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

Monday, 11 March 2019

Now most people with egg allergies can get a flu shot

When a person with a life-threatening allergy is exposed to his or her “kryptonite” (be it peanuts, bee stings, latex, or something else) the result is an intense immune response called anaphylaxis. The throat tightens, the tongue swells, blood pressure can crash, and it can become hard, maybe even impossible, to breathe. Rapid treatment is critical. “If a reaction is that severe, epinephrine basically saves a person’s life until she or he can get definitive healthcare,” says Dr. Susan Farrell, emergency room physician and assistant professor at Harvard Medical School.

Epinephrine is cheap — about $5 per milligram. The problem is that for people at risk for anaphylaxis, epinephrine needs to be handy and given quickly when an allergy exposure occurs. That’s the “beauty” of the EpiPen. The device makes it easy to keep an emergency dose available and simple to administer correctly. The dose delivered by the adult EpiPen is an inexpensive 0.3 mg. The medication is not costly; it’s the injector that’s expensive. But the high cost of EpiPens is not news. For a person with a high deductible insurance plan (or no health insurance at all), an EpiPen Two-Pak costs $622.09 at Walgreens. It is not much cheaper at other pharmacies and can still cost as much as $400, even with coupons and insurance combined.
Why are EpiPens so expensive?

A lack of competition is one of the reasons that Mylan, the company that makes EpiPens, can continue to increase the price. A similar product called Auvi-Q was pulled off the market due to concerns that the device did not deliver the right dose of medicine, according to Dr. Ana Broyles, allergist and immunologist at Boston Children’s Hospital. Other alternatives have not been that much more successful. Adrenaclick, for example, is significantly cheaper than the EpiPen ($188 at Walmart’s pharmacy) but Dr. Broyles finds it harder to use. It is rarely prescribed. Other companies have been trying to develop generic (and thus cheaper) versions of the EpiPen, but none have received FDA approval yet.
A proposed solution that won’t actually bring down the cost — and has the potential to influence “independent” recommendations

Most people who need this device don’t buy just one. They have them all over the place — the car, the office or school, a pocket or a purse. That’s why it hit consumers especially hard when they were forced to pay upwards of $500 for two EpiPens. Surprisingly, it was Mylan that proposed a solution to the soaring cost. It recently asked the U.S. Preventive Services Task Force (USPSTF) to place the EpiPen on its list of preventive medical services. That would make it completely covered by all insurances, including the Affordable Care Act and private insurance companies. There would be no co-pay, which sounds great.

But the mission of the USPSTF is to evaluate strategies to maintain health and prevent illness. Epinephrine is not preventive. It is not something you inject before you’ve been exposed to an allergen. It’s not something you take regularly to prevent a reaction. It’s a medication you inject after you’ve had a reaction. So, should the USPSTF make recommendations on EpiPens at all? Just yesterday, an opinion piece in the Annals of Internal Medicine argues that EpiPens are not only not a preventive service but in order for the USPSTF to remain completely unbiased and evidence-based, its recommendations should not determine insurance coverage at all.

Even if EpiPens did land on the list of preventive medical services, it probably wouldn’t benefit consumers in the long run. Mylan could continue to raise prices with little backlash from the public and would have no incentive to keep prices competitive or reasonable. While you wouldn’t be paying for your EpiPen out of pocket, your employer or your insurance company would. And those costs could simply circle back to you in the form of increased premiums or other lost benefits.

With so many children and adults at risk for severe allergic reactions, this discussion is important. Developing generic versions of the same medication and an equivalent delivery device creates competition. Those with allergies need better options, including improved access at lower cost — and transparency. Several contemporary clinical trials have shown that cholesterol-lowering statin drugs reduce the risk of heart attacks in patients with coronary artery disease. This compelling body of evidence has led to the question of whether other drugs that lower cholesterol also reduce heart attacks. Older studies had certainly shown this, though these studies were from an era prior to widespread statin use. A recent study showed that in patients with a mild heart attack, adding ezetimibe — a drug that interferes with cholesterol absorption from the intestines — to a statin reduced cardiovascular risk compared with a statin alone.

