Showing posts with label Public health. Show all posts
Showing posts with label Public health. Show all posts

Friday, 12 April 2019

Myths about using Suboxone to treat opiate addiction

It used to be that prostate cancer screening was routine for men over the age of 50. Positive results on the prostate-specific antigen (PSA) test would trigger a biopsy, and findings of cancer would lead almost inevitably to treatment.

But recently, the rate of PSA screening in the United States has fallen sharply — and the number of new cases of prostate cancer has dropped, too. That’s according to a pair of studies published together this past November in The Journal of the American Medical Association. The studies couldn’t prove that these two trends are causally related; however, the authors speculate that they are. That is, the drop in the number of new cases likely reflects declines in screening, rather than a drop in the number of men who actually have prostate cancer.

Like some other cancer screening tests, such as mammography for breast cancer, the PSA test has come under growing scrutiny. Experts say that it flags too many low-risk tumors that might never become harmful during a man’s lifetime. Treating those cancers can expose men to a needless risk of impotence, incontinence, and other side effects.
Why the numbers are dropping

In 2008, the United States Preventative Services Task Force (USPSTF), an influential volunteer panel of medical experts, came out against PSA screening in men older than 75. Then in 2012, they issued an updated recommendation against screening for all men, regardless of age, race, or family history. These recommendations are controversial. Even though many experts acknowledge the PSA test’s limitations, they worry that abandoning the PSA test altogether will boost diagnoses of late-stage tumors that may no longer be curable.

One of the newly published studies reviewed national PSA screening data collected between 2000 and 2013. Results showed that screening rates started falling in 2010, but only among men younger than 75, and especially within the 50-54 and 60-64 year age groups. The overall screening rate (for all men combined) fell from 36% to 31%.

The second study detected a similar drop in PSA screening rates — from 37.8% to 30.8% — as well as a 22% drop in new prostate cancer diagnoses. The authors of this study reviewed data maintained by the National Cancer Institute and found the number of diagnoses per 100,000 men ages 50 and older had fallen from 540.8 cases in 2008 to 416.2 cases in 2012. The biggest declines came after the USPSTF released a preliminary draft of its updated screening recommendations in October 2011.

“These are the first national, population-based data showing what appears to be an effect on prostate screening and diagnoses from the Task Force recommendations,” said Ahmedin Jemal, DVM, Ph.D., vice president of surveillance and health services research at the American Cancer Society, and a key author of the first study.
Don’t write off PSA screening just yet

In an accompanying editorial, Dr. David F. Penson, the chairman of urologic surgery at Vanderbilt University Medical Center, cautioned that the “pendulum” of popular opinion might be swinging too far away from screening. But rather than stopping screening altogether, Penson called for smarter, more targeted screening approaches directed mainly at men considered at high risk of developing prostate cancer.

“These new findings are an expected consequence of the Task Force’s conclusion that PSA testing probably causes more harm than good,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of However, Dr. Garnick also called for better screening tests, acknowledging that the number of men presenting with more advanced prostate cancer is now likely to rise. “We also need studies that offer focused screening to those at potentially high risk of more aggressive forms of prostate cancer,” he said. “The research should test whether early treatment saves lives or decreases the rates of prostate cancer mortality. Until we have those data, the true effect of decreasing screening rates will remain unknown, and the debates about PSA testing will continue, with no clear answers in sight.” Traveling with your children can be a great way to explore new places, spend time together as a family, and visit with those friends and family members who don’t live nearby. To have the safest and healthiest trip possible, keep in mind these travel tips.
Bring the important things from your medicine cabinet

    Pack any prescription medicines your child takes. Check to be sure you have enough for the whole trip.
    Bring commonly used over-the-counter medicines, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), antibiotic ointment, cold medications (as recommended by your doctor), and diphenhydramine (Benadryl).
    Carry a thermometer and a few Band-Aids on every trip; they can come in very handy. Consider a pair of tweezers, too, if your child gets splinters often.

