inflammatory markers decreased. Researchers also found that BDNF levels tripled. Participants felt less depressed, less anxious, and had fewer physical symptoms.

These studies suggest that yoga could slow down the harmful effects of chronic stress at both the psychological and physical levels. It also indicates the benefits of a yoga practice that incorporates more than just poses by including yoga breathing and meditation or deep relaxation.

There are many simple yoga breathing (pranayama) techniques that can lower your stress levels that you can do at home for as little as a few minutes a day. Yoga breathing types can be calming or activating, depending on the type. One example of a calming yoga breath is alternate nostril breathing. You can practice it for as little as one to two minutes at home.  If you want to stop your child from being bullied — or better yet, prevent it in the first place — there is a very simple thing you can do: talk to your child.

I don’t so much mean talk to your child about standing up to bullies, or about letting a teacher know if they see or experience bullying, although both of those are important messages for your child to hear. I mean literally just talk to your child, so that you can better get to know him or her — and better get to know what their daily life is like.

As parents, we like to think that we know this already. But the reality is that once our children head off to school we don’t know everything about them. We don’t know what all of their interactions with others are like; we don’t know all the details, such as who they sit with at lunch, what happens in the locker room, or what happens when they get on the bus.

That’s where the talking comes in. According to, talking to your child for 15 minutes a day can make all the difference when it comes to helping keep them safe from bullying.

As any parent will attest, talking with our children doesn’t always go the way we think or hope it will. The answers to “How was your day?” or “What did you do today?” tend to be “Fine” and “Nothing,” neither of which are conversation starters. In general, our interactions often tend to be logistical and closed-ended, like “Did you get your homework done?” or “What time does practice end?”

The conversations that make a difference are more open-ended ones. “Tell me about your day,” for example, or “Did anything good happen today? Anything bad?” Asking open-ended questions about teachers, classes, the lunchroom, sports teams, and any other parts of your child’s life can get conversations started. You can and should ask follow-up questions, but as much as you can, try not to be interrogatory. The more you let your child tell you things the way they want to, the more you keep it comfortable and build trust, both of which are crucial. “Tell me more about that” and “What happened next?” are good ways to keep your child talking.

Because, really, that’s what you want to do. You want to keep the lines of communication open, and make it clear to your child that you are interested in the details of his daily life and that you care about what makes him happy, angry, or sad. By talking for 15 minutes a day, you can learn a lot — including about bullying or circumstances that might lead to bullying.

Those 15-minute conversations can help you help your child navigate difficult situations and help you troubleshoot and problem-solve together. They can also help you understand better what your child enjoys, which helps you guide him toward people and activities that can bolster his self-esteem and build friendships — and can help you understand who the important people are in his life, so you can get to know them better.

Our lives are busy, but 15 minutes aren’t hard to find. Eat dinner together (cook together, too) or have an afternoon snack together. Talk during car rides. Hang out on the couch before bedtime. Shut off the devices and concentrate on each other instead. It truly can make all the difference, in so many ways.

To learn more about who is at risk for bullying, warning signs that your child is being bullied (or is a bully), and what you can do, check out all the really helpful information on, and learn more about KnowBullying, a free smartphone app for parents and caregivers. Medication side effects are a big problem. It’s estimated that about half of filled prescriptions are not taken as directed, and a major reason for this is side effects. If you’ve ever had diarrhea, felt sleepy, or developed a rash after taking a new medication, you know how unpleasant side effects can be. And sometimes it’s much worse than unpleasant: drug side effects can cause permanent damage and even be deadly.
Predicting success… and side effects

Wouldn’t it be great if your doctor could predict which medication is most likely to work for you and least likely to cause side effects? Pharmacogenetics — the use of genetic information to predict the risks and benefits of a medication — could do just that. The idea is that your genes may provide helpful clues regarding which medication is best in your particular case. There are already examples of this, such as:

    Azathioprine: this is an immune-suppressing medication that some people have trouble metabolizing due to the genes they inherited; a blood test prior to the start of treatment can identify those most at risk.
    Allopurinol: certain ethnic groups (e.g., those of Han Chinese or Thai extraction) are more likely to carry a gene that increases the risk of a severe allergic reaction to allopurinol, a medication primarily used to treat gout.

While these examples deal with medication risks, individual genetic testing may also be able to identify which medications are most likely to help a person based on their genes.
A new study looks at statins

Statin drugs are among the most widely prescribed medications in the world. They lower cholesterol, reduce inflammation, and have been proven to reduce the risk of heart attack and stroke in those at high risk for these conditions. However, a limiting side effect is muscle pain, an annoying symptom that may require discontinuation of the drug. (A more serious muscle disease may develop, especially when statins are combined with other drugs, but fortunately these more serious reactions are rare.) As there are several formulations of statin drugs, for any given person one statin drug might cause trouble while another might not. These variations might also be determined, at least in part, on that person’s genes.

Prior research has suggested that people who carry certain genes are more likely to develop muscle pain when taking statins, and certain statins might cause more trouble than others for people with a higher-risk gene. These genes direct the synthesis of a protein involved in transporting drugs into liver cells.

A new study enrolled 159 people who had previously developed muscle pain when taking a statin to determine whether sharing the results of their genetic tests could be helpful in choosing a statin drug that would not cause muscle pain.

The researchers divided study subjects into two groups:

    One group was provided with the results of their genetic testing. If a high-risk gene was found, they were offered a statin considered to be less risky; for those without the high-risk gene, the group was offered any of several statins.
    The other group (the “usual care” group) wasn’t told their genetic test results until the study was completed. For this group, decisions regarding statin choice were based on “standard guidance regarding statin selection and dosing.”

In the first three months, nearly 60% of those in the first group decided to take a statin; only a third of those in the other group did so. As a result, within eight months cholesterol levels tended to be better in those receiving their genetic test results. The impact of this approach could be large, as all of the study subjects had previously stopped statin medications due to side effects.
Is it in the genes… or the “nocebo effect”?

