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

Friday, 8 February 2019

Good news about the HPV vaccine

In 2015, the opioid crisis was escalating to emergency-level proportions, claiming as many lives as car accidents. As the daughter of a longtime drug addict, the current burgeoning opioid epidemic managed to be both familiar and strange to me at the same time. My mother developed her addictions during the height of drug epidemics that occurred in New York City in the mid-1980s. The timeframe also marked the infancy of the AIDS crisis and the height of Reagan-era “Just Say No” programs. Back then, addiction was treated and viewed more as a crime than a disease, supposedly committed by scoundrels and misfits. The theory held that respectable people did not associate with addicts, much less share their homes and their blood with them.

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

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

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

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

When I hear of people with pain being shamed and stigmatized for trying to fill prescriptions for medications many of them have been using responsibly for years and even decades, it reminds me of the same shame that was thrust onto my mother and family, while we were also deprived of comprehensive and humane treatment for, and even genuine acknowledgement of, our disease. I hope the medical field will work to adopt more nuanced and individualized approaches to treating both pain and addiction that do not cater to one demographic at the expense of the other.
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. In the late 1980s, psychologist James Pennebaker developed a form of writing therapy called expressive writing. When you engage in expressive writing, you write about your deepest thoughts and feelings without concern for spelling, grammar, or sentence construction. It is free-flowing and unfocused self-expression.

Although not everybody benefits from expressive writing, recent studies have shown that expressive writing helps anxious individuals perform better on tests. We’re not sure exactly why this is, but one leading theory is that writing about test anxiety “offloads” worrisome thoughts, thereby freeing up mental resources to concentrate on the test.

While this theory is appealing, more data was needed to substantiate it. That’s what psychology graduate student Hans S. Schroder and his colleagues set out to explore. Their study involved people who had been preoccupied by worry for a long time. The team looked for brain wave changes as a result of expressive writing to see how the writing was helping, if at all.
Worried people and their brain waves

Your brain is constantly creating electrical signals. You can see these signals when you place electrodes on the scalp and connect them to a monitoring device called an electroencephalogram (EEG). They look like waves. Every time you encounter any stimulus or event (e.g., a frightening sound, an unusual thought, or a reason to move), these brain waves change. And you can see this response on the EEG as well.

One important type of brain wave is a sharp negative (downward) signal that occurs when you make an error, even if you are not aware of it. And in people who worry, this negative signal is much larger. The larger signal reflects the compensatory effort that anxious people need to make when tuning out distracting worries. This extra effort uses thinking resources that could otherwise be better used to focus on other activities, for example answering test questions.

If expressive writing frees up mental resources, we would expect the negative signal to be reduced, as there would be fewer distracting worries stored in the brain.
The experiment: brain waves, worry, and writing

Schroder and his colleagues conducted an experiment on 44 female students from a midwestern university. They chose females because prior studies had shown that women in particular show the exaggerated negative signal when they worry. Also, women in general have more anxious apprehension than men.

One group of participants was asked to engage in expressive writing about their worries, while the comparison group was asked to engage in writing unrelated to their worries. Then they were also given a computer task designed to elicit the negative-signal brainwaves.
How expressive writing changes the brain waves of worriers

Compared to writing about things other than one’s worries, expressive writing about one’s worries did in fact reduce the size of the negative brain wave signal in people who worried a lot. This implied that “offloading” your worries into free-form writing frees up mental resources that you can then use to complete tasks more easily.

What can you do if you worry a lot? Based on this study, expressive writing about your worries will help you become less distracted, thereby making your brain less reactive and more focused. It is this unfocused activity — free-flowing writing that documents whatever comes to mind without concern for technical errors — that will help your brain become more focused, thereby allowing you to complete tasks more successfully. In fact, many other forms of unfocus can help you focus more easily too.

So, before you have to concentrate on anything, spend eight to 10 minutes writing out your worries. When you do, your worry is less likely to get in your way, and you will likely complete tasks more easily, with your worries out of your brain and on the task at hand instead. 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). Did you know certain viruses can cause cancer? Two common examples include hepatitis C (which is linked with liver cancer) and human papilloma virus (HPV, which causes cervical cancer). The discovery of these virus-cancer connections is particularly important, because if a vaccine can prevent these viral infections it may also prevent cancer. And there is preliminary evidence that the HPV vaccine is making this happen. More on that in a moment.
What is HPV?