Now, a carefully done meta-analysis synthesizes all the studies to date and provides some new insights. A meta-analysis is a way of combining data from many studies over several years and analyzing the data to provide a bottom-line message. This particular meta-analysis consisted of data drawn from 49 studies of a total of 312,175 patients, a staggering number. The authors included only randomized clinical trials — the most rigorous type of study — and went back all the way to 1966 in their search for relevant trials.

The degree of benefit provided by statin and certain non-statin approaches that work predominantly by increasing the number of receptors in the body to clear out LDL cholesterol was roughly similar. The non-statin approaches included diet, bile acid sequestrants, ezetimibe, and ileal bypass surgery. Additional non-statin drugs assessed included niacin and fibrates. Both types of drugs offered cardiovascular risk reduction as well, though a major caveat regarding the data supporting use of these non-statin drugs was that the trials were not done on top of statins, or did not show clear benefits when added to statins.

Another important observation in this analysis was that lower levels of achieved LDL cholesterol were associated with even lower rates of major coronary events. This held true both for secondary prevention (that is, in patients with known atherosclerosis) as well as for primary prevention (that is, in patients with elevated cholesterol and cardiovascular risk, but without apparent atherosclerosis). The data drawn from the recent studies of the potent injectable PCSK9 inhibitor drugs also seem to support the relationship of lower cholesterol levels being more beneficial. However, it should be noted that large cardiovascular outcome trials are ongoing with these expensive injectable agents, to see if in fact they do decrease heart attack rates to the extent predicted from the large reductions in cholesterol they produce.

Thus, it appears that a variety of methods to lower cholesterol — several drugs and also diet — lower cardiovascular events, such as the chances of developing a heart attack. For patients at high cardiovascular risk, in addition to a healthy diet, statins remain the first-line drug therapy. For patients who cannot tolerate statins, non-statin drugs, including some of the older drugs, may provide a reasonable degree of benefit. The answer to whether even lower degrees of cholesterol reduction achieved by PCSK9 inhibitors further decrease cardiovascular risk is eagerly awaited. There are hundreds of viruses that can cause respiratory illnesses; influenza (the “flu”) is just one group of viruses which can cause mild to severe illness, and sometimes even death. Certain people — such as the very young or the very old, pregnant women, or those with chronic medical conditions like asthma, diabetes, or heart disease — are at greater risk for serious complications from the flu. Though the numbers fluctuate, the flu leads to hundreds of thousands of hospitalizations and anywhere from 3,000 to 49,000 deaths every year in the U.S., based on the numbers from the last few decades. How bad the flu season is depends a lot on the circulating flu viruses and whether the flu vaccine is well-matched, both of which usually change from year to year.

Typical flu symptoms come on quickly and include high fever, chills, headache, body aches, non-productive cough, and sometimes sore throat and stuffy or runny nose. Getting the flu vaccine at the beginning of the flu season (around October) is one of the best ways to protect yourself from this miserable illness. The CDC recommends routine yearly vaccination for everyone six months and older, unless they have had a previous serious allergic reaction to the influenza vaccine.
What if you have an egg allergy?

Because most influenza vaccine products are made with a small amount of egg protein, previous guidelines advised against using these vaccines in those with a severe egg allergy. This year, the Advisory Committee on Immunization Practices (ACIP) now states that people with egg allergies can receive influenza vaccines as long as they have never had a serious allergic reaction to the actual influenza vaccine or its other ingredients in the past. Specifically:

    People with a hives-only allergy to eggs can receive any licensed, recommended, age-appropriate vaccine.
    Those who report serious reactions to eggs other than hives (even anaphylaxis, a severe life-threatening allergic reaction) may receive any licensed, recommended, age-appropriate vaccine, but it should be administered in a medical setting (such as a clinic or hospital) by someone who can recognize and treat severe allergic reactions.
    Prior recommendation to monitor for 30 minutes after receiving the flu vaccine was removed, but the ACIP has a general suggestion to observe patients for 15 minutes after all types of vaccines, though this would not catch delayed serious reactions that happen much later.
    Another option for people 18 years and older is the egg-free recombinant influenza vaccine (RIV) Flublok.