One interesting aspect of this study is that the “nocebo effect” could have been responsible for at least some of the study subjects’ past side effects. The nocebo effect is a phenomenon in which the expectation of a side effect makes it more likely to occur, similar to how the expectation of benefit may make a placebo more likely to work. People who had previously had muscle pain with a particular statin might have the expectation of recurrence with any statin, but armed with genetic information that might help reduce risk, that expectation of trouble might be lessened. Genetic testing could lead to fewer side effects, not only by directing the choice of medications but also through a reduction in the nocebo effect.
We’re not there yet

Here’s the part where I’m obligated to mention the limitations of using genetic testing to direct drug treatment. First, in most cases, prediction isn’t perfect. Some people with a high-risk gene are fine when they take the medication; similarly, those lacking the high-risk gene can still react badly to the drug. One reason for this is that the benefits and risks of drugs are rarely determined by a single gene and many other factors matter, such as other medications taken and other medical problems. Another concern is cost. Many genetic tests are costly and it’s often unclear whether the benefits (which may be modest) are worth the expense. It’s possible that as genetic testing becomes more common and extensive, costs will come down; and as more genes are studied, the benefits of testing may become clearer (and, hopefully, more robust).
Read More »

What parents should know — and do — about young children and mobile devices

I’ve been a parent for six years, and I still feel like I’ve always just missed some two-week window that would easily set up my oldest for the rest of his life. First it was swimming, then play dates, then soccer. The latest was riding a bike. In August, Milo was past 5 and a half years old and ripping his Big Wheel through the neighborhood. He loved it, but I feared that I had blown the chance to teach him to ride a two-wheeler before kindergarten started.

So, me being me, I scrambled and tried to undo time. I bought him a used BMX bike and removed the pedals. He went up and down our sidewalk; the cracks and roots made that two weeks of uselessness. He kept at it, but I didn’t see balance clicking in. However, on a Thursday afternoon while we were walking on our just-repaved road, Milo picked up his feet and started rolling. By Saturday, when he was pedaling without pedals, I realized it was time to reattach the real things. Before I could finish, “Just remember that you have to…,” he said, “I got this.” And he did and he hasn’t stopped.

I’d love to take credit. The most I can claim is that I went outside with him. But I knew one thing quickly: the playground basketball court wasn’t going to contain him for long. I also know that kids can’t ever be 100% prepped — that’s the point of learning — but streets are different than soccer and even kindergarten. They come with cars, distracted drivers, and more cars.

Pata Suyemoto is an instructor at the Bicycle Riding School in Somerville, Massachusetts. She says there’s no one method for teaching how to bike in traffic, but there are fundamentals to instill: visibility, predictability, and paying attention, not always the top three priorities for a kid. And she has some suggestions for parents on how to get your child there:

    Get on a bike yourself. It’s the best way to model anything, from using crosswalks to making turns to wearing a helmet. By riding, you’ll also experience what your child is contending with. You’ll see the limited sightlines, feel the rocky paths, and, if you have someone who loves to skid to a stop, you’ll know the loose dirt before an intersection. And with that information …
    Predict routes. You have to constantly scan and make notes about challenging areas, so you can give a heads-up to your child and chart the safest course. Don’t worry so much about explaining the whys — understanding comes with maturity. Just lay out a clear plan for what you want, such as, “At this intersection, stop on this corner, press the button and look both ways.”
    Practice passing. Riding in a straight line isn’t hard; the challenge is when a car passes. The narrowed space throws people of all ages. On a quiet street, bike path, or empty parking lot, take turns passing each other in a controlled way, and occasionally ride close alongside your child. He’ll see that he’s safe and can still maintain a line.
    Be prepared to repeat yourself. A new pattern is rarely set with one reminder, let alone two, 10, or possibly 100. Kids are constantly being distracted on a bike by everything from dogs to friends to Halloween decorations. You need to stay on message, and since you’re also on a bike, whenever your child isn’t focused, stop the ride and point out what was missed and what needs to be done. When there’s success, praise it, and make following directions into a game. At every cross street, have your child yell out, “I’m looking.” It gives her some control and you can see what she’s processing. It also reins in your voice, so you’re not constantly talking and running the risk of getting tuned out.
It used to be common for doctors to turn down or stop the pain medication flowing in an epidural during labor if progress slowed down. This practice was particularly common if the pushing stage of labor was prolonged. Many doctors and nurses, myself included, believed that the pelvic muscles were not optimally working because of the numbing effect of the epidural anesthesia. We also thought that women could not focus on the right place to push without pain as a guide. We especially worried that epidural anesthesia in labor might increase the chance of a having a cesarean. So, many women tried to go without epidurals and endure the pain so they could lower this risk.

It seemed like common sense, and if it were true, then the tradeoff of pain in labor might be worth the gain of a shorter labor, and especially a lower cesarean risk.

Thanks to one of my colleagues who is a specialist in obstetrical anesthesia at Beth Israel Deaconess Medical Center, Dr. Phil Hess, we now have strong evidence just published in the journal Obstetrics and Gynecology that epidurals do not prolong labor or increase cesarean rates. Common sense is not evidence, and we owe it to our patients to practice the best evidence-based medicine we can.

Dr. Hess and colleagues enrolled women who volunteered to be randomized into two groups. One group was given the usual self-administered epidural pump in the second stage of labor and the other received a sham medication. Women in both groups could ask for more pain medications. The investigators found that there was no difference in labor length or in cesarean rates, and both groups had equally healthy outcomes.