Kids need car seats

    Make sure you have the proper seat for your child’s age and weight, and that it’s correctly installed in the vehicle you are traveling in. The website of the American Academy of Pediatrics offers tips on choosing and installing car safety seats.
    If you are traveling by plane, the Federal Aviation Administration strongly recommends bringing car seats for infants and toddlers and fastening them to an airplane seat. Remember that you will have to purchase a separate ticket for the child in order to use the seat. Check with the airline to see if discounts are available. The car seat must be less than 16 inches wide to fit; be sure to measure before you go! Booster seats are not allowed on planes.

Be aware of common travel health problems

    If your child easily gets carsick, make sure she is high enough in the car to see out the window, as this can help. Keep a window cracked open for a breeze, and have some light snacks such as pretzels available; both can help nausea go away. If your child has particularly bad carsickness (for example, she vomits every trip), talk to your doctor about medications she might take.
    Ear pain can be a problem when people fly. Having an infant nurse or take a bottle during take-off and landing is a good idea, as swallowing helps combat ear pain. For older children, try having them drink, chew gum (sugarless, of course!), or play a yawning game to prevent their ears from blocking up.
    Since schedules and what you eat when traveling are often different than when you’re home, constipation (not having a bowel movement as often as usual) may happen. Give your child plenty of fluids, and make sure there is fiber (fruits, vegetables, whole grains) in his diet.
    Germs can be anywhere when you travel. Carry hand sanitizer with you at all times, to help you bring fewer of them along with you!

Don’t forget about childproofing

    Bring along a childproofing kit with outlet covers, cabinet locks, and whatever else you use at home.
    If staying at someone’s house, you may not be able to childproof the entire place. Ask if there is one room you can completely childproof, so you can relax better while your child is there. Think about the biggest dangers, such as medications, cleaning fluids, knives, and potential choking hazards. Ask if those and any other particularly dangerous things can be moved and/or locked out of reach during your stay.
    For infants and toddlers, a portable crib can serve as both a bed and a safe place to play.
    Consider bringing safety gates with you to block stairs or to help keep your child in a safe room. Your host may appreciate it if you use the kind that open out, as opposed to ones that need to be climbed over.

Do your homework

    Write down your child’s medical information, especially medication allergies (if you forget the name of the antibiotic that gave him the rash, find out before you go!), health problems, and prescription medications. Keep it with you at all times. If your child needs to see a doctor while you are traveling, she’ll need to know these things.
    Bring the names and phone numbers of all doctors your child sees, including specialists, in case you or a doctor you see needs to contact them.
    Ask your doctor about the best hospitals in the area where you are traveling, so you’ll know where to go if necessary.
    Make sure you bring your health insurance cards, and check with your insurance company about coverage out of your area. Most companies will cover emergency care if your child needs it, but you may need to call for approval or go to a particular hospital.

If traveling outside of the country…

    For travel to certain countries, your child may need special vaccines. To find out the latest recommendations, visit the Traveler’s Health section at the U.S. Centers for Disease Control and Prevention (CDC) website. Do this at least six to eight weeks before traveling, as many of the vaccines need to be given at least a month before travel and you may need an appointment at a special travel clinic to get certain vaccines.
    Find out about the particular health risks, such as malaria or dengue, in the country where you will be traveling so that you can talk to your doctor before you go about how to prevent them. The CDC’s website can help with this. It also has lots of useful, practical information about topics such as safe food and water and traveler’s diarrhea.

It sounds like a lot, but mostly it’s just a matter of planning. And it can make a big difference when it comes to making your trip memorable for all the right reasons. In the United States, depression is the top cause of disability, but only 21% of patients diagnosed with major depression get treatment that meets the guidelines of the American Psychiatric Association. Of people seeking depression treatment, those who’d like to be treated with live psychotherapy outnumber those who’d like to be treated with medication three to one, but those who want live therapy often don’t receive it. Access to psychotherapy is limited by the number of professionals in one’s region, cost, and logistics — not to mention stigma. And when people do get therapy, therapists may not provide care that is evidence-based.