Why this change?

Supercharge your cold and flu defenses!

27 surprising secrets, smart strategies, and simple steps to keep your immune system at its cold-and-flu-fighting best

It turns out that anaphylaxis as a result of the flu shot is quite rare. Ten cases of anaphylaxis were reported among the 7.4 million trivalent inactivated influenza vaccines — vaccines that use killed viruses to protect against three strains (types) of flu — that were given alone, corresponding to a rate of 1.35 events per one million shots. These reactions may have been due to ingredients other than the very small amount of egg protein in the vaccine. Rare cases of anaphylaxis following the flu vaccine in patients with egg allergies have been reported. However, there are several studies of children and adults with egg allergies, including one review of over 4,000 patients, who were given trivalent flu shots and none developed anaphylaxis. Studies with live-attenuated influenza vaccine (FluMist) showed similar findings (though the FluMist is not recommended this year because of concerns of lower effectiveness).
Get your flu shot

So the good news is that if you have been avoiding the flu shot in the past because of an egg allergy, studies suggest that a severe allergic reaction to the flu vaccine is quite rare. So if you have never had a bad reaction to the flu shot itself, try to protect yourself this year by getting a flu shot now. Go to your doctor or hospital to get vaccinated. This way you can get prompt treatment in the unlikely event that you have an immediate severe reaction.
Read More »

Things you might not know about childhood asthma

When it comes to health supplements, glucosamine and chondroitin are among the most popular. Just how popular are they? According to one estimate, about one in five Americans takes glucosamine and one in 10 takes chondroitin. The cost of these and other non-vitamin supplements and herbal remedies is close to 15 billion dollars per year. So you’d think they must be highly effective. And yet, that’s not so clear.

They are touted not only as arthritis pain relievers but also as treatments to prevent joint disease. Yet, a number of past studies have come to mixed conclusions — some small studies found that people felt better taking glucosamine and/or chondroitin, but at least as many have found no benefit. A 2010 analysis of multiple studies (called a meta-analysis) found that among more than 3,800 people with osteoarthritis of the knee or hip, treatment with glucosamine, chondroitin, or the combination was no better than placebo. The case for these supplements protecting joint health or preventing arthritis is similarly weak.
A new study of glucosamine/chondroitin

A new study of glucosamine and chondroitin enrolled 164 patients with knee pain due to osteoarthritis and gave half of them a combination of glucosamine and chondroitin; the other half received an identical placebo pill. The study was stopped early for an unusual reason — those taking the supplement actually reported worse symptoms than those taking a placebo. This raises the possibility that taking glucosamine and chondroitin might make your joints feel worse than doing nothing.

Does this spell the end of people taking glucosamine, chondroitin, or both? It’s unlikely. While the evidence of benefit is certainly not compelling, people who feel it is helping them may not care so much about individual studies. Even if a treatment is not effective on average, there may be folks who, for whatever reason, get real relief from it. And, even if the benefit is from the placebo effect, the benefit is real and that is hard to give up on. Finally, people are taking glucosamine and/or chondroitin for a number of reasons and conditions other than osteoarthritis of the knee — so this study may not apply to them.
And what about the downsides?

In general, glucosamine and chondroitin are thought to be safe. However, as with any medication, there are potential risks. In this latest trial, people taking the glucosamine-chondroitin combination reported diarrhea and abdominal pain more often than those taking the placebo did. Other reported side effects include

    heartburn
    drowsiness
    headaches
    allergic reactions (especially if you have an allergy to shellfish).