What is an epidural? Think of it as numbing medicine for the spinal cord, similar to Novocain, the medicine that is commonly used to numb the nerves in your mouth when you have a dental procedure. The difference is that for labor, the medication is injected near the lower spinal cord in order to numb the pain of a baby passing through the pelvis. The medication used in an epidural is a mix of a Novocain-like drug along with a narcotic medication. Unlike a shot or a pill, nearly no narcotic enters the woman’s bloodstream, so the baby’s exposure to narcotics via the bloodstream is virtually nil, which is a great benefit. From the level near the spinal cord that the drug is injected on downward, the body gets numb and a woman feels very little pain, leaving instead a vague sensation of pressure. For labor a dilute mixture is used, so women can typically feel their legs and feel pressure in the pelvic area, so they know where to focus on pushing the baby out.

This study confirms what many of us suspected. Women don’t need the incentive or focus of pain to push a baby out. They need verbal support and guidance! There’s no other place in medicine where we would subject a woman to pain and not offer pain relief. And now we can do so without women feeling guilt or fault if they have a cesarean (not that they should ever feel that way — except they do).
Read More »

Taking an anticlotting drug? If you need a procedure, be prepared

My local farmers’ market was busy with the Saturday morning bustle of people buying homemade goods and locally grown fruits and vegetables. One of the vendors had a swarm of customers inspecting freshly baked breads. “They’re sprouted-grain breads,” the baker told me, and explained that they tasted better and were healthier than regular whole-grain breads. A sample was delicious — the recipe included sprouted Kamut and spelt, and the bread had a nutty flavor — but was it more nutritious than the regular whole-grain bread I’d just purchased from another vendor?
About sprouted grains

For more on the subject, I turned to Kristina Secinaro, a registered dietitian at Harvard-affiliated Beth Israel Deaconess Medical Center.

She explained that sprouted grains are simply whole-grain seeds that have just begun to sprout. In order to catch the sprouts at just the right moment in the growing process, whole-grain seeds are typically soaked and then nurtured in environments with controlled amounts of warmth and moisture. This can be done at home (in a vented jar) or at food manufacturing plants (in special equipment).

The moist environment can promote bacterial growth. For that reason, Secinaro recommends that you don’t eat raw sprouted grains. Instead, mash them into a paste for use in baked goods, or cook the raw sprouts before adding them to a meal. Cooking or baking the sprouts should be enough to kill any bacteria. You’ll also need to refrigerate cooked sprouts and sprouted-grain baked goods.
Are they better than regular whole grains?

Sprouted grains have many health benefits. It’s the result of catching the sprouts during the germinating process. “This germinating process breaks down some of the starch, which makes the percentage of nutrients higher. It also breaks down phytate, a form of phytic acid that normally decreases absorption of vitamins and minerals in the body. So sprouted grains have more available nutrients than mature grains,” Secinaro says. Those nutrients include folate, iron, vitamin C, zinc, magnesium, and protein. Sprouted grains also may have less starch and be easier to digest than regular grains. “It may help people who are sensitive to digesting grains,” Secinaro says.
How much better?

Sprouted whole grains and regular whole grains contain the same nutrients, but in different quantities. “I do think there are benefits to sprouted grains, but they’re not a cure-all. I would replace some whole grains with sprouted grains at least once a day,” says Secinaro, “and over all, aim for three to six servings of whole grains each day.” A serving might be a piece of whole-grain bread or half a cup of whole-grain pasta.

But just because a product contains sprouted whole grains, that doesn’t mean it has more nutrients than a regular whole-grain product. You’ll have to read the Nutrition Facts label to compare nutrition content.
Buying sprouted-grain products

You can find sprouted-grain goods (flours, breads, buns, muffins, tortillas, crackers, and even pizza crust) at a farmers’ market, like I did, or in a grocery store. “They should be in a refrigerated or frozen section. If they’re not, they probably have preservatives in them, although sprouted quinoa or rice flour is safely kept on the shelf,” Secinaro says.

But don’t assume the products are made of 100% sprouted grains. Sometimes there are just small amounts of sprouted grains in a product, so read the ingredients list or talk to the food maker who’s selling it.In 2015, the opioid crisis was escalating to emergency-level proportions, claiming as many lives as car accidents. As the daughter of a longtime drug addict, the current burgeoning opioid epidemic managed to be both familiar and strange to me at the same time. My mother developed her addictions during the height of drug epidemics that occurred in New York City in the mid-1980s. The timeframe also marked the infancy of the AIDS crisis and the height of Reagan-era “Just Say No” programs. Back then, addiction was treated and viewed more as a crime than a disease, supposedly committed by scoundrels and misfits. The theory held that respectable people did not associate with addicts, much less share their homes and their blood with them.

The intense societal shaming and criminalization of her addictions led to more resistance by my mother to seek the treatment she needed, until she eventually stopped trying to quit altogether. The stigmatization of her disease impacted me profoundly as a child — almost as much as the regular abuses I endured from her due to her addictive behavior. Whether it was being the regular target of smacking, lying, spitting, stealing, or vicious name-calling, it stung all the more because society made me feel complicit by relation. I had no healthy outlet to vent my escalating outrage at my own victimization, at an age when I was too young to properly process or even fully understand what was happening. I learned to stay silent, to repress my feelings, and to isolate myself, so as not to mistakenly disclose our family secret and be swept away into the foster care system, potentially separated forever from my younger brother.

Nowadays, when I see the constant commercials and articles offering support and compassion to those suffering from opioid addiction, I am struck by ambivalence. While I feel both heartened and relieved that addiction is finally being treated as a disease for which such supports can exist, I am also embittered that it did not happen when I needed it. I am angry that the shift in dialogue around addiction — and the companion funding being offered for programs that stress rehabilitation over incarceration for those afflicted — is likely due to the demographic differences in race, class, and regional areas impacted by this epidemic as opposed to the epidemic that claimed my mother. My family was poor, undereducated, and hailed from a low-income inner-city neighborhood where most residents were not white. Thus, we were ignored.