One way to get high-quality psychotherapy to people who need it is to automate and computerize the treatment process and deliver it through websites and apps. This could potentially offer guidelines-based treatment to anyone, anywhere, anytime, at a modest cost. Stand-alone computerized cognitive behavioral therapy (CCBT) has been found to be effective for the treatment of depression, and is already available from a few entities. But it’s still not known how much, if at all, CCBT would improve treatment of depression in primary care, so a group of researchers in the United Kingdom recently tested the advantages of adding CCBT to standard treatment. They randomly assigned 691 people with depression into three different groups. One group received standard care, and the others received standard care plus one of two online CCBT programs.
Comparing CCBT with standard care for depression

As it turns out, standard depression treatment in UK primary care centers is quite good. Citizens are routinely offered antidepressant medications, psychotherapy, and access to community mental health teams, psychologists, psychiatrists, and counselors — a range of resources seldom available in US primary care practices.

There was a lot of crossover between the study groups. In the “standard care” group, 19% ended up using CCBT even though they weren’t specifically assigned to that treatment. Between 77% and 84% of all three groups used medication to treat their depression, and “live” mental health specialists were seen by 17% of one and 24% of the other CCBT group.

Against this backdrop — with many participants in the CCBT groups also receiving mental health specialty treatment and 19% of the standard-practice group receiving CCBT — no significant difference in depression treatment results was found. However, in the US, the findings may have been very different, considering the limited array of mental health resources in most primary care clinics.

It would be most interesting, and more important, to know the benefit of using CCBT for patients who receive nothing else — no medication and no access to mental health specialists. It’s for these patients that CCBT might be the most beneficial.
Challenges in getting people to use CCBT for depression treatment

Both of the CCBT websites had been tested in previous clinical trials and both had been found to be effective treatments — but they’re only helpful if people use them. Even though the two stand-alone CCBT websites were designed to be used over either 6 or 8 “sessions,” most people only used them once or twice, even though the study provided reminder calls to the participants. People with depression can experience fatigue, impaired concentration, and feelings of hopelessness. Getting them to consistently use CCBT websites on their own schedule is a challenge — even if these programs might be helpful in the end. More structure may be needed to keep people using CCBT.

What’s the take-home? The biggest challenge isn’t building a CCBT program that works; it’s building one that people will use. Just as you need to entertain before you can educate, any CCBT program needs to be extremely engaging to users — and to provide immediate value from the first session. And, although the treatment-anywhere-anytime concept is alluring, relying on people to schedule CCBT themselves on their own time, in their own homes, may lead to high levels of drop-off; after all, you can always get around to it later. When I was growing up, my doctor still made house calls when we were too sick to get to his office. But he stopped visiting people at home long before he retired. Both he and his patients realized they were perhaps better served by going to his clean, well-equipped office for whatever care they needed.

So I was more than a little surprised when a woman representing my health insurance plan called to schedule me for a home visit from either a nurse practitioner or physician. I have a Medicare Advantage plan, and I thought I was being offered this visit because the caller assumed I was frail and house-bound. I assured her I could easily get to my doctor’s office if I needed to. I’d also just had my annual physical, my immunizations and screenings were up to date, and I felt great. Why would I need a home visit?

The only reason she could give was that the clinician would have more time to spend with me than my own doctor did. The home visit would last 45 minutes to an hour and would include a health history, a physical exam, screenings, and health advice. Since I work full-time, I could schedule the visit for a weekend. And she’d even throw in a $25 Walmart gift card if I completed the exam.

I declined, feeling a little creeped out — especially after checking with my doctor and learning that she knew nothing about this. So I did a little research.