A small 2013 study found that taking glucosamine may increase the risk of glaucoma, a condition that can threaten vision if not treated. Chondroitin may act as a blood thinner, so it comes with a warning about potential bleeding. Another concern is drug interactions, a problem that can develop with any combination of medications; check with your doctor or pharmacist before taking glucosamine and/or chondroitin. Many doctors warn patients that the FDA does not regulate supplements such as glucosamine and chondroitin, so they may not contain the amounts stated on the label or there could be contaminants in them.

And, of course, there is cost to consider — health insurance usually doesn’t cover these supplements. (I found a glucosamine-chondroitin supplement online for $17.50/month at a popular online supplement chain.)
Should you give it a try?

When my patients ask me about whether they should take glucosamine and/or chondroitin, I keep an open mind. I check on reports of interactions with my patient’s current medications, let them know that the FDA does not regulate these products, and that they are considered unproven. But if a patient is interested in taking these supplements, I rarely object. And if, after a period of time, they have noticed no improvement, I might suggest they discontinue them. As long as they have the information they need and the treatment seems safe, whether to take an over-the-counter supplement for joint symptoms is a decision I leave to my patients.

For advocates of glucosamine and/or chondroitin, this recent study is only the latest bit of bad news. But this is not likely to be the last word. There are different types and doses available and they are taken for a number of different conditions. There may be certain situations in which they are particularly helpful. We’ll need additional research to know what they are. Over the years, more than a few patients in my women’s health practice have told me that their hormonal birth control — the pill, patch, ring, implant, injection, or IUD — made them feel depressed. And it’s not just my patients: several of my friends have felt the same way. And it’s not just me who has noticed this; decades of reports of mood changes associated with these hormone medications have spurred multiple research studies.

While many of these did not show a definitive association, a recent critical review of this literature revealed that all of it has been of poor quality, relying on iffy methods like self-reporting, recall, and insufficient numbers of subjects. The authors concluded that it was impossible to draw any firm conclusions from the research on this subject.
A strong study on hormonal birth control methods and depression

However, a just-published study finally meets the criteria to qualify as high-quality, and therefore believable. The study of over a million Danish women over age 14, using hard data like diagnosis codes and prescription records, strongly suggests that there is an increased risk of depression associated with all types of hormonal contraception.

The authors took advantage of Denmark’s awesome nationalized information collection systems, including diagnosis and prescribing data. These exist because the country has had a well-run and organized national health system for decades. They have reams of data on every single person in Denmark going back to the 1970s. Additional available information used in this study included education level, body mass index, and smoking habits. All of this was de-identified to protect the individuals involved, so there was no potential violation of privacy.* Surprising connections between hormonal birth control and depression emerged.

This study looked at women aged 15 to 34 between 2000 and 2013, and excluded those with preexisting psychiatric conditions, as well as those who could not be prescribed hormones due to medical issues like blood clots, and those who would be prescribed these medications for other reasons. They also excluded women during pregnancy and for six months after pregnancy, and recent immigrants. This way they wouldn’t accidentally include women with an unrecorded history of any of these conditions.

The researchers analyzed hormonal contraceptive use and subsequent depression in two different ways. They evaluated women who had received a diagnosis of depression as well as women who had received a prescription for antidepressants; these analyses were run separately, and they obtained statistically equivalent results.
Risk of depression with hormonal birth control, small but real

All forms of hormonal contraception were associated with an increased risk of developing depression, with higher risks associated with the progesterone-only forms, including the IUD. This risk was higher in teens ages 15 to 19, and especially for non-oral forms of birth control such as the ring, patch and IUD. That the IUD was particularly associated with depression in all age groups is especially significant, because traditionally, physicians have been taught that the IUD only acts locally and has no effects on the rest of the body. Clearly, this is not accurate.