As noted by the National Survey on Drug Use and Health, 75% of all opioid misuse starts with people using medication that wasn’t prescribed for them. Furthermore, 90% of all addictions begin either in adolescence or early adulthood, while most of those who misuse opioids already have a prior history of abusing alcohol and other drugs. In my mother’s case, she began experimenting with cocaine first before jumping to injecting heroin in her mid-twenties; there was no prescription medication involved. My uncle (who was also my godfather) died of an overdose of Xanax (which is a benzodiazepine, not an opioid) after mixing it with too much alcohol. My brother became addicted to my mother’s prescription Dilaudid (a class of opioid) while she was in the late stages of terminal cancer; this occurred in his mid-twenties, after he had struggled for more than a decade with alcoholism.

I personally decided to opt out of using opioids for long-term management of my own pain symptoms because I did not want to risk becoming addicted, considering my own substantial family history and potential genetic predisposition to the disease. However, I understand my decision is a personal one and not something I can or should expect of other people who live with chronic pain. For some patients, long-term opioid treatment can provide adequate pain relief without detracting from their quality of life, but for others it can do more harm over time.

When I hear of people with pain being shamed and stigmatized for trying to fill prescriptions for medications many of them have been using responsibly for years and even decades, it reminds me of the same shame that was thrust onto my mother and family, while we were also deprived of comprehensive and humane treatment for, and even genuine acknowledgement of, our disease. I hope the medical field will work to adopt more nuanced and individualized approaches to treating both pain and addiction that do not cater to one demographic at the expense of the other. Millions of people with cardiovascular disease take drugs that help prevent blood clots, which can lodge in a vessel and choke off the blood supply to part of a leg, lung, or the brain. These potentially lifesaving medications include warfarin (Coumadin) and a class of drugs called non-vitamin K antagonist oral anticoagulants or NOACs. Examples include dabigatran (Pradaxa) and rivaroxaban (Xarelto).

However, if you’re taking one of these drugs and need an invasive procedure — anything from a tooth extraction to a hip replacement — managing the risks can be tricky, says cardiologist Dr. Gregory Piazza, assistant professor of medicine at Harvard Medical School. “There’s a higher-than-normal risk of bleeding during and after the procedure, because your blood doesn’t clot as easily,” he says.

But stopping an anticlotting drug is also risky. Doing so increases the chance of a blood clot, especially if you have surgery, which also leaves you more prone to a clot. “Walking the tightrope between these two extremes can be a challenge for clinicians,” says Dr. Piazza. They need to consider if, when, and how long a person might need to stop taking their anticlotting medication. And the answer hinges on many different factors.
Different risk levels

Each year, about one in 10 people taking a NOAC requires a planned invasive procedure. These include diagnostic tests and treatments that require a doctor to use an instrument to enter the body. Some are more risky than others, of course. Minor procedures such as a skin biopsy aren’t very worrisome, because you can compress and bandage the wound, says Dr. Piazza.

Tooth extractions can bleed a fair amount. Compresses and topical treatments are usually sufficient for controlling the bleeding, although your doctor might suggest skipping your anticoagulant the day of the procedure.
Biopsies, injections, and surgeries

Deciding to stop an anticoagulant for a colonoscopy is more complicated. A diagnostic colonoscopy isn’t likely to cause bleeding. But if the doctor has to remove any polyps from the colon, the risk of bleeding rises. Other procedures that require careful planning for people on anticoagulants include breast and prostate biopsies, as well biopsies of internal organs, such as the kidney or liver, which can lead to hard-to-detect internal bleeding.

Another common procedure (especially in older people) is a steroid injection in the spinal column to treat back pain. This, too, may cause undetected and potentially dangerous bleeding around the spinal column in people taking anticoagulants.

People nearly always have to stop taking anticlotting medications a few days prior to any type of elective surgery. Sometimes, doctors will use injectable, short-acting anticlotting drugs right before and immediately after the operation. This technique, called bridging, helps them better balance the degree of blood clotting during that critical window of time.
A key conversation

In addition to the procedure itself, other factors that affect anticoagulant decisions include a person’s age, any other health problems or medications they take, and whether they’re taking warfarin (which stays in the body for days) or a NOAC (which may lose some of its effect after about 12 hours). Because of all these variables, the best strategy is to make sure that the doctor slated to perform your procedure talks directly with the doctor who prescribed your anticoagulant, says Dr. Piazza. “If that conversation doesn’t take place, patients can have problems with either bleeding or clotting,” he says. Many physicians who do procedures aren’t as familiar with NOAC prescribing guidelines, so they may mistakenly keep people off these medications for a week or more, putting them at risk for a clot.
Read More »

Using social media to help parents get vaccine questions answered

I recently wrote about how my oldest son learned how to ride a bike. His excitement got me to buy a used one, mostly because running after him down the street wasn’t going to be a solid long-range plan. Now, Milo and I get to explore on two wheels. We discovered a pond with ducks not far from the house and we’ve met a lot more people in the neighborhood, mostly ones who own dogs.

It’s also been a great way to show him what I want him to do on the bike — stay to the side of the road, wait until cars stop before you cross, and look behind you to see …

Maybe not that one. I once had that easy range of motion, but it’s gone, and I blame Milo and his younger brother Levi. I love them, but they’ve destroyed my neck. They’ve also destroyed my lower back, sleep rhythms, and knowledge of current events. But right now, it’s about the neck, and they’re not going to smile their way out of it. For six years, I’ve been constantly looking down, to read to them, to answer their questions, to hold them until I fall asleep in chairs with them.

Again, all their fault. Or maybe not completely.

Vijay Dayanani is a physical therapist at Harvard Medical School-affiliated Spaulding Outpatient Center and says the main culprit is technology. Laptops, iPads, and cell phones have created a looking-down culture, bringing the neck out of its ideal neutral position and perpetually stressing the muscles to where they eventually lock up. Parenting just compounds the problem by offering no break from the bad mechanics. More than that, Dayanani predicts that he’ll be treating a lot more neck arthritis in the future. Same goes for the fingers, particularly thumbs, from the incessant texting.