I learned that these visits are legitimate — in fact, over a million patients have signed up for them so far. And I learned that the extra exam had reduced hospitalizations, primarily for patients with diabetes, heart failure, or chronic obstructive pulmonary disease. But what still puzzled me was why my insurer would want to incur the extra expense of duplicating the exam and tests I had just gotten from my doctor. I don’t have any serious conditions and my doctor consistently receives top grades from all the ratings systems.
A method to the supposed madness

Dr. Michael McWilliams suggested an answer. As an associate professor of health policy at Harvard Medical School, he understands the arcane regulations that cover how Medicare reimburses my Medicare Advantage plan for the care I get. He told me that each of us covered by these plans is assigned a risk score. As we develop more health problems, our risk score increases. “The home visits conducted by Medicare Advantage plans allow for the capture of more diagnoses, which in turn increases the risk score that adjusts plan payments from Medicare.  Generally speaking, the more diagnoses recorded, the higher the payment,” Dr. Williams says.

He explains that the risk adjustment system was created to ensure that plans don’t enroll only the healthiest patients, who are less likely to run up charges for expensive procedures and hospital stays. To provide an incentive for insurers to cover sicker patients, the plans are paid commensurately more for their care.

I’ve received two more calls since I first declined the home visit, each more persistent than the last. Now I understand why. If the clinician could diagnose me with a serious health condition, the company could raise my risk score and get a higher Medicare reimbursement each time I visit the doctor.
What to consider if you’re offered a home visit

If you or someone you know is offered a home visit from a Medicare Advantage plan, keep the following in mind:

    If you have a serious health condition, the extra care might help you avoid a hospital stay.
    The care they provide isn’t ongoing. This is the only time you will see the clinician who examines you. The results of the exam and tests will be forwarded to your regular clinician for follow-up.
    If you are healthy and the visit results in an increased risk score, you won’t have to pay more for your care. But the higher Medicare reimbursement your insurer receives may contribute to the nation’s rising health care costs.
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Friday, 8 February 2019

Adding lifestyle changes to medication can deliver a knockout punch

Does screening for prostate cancer with the prostate-specific antigen (PSA) test save lives? A new study suggests that it does, but at the risk of exposing men with slow-growing tumors that may not be life-threatening to treatments they may not really need.

Published in Annals of Internal Medicine, the study reconciles conflicting results from the two largest clinical trials yet looking into whether PSA screening reduces prostate cancer death rates. One of them, the Prostate, Lung, Colorectal and Ovarian (PLCO) clinical trial divided 76,693 American men between the ages of 55 and 74 into two groups. Half the men got a PSA test every year for six years, while the other half — the control group — got their usual medical care, which may or may not have included screening. Results published in 2012 showed that more men from the screening group were diagnosed with prostate cancer after 13 years of follow-up. But prostate cancer death rates in the screening and the control groups were the same, indicating that PSA screening hadn’t saved any lives.

The other clinical trial, called the European Randomized Study of Screening for Prostate Cancer (ERSPC), enrolled 182,160 men, aged 50 to 74, from various European countries. Half of those men were offered PSA screening once every four years; the remaining men in the control group got usual medical care, which might have included screening. Results also published in 2012 showed that after about 11 years of follow-up, 299 men from the screening group had died of prostate cancer, compared to 462 men from the control group. Those data suggested that screening lowers the relative risk of prostate cancer death by 21%.

Researchers have been grappling with these conflicting results ever since, especially because the PLCO trial had a significant shortcoming. As was not the case in the ERSPC trial, large numbers of men in the PLCO control group had at one time or another been given a PSA test. The PLCO researchers should have been comparing prostate cancer death rates among men who had been screened or not screened for the disease. But the PLCO screening and control groups weren’t dissimilar enough in this respect that researchers could detect survival differences between them reliably.
A new approach

To address that problem, the research team combined and then reanalyzed data from both studies using different statistical methods that could limit the contaminating impact of PSA screening on the PLCO controls. And after this statistical adjustment, the researchers discovered that the final results from both trials were comparable: depending on the specific statistical analysis used, PSA screening was associated with a 25% to 32% lower relative risk of dying from prostate cancer.