Should we stop prescribing hormonal birth control? No. It’s important to note that while the risk of depression among women using hormonal forms of birth control was clearly increased, the overall number of women affected was small. Approximately 2.2 out of 100 women who used hormonal birth control developed depression, compared to 1.7 out of 100 who did not. This indicates that only some people will be susceptible to this side effect. Which ones, we don’t know. But I plan to discuss this possibility with every patient when I’m counseling them about birth control, just as I would counsel about increased risk of blood clots and, for certain women, breast cancer. In the end, every medication has potential risks and benefits. As doctors, we need to be aware of these so we can counsel effectively. Asthma is one of most common chronic diseases of childhood; almost 9% of children in the United States suffer from it. And yet I find it’s a disease that lots of people don’t understand — even parents of children with asthma.

Lungs are made up of lots of little tubes that lead into bigger tubes; they look almost like sponges. In asthma, the tubes get irritated and narrowed, making it hard for air to get in and out. Lots of different things can cause that irritation, such as allergies, cold air, chemicals in the air, exercise, the common cold, or even stress.

As a pediatrician, I see children with asthma almost every day — and have lots of conversations with their families. Over the years, I’ve found that there are lots of misunderstandings about asthma, and those misunderstandings can cause real problems for children with asthma.

Here are three things you might not know about childhood asthma.
1. The symptoms can come and go

Many times, I’ve had parents tell me that their child doesn’t have asthma because they hardly ever wheeze. It’s certainly possible — common, even — to have some wheezing with a bad cold or lung infection and not have asthma. But if that has happened a couple of times or more, then we generally call that asthma.

It’s understandable to want to dodge the diagnosis — who wants their child to have a chronic disease? But it’s actually really helpful to make the diagnosis, because that way we can be watchful and figure out what triggers a child’s symptoms. Once we know the triggers, and know the signs that an asthma attack is beginning, there is so much we can do to help the child. We can avoid triggers, like by staying away from cats, or doing lots of hand washing to avoid illness. We can manage the triggers, like by wearing a scarf over the mouth and nose in cold weather, or by using an inhaler before vigorous exercise. We can be sure they get a flu shot, as influenza can make children with asthma very sick.

The goal is always to help children with asthma lead the healthiest, most normal lives possible. We can’t even begin to do that if we don’t make the diagnosis.
2. You can have asthma without hearing a wheeze

The wheeze is often not at all obvious; you may need a stethoscope and trained ears to hear it. Also, some children with asthma don’t wheeze at all: they just cough. Coughing is the main symptom of asthma in most children. It’s how the body tries to get and keep those airway tubes open.

Now, of course there are plenty of other reasons that children might cough. The common cold and postnasal drip from allergies are the most common. But if your child coughs often at night or after exercise, has a frequent nagging dry cough, or gets a really bad, lingering cough with colds, you should talk to your doctor because it could be asthma.
3. Asthma is really treatable

As I said above, what we most want is for children with asthma to lead healthy, normal lives. And here’s the thing: we can make that happen. Not only can we work to avoid and manage triggers, and not only can we use medications to relieve the symptoms; there are medications we can use that can prevent them. A steroid inhaler or other preventative medication, used every day or during periods when asthma is worse or might get worse, can make all the difference. While some parents get nervous about using steroids, the dose is very low — and while some families find daily medications challenging, there are all sorts of strategies to make it work. It’s worth it. For some children, preventative medication can be the difference between wheezing all the time and not wheezing at all.

Which, you have to admit, is pretty great. So if your child has asthma, or you think they might have asthma, talk to your doctor and get your child started on the healthy, happy life they deserve.
Read More »

Friday, 8 February 2019

Why parents should use responsive feeding with their babies

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.
There is a saying that being poor is expensive. From personal experience, I know this to be true. But I think it also needs to be said that, especially in the United States, chronic illness can be quite expensive as well. In fact, there is a huge intersection between poverty and disability/illness. As with many intersections, it is a chicken-or-egg scenario, difficult to determine which is begetting which. But one thing is clear: there are often blind spots about these expenses in the medical community and how they can impact chronically ill people already struggling with finances.