So what’s needed is some adapting, wherever it can be found. Here’s how, he says:

Awareness. It’s basic, but it’s easy to not think about how you’re holding your body. With parenting, it’s even easier to forget to simply look up every once in a while. Ultimately, the more that can be done at eye level, the better. Having any kind of screen at a comfortable height will help; adjusting your work computer will help even more. When you’re standing, check in to where your pelvis is. You want to make sure to slightly rotate it forward, which will maintain the curve in your lower spine and automatically bring up the top of your body.

Give your eyes a target. Put any picture that you love on the wall opposite your desk. It might be a little gimmicky, but anything that will cause you to look straight ahead for a few seconds will give the neck muscles a chance to rest and unwind. Along with that …

Keep a bottle of water on your desk. And drink it. It’s good to get up and move around once every hour. You could set a reminder on your phone, but you also have to remember to do that. Even if you did, deadlines can cause tunnel vision, but having to go to the bathroom is a hard one to ignore.

Check your pillow support. It should fill the space from your shoulder to your ear to keep your neck properly aligned. A simple test: while lying on your side, open your eyes. You should be looking straight ahead and your head should be level.

Work your mid-back. They’re key postural muscles. Do lat pulldowns or seated rows — a pull versus a push exercise will make it less likely to round your back.

Use hot and cold. Ice and heat are classics for a reason: they help. For anything acute and severe, ice every hour for 10 minutes for up to 72 hours. For anything else, it’s whichever temperature you prefer, once in the morning, at noon, and at night for 15 minutes each time. As men age, the simple act of urinating can get complicated. Prostate surgery often leaves men vulnerable to leakage when they cough, sneeze, or just rise from a chair. Or the bladder may become impatient, suddenly demanding that you find a bathroom right now. “Thousands of years ago, it was not as much of an issue,” observes Dr. Anurag Das, a urologist at Harvard-affiliated Beth Israel Deaconess Medical Center. “There were lots of trees, and you could just find one and go.”

But tricky bladders can be whipped into shape. The first step is a careful assessment of what triggers those difficult moments. Often your doctor can suggest helpful strategies and possibly medication to improve urinary control.
How urinary incontinence works in men

Urinary incontinence means the accidental or involuntary loss of urine from the bladder. Many cases involve slight “dribbling.” The most common types are urge incontinence and stress incontinence. The usual causes of urge incontinence in men are involuntary contractions of the bladder muscles (overactive bladder). This is sometimes related to long-term blockage from an enlarged prostate. “You feel the urge to go but you start leaking before you make it,” Dr. Das says. “It could be a few drips, or it could be a larger amount if you can’t find the bathroom in time.” Many men notice that certain triggers set off their urge incontinence, such as hearing running water, entering a cold room, rising after sitting, or even just inserting the key in your home’s door lock.

Stress incontinence refers to urine leakage that occurs when coughing, sneezing, lifting a heavy object, or other activity. In men, this is usually caused by problems in the rings of muscle, or sphincters, that squeeze closed to seal off the bladder.

“If they are weak or damaged, then coughing, sneezing, running, or jumping can cause leakage,” Dr. Das says. In men, the most common cause of stress incontinence is sphincter damage after prostate surgery. Radiation treatment for prostate cancer can also cause it. The doctor will ask questions to figure out what may be causing the problem and how severe it is. You may be asked to go home and keep a voiding diary, which is a careful record of how often you need to urinate and the circumstances or triggers that lead to leakage. The male hormone testosterone contributes to normal brain function, and some research links memory loss in older men to testosterone declines that occur naturally with aging. However, testosterone is also like jet fuel for prostate tumors, causing them to grow faster, so during cancer treatment doctors will often give hormonal therapies that suppress its activities in the body. But do those therapies increase risks for dementia and Alzheimer’s disease? Some recent reports suggest that they might, although researchers have so far been unable to prove the connection, and other studies have found no link at all.

In October, researchers published the largest study yet of hormonal therapy as a possible risk factor for dementia and Alzheimer’s disease. The researchers scoured Medicare beneficiary data for 1.2 million men aged 67 or older with prostate cancer who were treated between 2001 and 2014. Of those men, 35% were treated with hormonal therapy. Published in the prestigious Journal of Clinical Oncology, the investigation found no convincing evidence that hormonal therapy poses a meaningful risk for either dementia or Alzheimer’s disease.

Dr. Kevin Nead, a resident in radiation oncology at the University of Pennsylvania’s Perelman School of Medicine, wrote an accompanying editorial about the study. He claims it had some notable strengths, including that the Medicare data was so broad that investigators could consider other potential causes of cognitive decline apart from hormonal treatment. Nead himself published a research paper in March suggesting that hormonal therapy might be associated with increased dementia risk. On the basis of this new analysis, he now downplays those findings. Even if a relationship between hormonal therapy and cognitive decline does exist, he says, “The absolute risk is small when compared to the absolute benefit of hormonal therapy for men with prostate cancer.”
As a pediatrician, I know that many times when parents are hesitant about vaccines, it’s because of something they read on the Internet. Sadly, much of the anti-vaccine information that is out there is either misinformation or misconstrued information — but once parents have read it, it’s not always easy to convince them that it’s misinformation or misconstrued. I’ve often wished that we could find more ways to get good vaccine information on the Internet, and give parents a way to get their questions answered and concerns allayed there, rather than getting worried.

That’s exactly what researchers from Kaiser Permanente did, in a study recently published in the journal Pediatrics. They recruited women in their last trimester of pregnancy, and randomized them into three groups. One group was given access to a website with vaccine information that had a social media component that allowed them to comment and ask questions. Another group was given access to a website with vaccine information but no social media component. The third group was a “control” group, given the usual care and not given access to the website. They gave all the women a questionnaire to see how they felt about vaccines, and found that about 14% overall were “hesitant” about vaccines.