Researchers have long agreed that the lifesaving benefits from PSA screening are small. The new study doesn’t change that overall perception, though it “does provide more evidence that screening can be beneficial,” said lead author Alex Tsodikov, a professor of biostatistics at the University of Michigan School of Public Health in Ann Arbor.

Still, the benefit should be interpreted in the proper context. Men in the United States have a roughly 3% risk of dying from prostate cancer over their lifetimes.

If PSA screening drops that risk by roughly a third, then the lifetime odds of dying from prostate cancer fall from 3% to just over 2%. Put another way, the new analysis shows that more than 1,000 men would have to be screened with a PSA test — and more than 35 treated — to prevent a single prostate cancer death.

In an accompanying editorial, Andrew Vickers, a biostatistician at the Memorial Sloan Kettering Cancer Center in New York, acknowledged that PSA screening “does good by saving lives, but also causes harms in terms of overdiagnosis and overtreatment.” Therefore, PSA screening should be deployed strategically to maximize benefits.

For instance, screening should be abandoned in men over the age of 70 who aren’t likely to benefit from it, and biopsies should be limited to men who screen positive and are also at high risk for aggressive, life-threatening prostate cancer according to new and emerging types of biomarkers, Vickers proposed. With these and other approaches, he claimed, overdiagnosis might be reduced by up to 70%.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of, cautioned that the lifesaving benefits of PSA screening remain uncertain, given underlying differences in how the PLCO and ERSPC studies were conducted.

Though statistical reanalysis can provide some additional clarity, “the new study does little to advance our understanding of the benefits versus harms from screening,” he said. “What we need, and what many investigators are working on, are ways to assign appropriate treatments based on a prostate tumor’s genetic makeup. Only then, in the context of prospective controlled studies, will we be able to place the utility of PSA-based screening in the proper context,” Dr. Garnick said. Osteoarthritis is the form of joint disease that’s often called “wear-and-tear” or “age-related,” although it’s more complicated than that. While it tends to affect older adults, it is not a matter of “wearing out” your joints the way tires on your car wear out over time. Your genes, your weight, and other factors contribute to the development of osteoarthritis. Since genes don’t change quickly across populations, the rise in prevalence of osteoarthritis in recent generations suggests an environmental factor, such as activity, diet, or weight.

Osteoarthritis of the knee will affect at least half of people in their lifetime, and is the main reason more than 700,000 people need knee replacements each year in the US.
The obesity-arthritis connection

To explain the rise in the prevalence of osteoarthritis in recent decades, most experts proposed that it was due to people living longer and the “epidemic of obesity,” since excess weight is a known risk factor for osteoarthritis. Studies have shown not only that the risk of joint disease rises with weight, but also that even modest weight loss can lessen joint symptoms and in some cases allow a person to avoid surgery.

But a remarkable new study suggests there is more to the story.
Challenging a common assumption

Researchers publishing in the Proceedings of the National Academy of Sciences examined skeletons from people who had died and donated their bodies to research. Information regarding presence of knee osteoarthritis, age at death, body mass index (BMI), cause of death, and other data were compared for more than 1,500 people who died between 1905 and 1940 (the “early industrial group”) and more than 800 people who died between 1976 and 2015 (the “post-industrial group”).

A third group of skeletons obtained from archeological sites were also assessed for osteoarthritis of the knee. They came from prehistoric hunter-gatherers living hundreds to thousands of years ago, and early farmers living between 900 and 300 BP. BMI could not be determined for these individuals, but gender could be determined and age was estimated based on features of their skeletons.

The findings were intriguing:

    The prehistoric skeletons and early 1900s cadavers had similar rates of knee osteoarthritis: 6% for the former and 8% for the latter.
    With a prevalence of 16%, the more recent skeletons had at least double the rate of knee osteoarthritis as those living in centuries past.
    Even after accounting for age, BMI, and other relevant information, those in the post-industrial group had more than twice the rate of knee osteoarthritis as those in the early industrial group.