Recently I attended a seminar on the topic and was immediately struck by the lack of attention to the expense of the nonpharmacological treatments being advised to take the place of opioids. I watched the doctors on the panel enthusiastically promote acupuncture, yoga, chiropractic care, biofeedback, massage, lidocaine patches, and TENS units. Yet, many of these treatments are not covered by most insurance plans and can be very expensive to pay for out of pocket. In the case of something like massage or acupuncture, it can cost well over $100 per visit. Since these therapies usually require multiple visits to achieve long-term outcomes, it can cost patients hundreds or thousands of dollars to cover the costs of such treatments. Considering that most people with disability live below the poverty level, many people with chronic pain may not be in a financial position to fund these alternative treatments — meaning they are basically unavailable to them.

Likewise, insurance doesn’t cover so many of the nutritional and herbal supplements and compounded medications that offer chronic illness patients a modicum of relief. Recently, my physiatrist wrote me a prescription for compounded low-dose naltrexone, or LDN, to treat my chronic pain. LDN is an opiate antagonist that has been demonstrated during limited clinical trials to reduce symptoms associated with many autoimmune diseases, including pain. However, I was informed by the pharmacy that my insurance plan would not cover it, and it was $80 for a month’s worth of daily dosages. I could not afford it, so I didn’t fill the prescription. Due to its expense, I couldn’t try a non-opioid medication that could have improved my function and quality of life.

Another example is one I face right now as someone with the connective tissue disorder Ehlers- Danlos syndrome. While there is no cure for EDS, I find that one thing that helps relieve some of my pain and minimize further injury is stabilizing my joints and soothing my spastic muscles. This requires generous use of splints, braces, and Kinesiology Therapeutic (or KT) Tape. None of these are covered by my insurance and can add up quickly — especially the KT Tape, which needs to be replaced weekly — straining my limited budget. Likewise, insurance also does not pay for the seat cushions that offer me better ergonomics at my home office so that my spine and hips don’t constantly lock up.

Insurance also didn’t cover the new bed I got last year that offers better back support, or the full-body pregnancy pillow (note: I am not pregnant) that I credit as only thing that has significantly improved my sleep in the past six months. Additionally, I am interested in obtaining some compression clothing, which has been indicated as having potential to improve mobility and pain in EDS patients. But because insurance won’t cover this either, it will require a financial investment on my part that is a huge gamble. If the clothing is not helpful, I’ve sunk in a significant amount of money I cannot recover. As a low-income individual, each choice is one I weigh heavily — the possible positive outcomes versus the potential for failure, and then the money wasted on it and what it could have otherwise gone to, such as rent or utilities.

I am not sure what can be done, except to pressure insurance plans to offer coverage of alternative treatments, and for more companies that offer such treatments or distribute supplements to offer sliding-scale or discounted rates to those of limited means. Hopefully, more pain clinics will start utilizing complementary methods to holistically treat pain symptoms, such as biofeedback and acupuncture, which will offer more incentives for insurance plans to cover them. This begins with awareness and needs to escalate to active advocacy to get us there. 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. “Earworms” are unwanted catchy tunes that repeat in your head. These relentless tunes play in a loop in up to 98% of people in the western world. For two-thirds of people they are neutral to positive, but the remaining third find it disturbing or annoying when these songs wriggle their way into the brain’s memory centers and set up home, threatening to disrupt their inner peace.
Which songs become earworms?

Certain songs are catchier than others, and so more likely to “auto repeat” in your head. When music psychologist Kelly Jakubowski and her colleagues studied why, they found these songs were faster and simpler in melodic contour (the pitch rose and fell in ways that made them easier to sing). And the music also had some unique intervals between notes that made the song stand out. The catchiest tunes on the UK charts between 2010 and 2013 were “Bad Romance” by Lady Gaga, “Can’t Get You Out Of My Head” (somewhat ironically) by Kylie Minogue, and “Don’t Stop Believin’” by Journey.
What predisposes to earworms?

In order to get stuck in your head, earworms rely on brain networks that are involved in perception, emotion, memory, and spontaneous thought. They are typically triggered by actually hearing a song, though they may also creep up on you when you are feeling good, or when you are in a dreamy (inattentive) or nostalgic state. And they may also show up when you are stressed about having too much to think about. It’s as if your stressed-out brain latches onto a repetitive idea and sticks with it. Also, if you have a musical background, you may be more susceptible to earworms too.