Of the women given access to a website (they used a login so that researchers could see if they used it), 35% visited it at least once. Interestingly, 44% of the vaccine-hesitant mothers visited, which is good news. We want vaccine-hesitant parents to look for information in good places. The mothers in the group that had a social media component generated 90 comments and questions. The majority of those comments and questions were directed toward the clinicians running the study, as opposed to between the women. They wanted to talk to the clinicians about their questions and concerns.

They followed the mothers until their babies were about 6 months (200 days) old to see if the babies got their vaccines, and if they got them on time. They found that 92.5% of the babies whose mothers had access to the website with social media were fully vaccinated, as opposed to 91.3% of the ones whose mothers just had website access, and 86.6% of those who got usual care.

The differences were small, it’s true, but having the ability to get information and ask questions had a statistically significant effect.

All parents want to do the right thing. They want their children to be healthy and safe. Parents who don’t vaccinate their children are worried that vaccines might hurt their child and might not work. The evidence shows abundantly that vaccines do work, that they do save lives, and that side effects are usually either minor or nonexistent. But that’s not always what parents hear or read.

Parents need and deserve good information, and they need and deserve the opportunity to talk about all of their concerns and ask all of their questions. In the setting of a busy pediatric practice, doctors don’t always have the time to sit, listen, answer questions, and discuss vaccines. We wish we always did, but the reality is that we don’t. But it’s not okay for doctors to simply say that we don’t have time. If we want to give parents what they need, and get more children vaccinated, we are going to have to come up with some creative solutions — like a website where parents can get information and share their worries and questions.

It’s also important that doctors fully realize just how much people rely on the Internet for health information, and take responsibility for either putting good information there themselves, or directing people to sites with good information.

Parents, and expectant parents, who have any questions or concerns about vaccines should let their doctor know. When we know before a visit, it’s easier for us to find ways to help. And as for sites with good information, here are my favorites:
Read More »

What’s new with the flu shot?

The American College of Cardiology and the American Heart Association certainly grabbed the attention of us busy primary care physicians with the recent release of their updated blood pressure guidelines. These organizations had piqued interest by declaring the release date and labeling it as “highly anticipated.” I pooh-poohed all that drama, but upon reading through the 114-page executive summary PDF with 21 authors and almost a thousand references, I have to say, I am duly impressed.

The definition of the diagnosis of high blood pressure and the decision-making process surrounding treatment have traditionally been quite individualized (read: all over the place). Personally, I invite these stricter measures, because they are accompanied by solid research, logistical guidance, and useful management strategies.

However, a whole heck of a lot of people just got pulled into a significant medical diagnosis.

Let’s review what’s new.
A new definition of high blood pressure (hypertension)

(Please note that all numbers refer to mm Hg, or, millimeters of mercury.) The guidelines, in a nutshell, state that normal blood pressure is under 120/80, whereas up until Monday, normal was under 140/90.

Now, elevated blood pressure (without a diagnosis of hypertension) is systolic blood pressure (the top number) between 120 and 129. That used to be a vague category called “prehypertension.”

Stage 1 high blood pressure (a diagnosis of hypertension) is now between 130 and 139 systolic or between 80 and 89 diastolic (the bottom number).

Stage 2 high blood pressure is now over 140 systolic or 90 diastolic.

The measurements must have been obtained from at least two careful readings on at least two different occasions. What does careful mean? The guidelines provide a six-step tutorial on how, exactly, to correctly measure a blood pressure, which, admittedly, is sorely needed. My patients often have their first blood pressure taken immediately after they have rushed in through downtown traffic, as they’re sipping a large caffeinated beverage. While we always knew this could result in a falsely elevated measurement, it is now officially poor clinical technique resulting in an invalid reading.
New recommendations on monitoring blood pressure

The new guidelines also encourage additional monitoring, using a wearable digital monitor that continually takes blood pressure readings as you go about your life, or checked with your own cuff at home. This additional monitoring can help to tease out masked hypertension (when the blood pressure is normal in our office, but high the rest of the time) or white coat hypertension (when the blood pressure is high in our office, but normal the rest of the time). There are clear, helpful directions for setting patients up with a home blood pressure monitor, including a recommendation to give people specific instructions on when not to check blood pressure (within 30 minutes of smoking, drinking coffee, or exercising) and how to take a measurement correctly (seated comfortably, using the correct size cuff). The home blood pressure cuff should first be validated (checked in the office, for accuracy).
If you now have high blood pressure, you may not need meds… yet

The guidelines also outline very clearly when a diet-and-lifestyle approach is the recommended, first-line treatment, and when medications are simply just what you have to do. Thankfully, the decision is largely based on facts and statistics. For the elevated blood pressure category, medications are actually not recommended; rather, a long list of evidence-based, non-drug interventions are. What are these interventions? Things that really work: a diet high in fruits and vegetables (such as the DASH diet, which is naturally high in potassium); decreased salt and bad fats; more activity; weight loss if one is overweight or obese; and no more than two alcoholic drinks per day for men, and one for women. Simply changing what you eat can bring down systolic blood pressure by as much as 11 points, and each additional healthy habit you adopt can bring it down another four to five points.

For people with stage 1 hypertension who don’t have cardiovascular disease and are at low risk for developing it (less than 10% risk of an event within 10 years), lifestyle changes are still the way to go. (Risk is determined using a well-researched, widely used formula available here.)

However, if a patient has any kind of cardiovascular disease and stage 1 hypertension (a blood pressure over 130 systolic or 80 diastolic), or no existing cardiovascular disease but a significant risk of developing it (over 10% risk within the next 10 years), then lifestyle changes plus medications are recommended. And, even if someone has less than a 10% risk, if their blood pressure is over 140 systolic or 90 diastolic, which is now stage 2 high blood pressure, they ought to be treated with medication as well.
Optimizing treatment of high blood pressure

The authors bring several evidence-based yet progressive concepts into the guidelines, the first of which is that high blood pressure should be treated using a team approach. This makes sense, as science supports more and better patient education around self-monitoring, nutrition, and lifestyle changes, as well as stress management. Telehealth is emphasized as a cost-effective method of ongoing monitoring that is more convenient for patients than frequent office visits.
And why should this all matter to you?