Limitations of this study include BMI estimates at the time of death that might not reflect body weight during most of the person’s life, a study population (bodies donated for medical research or from archeological digs) that might not be representative of the population at large, and lack of accurate information regarding diet, activity, and other important factors. Even so, the findings shake some long-held assumptions and make the rise in osteoarthritis in recent years more mysterious than before.
So what?

These findings call into question assumptions about the reasons osteoarthritis is becoming more common. And they suggest that slowing or reversing the dramatic increase in obesity in recent years may not have as much of an impact on knee osteoarthritis as we’d thought. Finally, if longevity and excess weight do not account for the rising rates of knee osteoarthritis, what does? The list of possibilities is long, and as suggested by the authors of this study includes:

As is so often the case in medical research, this new study raises more questions than it answers. We’ll need a better understanding of why and how osteoarthritis develops before we can prevent it or improve its treatment. There are already many dedicated researchers exploring these important questions.
For most of us, whether to screen for cancer is a no-brainer. Who wouldn’t want a simple test to prevent cancer or identify it at an earlier, more treatable stage? However, as with many things, the screening decision is more complex than it may appear. For example, the test may not be particularly “simple,” such as undergoing screening colonoscopy. For prostate cancer, even after 30-plus years of using a screening blood test called the prostate specific antigen, or PSA, it still isn’t clear how well it prevents prostate cancer deaths. This has led to conflicting and changing recommendations about whether to screen or not. Earlier this year, I commented on revised recommendations from the US Preventive Services Task Force (USPSTF) — a group that advises primary care physician such as myself about a wide range of topics including cancer screening.
A new look at old studies

The PSA test was used for many years without any clear evidence for or against it, and without the USPSTF providing a specific recommendation. This changed in 2009 after the publication of two large trials, one from the US and the other from Europe. Unfortunately, they showed conflicting results — no benefit in the US trial versus a small benefit in the European one. This led the USPSTF to recommend against PSA screening based on the negative results from the US trial, as well as evidence of potential harms of PSA testing from overdiagnosis and treatment of small, benign-appearing cancers unlikely to spread or lead to death. Earlier this year, the USPSTF proposed changing its recommendations to say that health care providers should now discuss the pros and cons of the test with eligible male patients to help them decide whether to have the test or not, using a process called shared decision making.

If all this wasn’t confusing enough, a new study recently re-examined these two (now old) trials and concluded that they really aren’t as different as we thought. The authors of the new study did new analyses showing that PSA testing decreased prostate cancer deaths similarly in these trials. So, what’s going on, and will the USPSTF again change its recommendation?

In brief, the new study used original data from these two trials and computer modeling to control for important differences. These differences included lower rates of prostate cancer overall and more control patients getting a PSA test done (who shouldn’t have) in the US trial. The European trial performed PSA screening less frequently but called the test result abnormal at a lower value than the US trial. After accounting for all these differences, the new study reported that men in both trials who underwent screening as recommended had lower rates of death due to prostate cancer.
What now?

Though this new study may explain why these two trial results differed, I don’t expect the USPSTF will change its recommendation. Personally, I have long favored shared decision making with my patients, and think the USPSTF finally got it right. Why? First, despite all the fancy modeling in this study, it sought to examine the benefit of the PSA test under ideal circumstances, rather than what actually took place. Moreover, the benefit of PSA testing seems large in relative terms (20-30%), but is small in absolute terms. I’d have to screen over 1,000 men with the PSA test to prevent one prostate cancer death. Moreover, decades of using the test have also uncovered real harms — many men are being diagnosed and treated for prostate cancers that otherwise never would have been detected or caused harm. Finally, prostate cancer therapies for those with serious disease needing treatment have improved a great deal since these trials were done, lowering the value of earlier detection.