HPV is a group of viruses that may cause warts (papillomas) and a variety of cancers, including those involving the throat, rectum, penis, and cervix. HPV can spread between people by skin-to-skin contact, mostly during sexual activity. There may be no symptoms or signs of any illness at the time you get it. In some people, it sticks around and causes trouble years or decades later. HPV infection is quite common: an estimated 80 million people in the US are currently infected.
The HPV vaccine

Most people are exposed to HPV at some point in their lives through sexual activity. That’s why the vaccine is routinely recommended for teenagers, to protect them before they become sexually active. Specifically, the vaccine is recommended for:

    kids (girls and boys), ages 11 to 12
    women through age 26 and men through age 21 if they did not receive it earlier
    men who have sex with men (or intend to) through age 26
    transgender adults through age 26
    young adults with diseases that suppress the immune system (such as HIV) through age 26.

Does the HPV vaccine work?

Past studies have demonstrated that the HPV vaccine is highly effective, with protection rates of 97% or higher for the strains covered. And it’s estimated that with widespread vaccination, more than 90% of the 31,000 HPV-related cases of cancer that occur each year in women and men could be prevented. Studies have already shown a drop in precancerous abnormalities in the Pap smears of women in recent years, as well as a reduction in genital warts among young adults.
More good news

A recent study reports some impressive trends in the years since HPV vaccinations began:

    Between 2009 and 2015, HPV infections among women 18 to 59 fell by 32%; and the drop in infection rates was most dramatic (65%) among women 18 to 26.
    And… rates of HPV infection fell even among women who were not vaccinated. Among unvaccinated women 18 to 26, HPV infections fell by 50% (from nearly 20% to about 10%).
    Rates of other sexually transmitted diseases (such as gonorrhea and herpes) did not fall during the years of this study, so the use of condoms or other changes in sexual practices were considered unlikely causes of the drop in HPV.

It may seem strange that unvaccinated women experienced fewer HPV infections since approval of the vaccine. The likely explanation is “herd immunity.” When an infection becomes less common in a population, there is less opportunity for that infection to spread; when the drop is significant enough, even unvaccinated people benefit.
Room for improvement

Recent estimates suggest that only 60% of children are being vaccinated for HPV as recommended, and the rate is much lower for boys than girls. As with any new vaccine, it takes time for widespread acceptance, but as more studies (like this one) demonstrating effectiveness and longer-term studies of safety are published, vaccination rates are expected to increase. If they do, the impact on cancer prevention should be even greater than found in this recent study. This includes not only cervical cancer, but other cancers in men and women (such as those involving the throat and rectum) linked to HPV.
The news may get even better

It can take decades for cancer to develop among people with HPV infection. Since the vaccine has only been available for about 10 years, we won’t know for a while just how helpful it is at preventing infections and the cancers to which they are linked. So, stand by. The full benefits of HPV vaccination aren’t yet known. Of course, future research will also be needed on any potential risks of HPV vaccination that have not yet been recognized. So far, the news has been good, and likely will keep getting better.
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).
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Sunday, 3 February 2019

Is “man flu” really a thing?

Just as we’ve finished welcoming the new year, sports fans are getting ready to celebrate the Super Bowl. This event marks the single most active gambling-related activity in the world. For most gamblers, betting on the outcome of a sporting event, lottery drawing, casino table game, or any event with an outcome determined by chance represents an entertaining recreational activity. However, for some, gambling can become an addiction.
Excessive gambling recognized as an addiction

Gambling disorder is now a part of the American Psychiatric Association’s latest version of its diagnostic manual (DSM-5). Gambling is the first “behavioral” addiction included in the substance-related and addictive disorders section of the manual. For the first time, the APA recognizes that substance-related addiction and difficult-to-control behavioral addiction are similar enough to be grouped as comparable expressions of addiction.

Now, clinicians, scientists, policy makers, gambling purveyors, and the public alike recognize that addiction can emerge from patterns of excessive behavior that derive from either using a substance, such as tobacco or alcohol, or engaging in activities like gambling, video game playing, or sex. This might come as a surprise, but it’s true. You can become addicted to gambling just like you can become addicted to alcohol or other drugs.
History and causes of gambling problems

Historically, opinions about gambling have tended to mirror the social and moral climate of the day. Gambling problems aren’t anything new; there were scientific papers written about excessive gambling as far back as 1798 and, reaching even further back into history, there are cave drawings depicting gambling-related behaviors. However, the concept that problem gambling is not a moral defect but instead a disorder is relatively new. Most experts and clinicians now consider gambling addiction as a legitimate biological, cognitive, and behavioral disorder. Further, although mental disorders can lead to problem gambling, gambling to excess also can lead to other problems.

Gambling problems have many potential causes: genetics, erroneous thought patterns, impulse control disorders, poverty, and personal experiences, for example. An estimated 2% to 3% of the US population has experienced some kind of gambling-related problem during the past 12 months. That means about 5.5 million people currently have a gambling disorder, or gambling-related problems that don’t quite rise to the level of a disorder.
Do you have a gambling problem?