Mountains of research over time have shown a very clear link between high blood pressure and cardiovascular disease. A 20-point higher systolic blood pressure or a 10-point higher diastolic blood pressure is associated with double your risk of death from a heart attack, stroke, or other cardiovascular complication (like abdominal aortic aneurysm or heart failure). What many people don’t realize is that those who survive these events find their lives permanently altered by disability and medical complications.

Much is being made of the fact that the new definitions of high blood pressure will mean roughly half of all US citizens will be considered to have high blood pressure, but when you really look at the numbers, as cardiologists already have, not that many more people will actually be advised to take medications. Although the public has good reason to be suspicious of “big pharma,” that’s not what this is about.

Diet and lifestyle changes are powerful medicine. Even if your blood pressure is normal now, you can help to prevent it from becoming elevated starting today. Eat more fruits, veggies, and whole grains, and limit foods high in sodium and unhealthy fats. Be as physically active as possible.
Be physically active. Exercise busts stress, boosts the mood, and elevates our energy level, not to mention the heart health benefits. Believe it or not, you can exercise just about anywhere, anytime. It doesn’t have to be at the gym. It doesn’t have to be a scheduled class. And it doesn’t have to be more than a few minutes a day. All activity counts. I encourage patients to think of an activity that they enjoy. Anything. Think about how that enjoyable activity can fit into your life: maybe you can ride your bike to work, or take your kids on an easy hike, or get the whole family to rake leaves with you. Let’s brainstorm about activities that will fit into your life: Maybe make your next meeting a walking one, or take a brisk walk at lunchtime. Try a few minutes on the exercise bike in the kitchen, or dancing around your living room in your socks. On my very busy days, I make sure I take the stairs whenever I have the option. I park farther away than I need to and walk a little more. If I’m going to the grocery store and I only need a few things, I use a hand basket instead of a cart. It. All. Counts. And the more, the better.

Eat well. That means eat healthy. The mountain of studies supporting a whole-foods, plant-based diet for our health is almost as large as the exercise one. Stay away from inflammatory, sugar-spiking, insulin-releasing foods like processed carbohydrates (think all added sugars and anything made with flour). Aim for things that grew on plants or trees. The more colorful the fruits or vegetables, the more vitamins, minerals, and antioxidants they have and the healthier they are. Vitamin pills and other supplements just don’t work as well. Not going vegetarian to save your life? Got it. Just get colorful fruits and veggies into your diet wherever you can. We don’t have to be perfect, but the more plant-based our diets are, the better.

Calm your mind. We all have stressors in our lives. What varies is how much we let the stressors stress us. What can we do? Yes, meditation works. The relaxation response works. Yoga works. But for those patients who stare at me blankly when I mention these, I talk about other calming activities. This can mean knitting, baking, walking, swimming. Anything quiet and peaceful, when one can take deep breaths and be calmly, enjoyably focused. Me? I try to do a few favorite yoga stretches at the end of the day, right before bed. This is usually after the kids fall asleep, and I can’t even be bothered to find my yoga mat. I just get right to it on the carpet in my daughter’s room: downward dog, plank, cobra, and then some of my own moves, to stretch out my back.

Sleep well. Aim for a refreshing amount of sleep. While this will differ for everyone, generally it’s about eight hours. It’s tempting to stay up late to cram in those last household chores or answer email, but really, the world won’t end if the laundry is dirty for another day, or the dishes are piled up in the sink. Sleep deprivation causes irritability, poor cognition, impaired reflexes and response time (think: car accidents!), and chronic sleep deprivation can contribute to depression and anxiety. Create a short, easy bedtime routine. Stretching or yoga, prayer, or reading a book can be relaxing. But stay away from your smartphone, tablet, or laptop, as the light interferes and interrupts the natural sleep onset. Alcohol near bedtime also interferes with sleep, and is a common cause of nighttime or early-morning awakening. As a neuroscientist I have been trained to think in a certain way, almost like a car mechanic, who “looks under the hood” at the brains of laboratory rats exposed to drugs. If we can figure out exactly which genes, proteins, brain regions, and neural connections go awry in substance use disorders (SUDs), we can fix those “broken” parts in the brain and design better long-term approaches to addiction treatment. While there is great promise in this approach, it’s not so easy to get under the hood of people who desperately need help with a SUD. It’s very different from working with lab rats. And it can take a long time — often decades — between discovering a way to redirect the addicted brain and an approved treatment.
Neuroscientists and practicing clinicians need to be partners in advancing treatment for SUDs

Obviously medical and mental health clinicians treat SUDs from the perspective of patient care. They are presented with real people who have very real, very immediate needs. These individuals have often lost their families, their jobs, and their basic health. Their lives may be in jeopardy because of the risk of overdose. The goal is to first detoxify the patients, then work with them, through initial recovery from the crisis and beyond, to prevent relapse. This is critically important work, but so is searching for potentially permanent solutions to SUDs. And the place to start is the brain.

Over the past 30-plus years, basic laboratory and translational research has expanded our understanding of the brain’s reward circuitry — specifically how dopamine, a neurotransmitter that is important in both our ability to feel pleasure and our brain’s ability to learn strong associations between cues in our daily lives that predict pleasure, operates. We now understand that the brain’s reward circuitry regulates both the “feel good” effects of a drug as well as the extreme physical and emotional discomfort experienced during withdrawal. The emotional signs of withdrawal can flare up for months or even years after attempts to quit, and these factors play into drug taking, craving, and relapse.
Neuroscience has already contributed to SUD treatment

Here are two examples of SUD treatments that regulate, directly or indirectly, dopamine’s role in the brain reward pathway.