Certain personality features also may predispose you to being haunted by a catchy tune. If you are obsessive-compulsive, neurotic (anxious, self-conscious, and vulnerable), or if you are someone who is typically open to new experiences, you may be more likely to fall prey to an earworm.
Why might earworms be good for you?

There is a particular characteristic of music that lends itself to becoming an earworm. In contrast to our daily speech, music typically has repetition built into it. Can you imagine how absurd it would be if people repeated themselves in chorus? Yet, though repetition of speech is associated with childishness, regression, and even insanity, in the case of music it may signify a process that becomes pleasurable when it is understood through repetition. Also, each time music repeats, you hear something subtly different. This learning may constitute one of the positive aspects of earworms. Also, earworms are a form of spontaneous mental activity, and mind-wandering states confer various advantages to the brain, contributing to clear thinking and creativity.
Are earworms ever worrisome?

Not all “stuck songs” are benign. Sometimes they occur with obsessive-compulsive disorder, psychotic syndromes, migraine headaches, unusual forms of epilepsy, or a condition known as palinacousis — when you continue to hear a sound long after it has disappeared. Persistent earworms (lasting more than 24 hours) may be caused by many different illnesses, such as stroke or cancer metastasizing to the brain. A physician can help you determine if your earworm is serious or not.
How do you get rid of earworms?

If you’ve had enough of your earworm and need to stop it in its tracks, you would be well warned not to try to block the song out, but rather to passively accept it. A determined effort to block the song out may result in the very opposite of what you want. Called “ironic process” and studied extensively by psychologist Daniel Wegner, resisting the song may make your brain keep playing it over and over again.

Some people try to distract themselves from the song, and it works. In one study, the most helpful “cure” tunes were “God Save The Queen” by Thomas Arne and “Karma Chameleon” by Culture Club. Others seek out the tune in question, because it is commonly believed that earworms occur when you remember only part of a song; hearing the entire song may extinguish it.

Other techniques found to be helpful include those from cognitive behavioral therapy, such as replacing dysfunctional thoughts like “These earworms indicate I am crazy” with “It is normal to have earworms.” A less intuitive cure for earworms is chewing gum. It interferes with hearing the song in your head. The habits we learn early can stay with us for a lifetime — which is why it’s better to learn good habits early, not bad ones. This is especially true with eating habits. More and more, research shows that overweight babies grow into overweight children, who grow into overweight adults. One of the very best ways to prevent obesity is to start before they are two years old, preferably right at birth.

That’s why the American Academy of Pediatrics really wants parents to know about responsive feeding.

Most parents feel better when their baby eats more — and eats on a predictable schedule. It’s comforting and reassuring. It helps parents feel certain that their baby has had enough to eat. It also makes it easier to organize the day or give instructions to babysitters. But when we push babies to eat more than they want, or to eat when they aren’t hungry, it can teach them bad habits that put them at higher risk of obesity.

It’s really important that babies eat when they are hungry and eat only as much as they need. That’s where responsive feeding comes in. Responsive feeding is learning your baby’s cues for hunger, and for being full, and responding appropriately to those cues.

If a baby is showing these signs, parents should stop feeding, even if the baby has eaten less than usual, or less than the parent would like them to eat. That way, the baby learns to listen to her hunger cues and stop eating when she’s not hungry anymore, habits that can help keep her at a healthy weight for life.

If a parent is worried that their baby isn’t getting enough to eat, or isn’t growing well enough, the best thing to do is call the doctor and make an appointment. At the appointment, the baby can be weighed and examined to check for any problems. If there are problems, the doctor and parents can make a plan to address them and get the baby back on track. If there aren’t any, parents can feel comfortable listening to and following the baby’s cues.
Read More »

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 stopbullying.gov, 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 stopbullying.gov, 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 »