If you answered yes to any of these questions, you should evaluate your gambling and how it fits into your life. There are many resources to help, and my colleagues and I have published an easily accessible book that can help you to evaluate your gambling and decide whether you might be a candidate for treatment. Some people need treatment to recover from addiction, while others recover on their own with no help from anyone.

To figure out whether you might benefit from a change, you need to take stock. A variety of mental health issues often accompany excessive gambling. You might have some of these symptoms even if they don’t reflect a full-blown disorder. It’s worth it to figure out whether gambling and associated activities are adversely influencing your life. Understanding how gambling works for you is a worthwhile exercise, even if you choose to continue gambling. It is easy to ridicule a 2000-year-old treatment that can seem closer to magic than to science. Indeed, from the 1970s to around 2005, the skeptic’s point of view was understandable, because the scientific evidence to show that acupuncture worked, and why, was weak, and clinical trials were small and of poor quality.

But things have changed since then. A lot.

Thanks to the development of valid placebo controls (for example, a retractable “sham” device that looks like an acupuncture needle but does not penetrate the skin), and the publication of several large and well-designed clinical trials in the last decade, we have the start of a solid foundation for truly understanding the effectiveness of acupuncture.
How do we know if acupuncture really works for pain?

Individual large-scale clinical studies have consistently demonstrated that acupuncture provided better pain relief compared with usual care. However, most studies also showed little difference between real and sham (fake) acupuncture. In order to address this concern, a 2012 meta-analysis combined data from roughly 18,000 individual patients in 23 high-quality randomized controlled trials of acupuncture for common pain conditions. This analysis conclusively demonstrated that acupuncture is superior to sham for low back pain, headache, and osteoarthritis, and improvements seen were similar to that of other widely used non-opiate pain relievers.

And the safety profile of acupuncture is excellent, with very few adverse events when performed by a trained practitioner. Meanwhile, basic science studies of acupuncture involving animals and humans have shown other potential benefits, from lowering blood pressure to long-lasting improvements in brain function. More broadly, acupuncture research has resulted in a number of insights and advances in biomedicine, with applications beyond the field of acupuncture itself.
Is acupuncture really that good?

We understand why there may be continued skepticism about acupuncture. There has been ambiguity in the language acupuncture researchers employ to describe acupuncture treatments, and confusion surrounding the ancient concept of acupuncture points and meridians, which is central to the practice of acupuncture. Indeed, the question of whether acupuncture points actually “exist” has been largely avoided by the acupuncture research community, even though acupuncture point terminology continues to be used in research studies. So, it is fair to say that acupuncture researchers have contributed to doubts about acupuncture, and a concerted effort is needed to resolve this issue. Nevertheless, the practice of acupuncture has emerged as an important nondrug option that can help chronic pain patients avoid the use of potentially harmful medications, especially opiates with their serious risk of substance use disorder.
Finding a balanced view

A post on acupuncture last year dismissed acupuncture as a costly, ineffective, and dangerous treatment for headache. This prompted us to point out the need for a measured and balanced view of the existing evidence, particularly in comparison to other treatments. Although the responses that followed the article overwhelmingly supported acupuncture, it nevertheless remains a concern that this practice attracts this kind of attack. Acupuncture practitioners and researchers must take responsibility for addressing deficiencies in acupuncture’s knowledge base and clarifying its terminology.

That said, we need to recognize that acupuncture can be part of the solution to the immense problem of chronic pain and opiate addiction that is gripping our society. That this solution comes from an ancient practice with a theoretical foundation incompletely understood by modern science should make it even more interesting and worthy of our attention. Clinicians owe it to their patients to learn about alternative, nondrug treatments and to answer patients’ questions and concerns knowledgeably and respectfully. For some people, many foods, medicines, and bee stings mean life-threatening allergic reactions that require immediate treatment with injectable epinephrine. For many people, January means the start of a new drug deductible to be met. In June 2017 the FDA approved a new form of emergency epinephrine called Symjepi, which may be good news for people who must be prepared in the event of a life-threatening allergic reaction.
The seriousness of a severe allergic reaction

Severe allergic reactions affect anywhere from 5% to 70% of persons, depending on age and prior exposure. Anaphylactic or “type 1” (immediate hypersensitivity) reactions are the most severe forms of allergic reaction to a substance: insect venom, foods, or some drugs. People who have had prior exposure to an allergic substance are “sensitized” and when they are re-exposed, can have a reaction within seconds to minutes. Anaphylactic reactions are caused by the release of histamine and other chemicals throughout the body, resulting in leaky blood vessels that contribute to swelling of tissues in the mouth and airway and very low blood pressure. These symptoms can lead to difficulty swallowing and speaking, wheezing and severe shortness of breath, and death.
Treating severe allergic reactions

The treatment for severe allergic reactions is the administration of epinephrine (adrenaline) at the first sign of symptoms. Epinephrine is one of the chemicals in the body that raises blood pressure and heart rate. Epinephrine can be administered through an IV in the hospital, but since the 1980s, epinephrine has been available as a pre-filled syringe that can be obtained with a prescription and immediately injected into the thigh muscle when severe allergic symptoms are recognized.