Buprenorphine (Subutex): Like methadone, buprenorphine is considered an opioid replacement therapy because it activates the same parts of the brain that opioids like heroin and oxycodone do. The difference is that it activates at a much lower level and doesn’t jolt the brain’s reward pathway, causing a surge of dopamine release like heroin or oxycodone would. It can help ease withdrawal symptoms and can be used for both initial recovery periods and maintenance of abstinence.

Bupropion (Wellbutrin, Zyban): It has several pharmacological actions in the brain, all of which combine to make bupropion an effective treatment for nicotine addiction (e.g., smoking or chewing tobacco). Its main action is to increase levels of available dopamine in the brain. Since a drop in dopamine is partly responsible for symptoms of nicotine withdrawal, bupropion can prevent this drop, and thus mitigate the strong cravings people experience when they try to quit smoking.
And neuroscience holds promise for better and safer treatments

Here are examples of newer approaches:

Transcranial magnetic stimulation (TMS): TMS uses magnetic fields to strategically stimulate parts of the brain. The FDA approved TMS for some neurological conditions in 2009. Since then the number of conditions for which TMS has shown positive effects has skyrocketed. For people with SUDs, the prefrontal cortex, the part of the brain that helps us not act on every impulse, is often sluggish. Scientists have shown that an underactive prefrontal cortex can set the stage for impulsive and compulsive behavior observed in SUDs. Recently, it was shown that using TMS to stimulate the prefrontal cortex of the human brain might help quell those insatiable urges to take a drug.

Kappa opioid receptor antagonists: These compounds, which block the actions of the naturally occurring neuropeptide dynorphin, can help prevent drug withdrawal from causing low dopamine levels. Here’s how: many drugs that can lead to substance use disorders, if taken long enough, increase dynorphin in the dopamine reward system, which inhibits dopamine release in the brain’s reward circuitry — and the person doesn’t feel good. However, blocking dynorphin receptors with synthetically designed compounds prevents this effect. Currently there are several ongoing clinical trials testing kappa receptor antagonists in SUDs.
Where do we go from here?

The good news is that carefully collected and analyzed laboratory data from preclinical studies have led to numerous treatment options for people with SUDs. But in real life, it’s never as simple as in the laboratory. Each person struggling with a substance use disorder has his or her unique constellation of social, genetic, and psychological factors that make some treatments more or less effective than others. But the better we understand the brain science of addiction, the more likely we will come up with an array of treatments that can help a broader range of those with SUDs.

To me, this means my brain-mechanic work looking under the hood of the brains of rats exposed to drugs is essential to the ultimate process of helping people suffering from SUDs, but only if I take the time to look up and discuss my findings with clinical colleagues. Likewise, the clinicians’ overwhelming job of helping people with immediate, life-threatening needs is essential, but only if they pause periodically to listen to our new brain discoveries that might revolutionize SUD treatments. Should you get the influenza (flu) vaccine this year? The short, quick answer (barring any medical reasons you shouldn’t, such as severe allergies), is yes! But recent research raises another important question: When should you get the shot?
Why a flu shot every year in the first place?

Getting infected with the flu can be dangerous — we’ve seen patients in the ICU who were previously healthy but had a horrible response to a strain of the virus and became very sick.

Every year the Centers for Disease Control and Prevention (CDC) and other agencies release flu vaccination guidelines in late summer to early fall. The flu vaccines are usually available by the end of the summer season. Figuring out exactly which strains of flu viruses the vaccine should protect against is often complicated. Basically, experts look at the influenza virus strains that were making trouble in previous years, and attempt to predict which strains are likely to cause the flu in the upcoming season.

The inactivated flu vaccine is the form of flu vaccine that is most commonly injected and contains parts of the virus but no live virus. Therefore, you should not be infected with the flu from the vaccine itself. Some people may feel “sick” after the vaccine with symptoms such as mild fever, pain in the injection site, fatigue — all of which may just be your body mounting an expected immune response against the foreign virus particles. For the 2017-18 season, the CDC and Advisory Committee on Immunization Practices (ACIP) have recommended against the alternative intranasal live attenuated vaccine, due to concerns about its ineffectiveness during the previous seasons.
Get your flu shot as soon as possible? Maybe not…

Recent studies have suggested that the flu vaccines may not be as effective when given too early. The US Influenza Vaccine Effectiveness Network compiled data on patients seeking care at outpatient clinics during the four previous flu seasons from 2011-12 to 2014-15. Although the data varied for different influenza strains, it did show that the vaccine was most effective at approximately two weeks after it was given. Protection against the flu then decreases every month. There could be many explanations for this: people may lose immunity during the season; different patient populations receive vaccines at different times; the virus may mutate during the course of the flu season, etc. This decrease in protection over time may even account for why some people who did get a flu shot go on to get the flu later on in the season (February or March). However, more research needs to be conducted to evaluate this further.
It gets even trickier

The problem is that we cannot predict exactly when the flu season will begin each year. In clinics and in the emergency department, we often see the flu season starting around December and lasting until the spring. And the flu shot is not 100% effective. Over the past few seasons, studies have shown that the vaccine reduced the risk of flu infection by 40% to 60%. For patients who are immunocompromised or have chronic medical conditions, it may still make sense to receive the vaccine earlier so that your body is protected against the virus whenever the season comes. But if you’re generally healthy, it may make sense to get the vaccine a little later in the fall.

But, as physicians, we really aren’t sure yet.
So, what should you do?

We need more research to determine the optimal timing of influenza immunization. Until we have more information, I still recommend getting the flu vaccine each year before the flu season starts, especially if you have other health problems, have a weakened immune system, or if your child is young enough to require two doses. Even if you are exposed to the flu virus later in the season and your immunity is not as strong against it, your body may still be able to fight off the virus quicker and more effectively than if you did not receive the vaccine at all. For those who are healthier and have access to primary care physicians, you could consider holding off until later in the fall; however, you may risk getting the flu if the season comes early.
Read More »