The prevalence of severe allergies has been increasing since 2000. Anaphylaxis to some external chemical or allergen occurs in 2% of the population, and it is estimated that approximately 500 people die from anaphylactic reactions per year in the US. Because of this, more and more people need to have epinephrine available wherever they are (home, school, when traveling). So it is no surprise that the manufacture and marketing of pre-filled epinephrine syringes has been big news in the last two years.
Keeping epinephrine at the ready

Spring-loaded autoinjectors that contain epinephrine have been manufactured by several companies since 1987. In the last 30 years, changes in pharmaceutical companies and patent transfers resulted in a near-monopoly in the production of pre-filled epinephrine products. From 2009 to 2016, one company with a 90% market share dramatically increased the consumer cost for epinephrine injectors, resulting in an investigation and eventual settlement with the US Department of Justice.

Although not a spring-loaded autoinjector, Symjepi consists of two single-dose, pre-filled syringes of epinephrine, for the emergency treatment of anaphylactic and severe allergic reactions in adults. Each pre-filled syringe contains 0.3 mg epinephrine, the recommended initial dose for emergency treatment of anaphylaxis.

At an anticipated lower cost and small size, Symjepi could be an attractive addition to this slice of the pharmaceutical world. In November 2017, the company also submitted a second new drug application to the FDA for a junior version (0.15 mg dose for children between 33 and 65 pounds). My first day returning to work after being treated for a severe opiate addiction was one of the most daunting moments of my life. Everyone in the office, from my manager to the administrative assistants, knew that forged prescriptions and criminal charges were the reason I had been let go from my previous job. My mind was spinning. What would my coworkers think of me? Who would want to work alongside an “addict”? Would they ever come to trust me? Did I even deserve to be here?

When my life was crashing and burning due to my addiction (detailed in my memoir Free Refills: A Doctor Confronts His Addiction), a return to work seemed like a distant prospect, barely visible on a horizon clouded by relapses, withdrawal, and blackouts. My finances, my professional reputation, and my family life were in terrible shape due to my drug-seeking behavior. Working was not a tenable option until I received treatment and established a solid track record of recovery, which a potential employer could rely on.

The fact that I was now in recovery was a great development, and it was further ratification of my progress that I had landed a job and was returning to work. So, why wasn’t I feeling overjoyed?
How stigma affects the return to work

As it turns out, the transition back to work after someone is treated for an addiction can be profoundly stressful. People recovering from addiction already tend to suffer disproportionately from guilt, shame, and embarrassment, and these feelings are often brought to the forefront during the unique challenges of returning to work.

Stigma is what differentiates addiction from other diseases, and is primarily what can make the return to work so difficult. If I had been out of work to receive chemotherapy or because of complications from diabetes, I certainly wouldn’t have felt self-conscious or self-doubting upon resuming my employment. With addiction, due to the prejudices that many people in our society hold, the return is psychologically complex and anxiety-producing. As I entered my new office, I was walking right into the fears, preconceptions, and potential disdain that my new officemates might share toward people suffering from a substance use disorder. For all I knew, I was the “dirty addict” that they now, against their wishes, had to work with.
“Bring your body and your mind will follow”

What I was taught in recovery, to deal with situations like this, is to “just keep your head up” and to “put one foot in front of the other.” Or, “bring your body, and your mind will follow.” When I first heard these phrases, I thought that they were mere platitudes, phrases without content, provided to motivate us through dark times. Now, I think they hold a great deal of wisdom.

As I walked through the door on my first day back, I did feel everyone’s eyes on me, and I did wonder if they were judging and criticizing me, but I made it to my desk without incident, and managed to power through my self-consciousness and get into the flow of my work. Every day, it became easier as I did a good job, deepened my connections with my colleagues, and accumulated good will, which would eventually replace any negative images that may have accompanied my arrival. Within weeks this was a non-issue, though at office get-togethers, my co-workers still somewhat awkwardly don’t know whether to put a wine glass at my place setting.

With all I had learned in recovery about communication, about humility, about connecting with others, I feel that I was in a better position to thrive in my workplace than I was before my addiction started in the first place. As more of my brothers and sisters in recovery return to employment, and as we succeed, the more difficult will it be for people to hold on to their negative attitudes and prejudices about substance use disorders. We can defeat the stigma by confronting it, putting one foot in front of the other, one step at a time.
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