I support calls to move on from the overly simplistic debate of PSA test: yes or no. Rather, it is time to figure out how to better inform all eligible men about the benefits and harms of PSA testing. For those who elect to have the test, we need to do a better job figuring out who needs treatment when prostate cancer is found, and how to make sure we avoid harming those without such disease — harm that can be both psychologic in terms of worry and physical in terms of side effects from treatment.

Plenty of research supports the common-sense notion that a healthy lifestyle can prevent or treat many diseases. A diet high in fruits, veggies, whole grains, and plant protein and low in processed carbs, added sugars, saturated fats; regular physical activity; and emotional well-being are the potent treatments that can prevent the need for or even replace many prescription medications.

Yet lifestyle interventions are still not “mainstreamed” into primary care.
The power of lifestyle changes for diabetes

Here is yet another study supporting intensive lifestyle intervention, this time for diabetes. The study authors seem to downplay their findings, which, frankly, baffled me. I’m happy to enthusiastically report that this study strongly confirms what I’ve often observed over the past 15 years in medicine: the way we live and what we put in our mouths can be way more powerful than many of the pills we’re prescribed.

Basically, the study authors recruited 98 people with type 2 (adult-onset) diabetes who were all pretty similar. They had had diabetes for less than 10 years and their blood sugars were not completely out of control (HbA1c* less than 9%); they were not on insulin; they all had a body mass index between 25 and 40 (that is, they were overweight).

They divided people into two groups for a year. Both groups stayed on their regular medications. The standard care group (34 people) received basic counseling and education in type 2 diabetes, including lifestyle advice by a nurse at the start of the study and again every three months.

The other group (64 people) also received a pretty intensive lifestyle intervention:

    five to six exercise sessions per week, consisting of 30 to 60 minutes of supervised aerobic activity, along with two to three sessions of weight training
    an individualized nutrition plan with dietary counseling, including calorie restriction for the first four months
    a smart watch/step counter and encouragement to be physically active in their leisure time (with a goal of at least 10,000 steps per day).

The lifestyle group did have slightly better overall blood sugar control after a year, but the real kicker was this: 73% of the lifestyle participants were able to decrease the dosage of their diabetes medications, compared to only 26% of the standard care group. And, over half of the lifestyle participants could safely discontinue their medications! As a matter of fact, 44% of the standard care group had to have their medications increased during the study, compared to only 11% in the lifestyle group.

*HbA1C is the abbreviation for hemoglobin A1c, the product formed by the attachment of glucose (blood sugar) to hemoglobin (a protein in red blood cells). A test for HbA1c is a useful measure of blood sugar control over time. An HbA1C level between 4% and 5.6% means that blood sugar has been in a good range over the past few months.
Other improvements in measure of health

In addition, the lifestyle group enjoyed significant improvements in pretty much all their measurements: weight (13.2 lbs. lost, compared to 4.4 lbs.), BMI (31 to 29, compared to 32.5 to 32), and abdominal fat (2 lbs. lost, as compared to 0.2 lbs.), with a gain in lean body mass (i.e. muscle). Over a third of the lifestyle group lost over 10% of their body weight, compared with 3% of the standard care group. And the lifestyle folks also experienced a significant improvement in their physical fitness, as measured by a fancy machine measuring oxygen uptake by the body during intense exercise.

The study authors seemed to emphasize that lifestyle improved blood sugar only modestly better than standard care at 12 months. What was incredibly striking, though, was the trend in the blood sugars over the entire year. At six months, the lifestyle group’s HbA1c levels decreased very significantly, from 6.6% to 6.2%, while the standard care group’s HbA1c increased from 6.7% to 6.9%. At 12 months, both groups drifted closer to where they had started, with the lifestyle group still a bit better than the standard care group at 6.3% as compared to 6.6%.
Why is this?

There are two possible reasons. One was that the lifestyle group had fully supervised exercise and dietary counseling sessions (including calorie restriction) for only the first four months, and after that, supervision was progressively decreased, and as a result people were less likely to stick with the program. In fact, the article shows that participation in the exercise and dietary counseling sessions dropped off over the year.

Another factor is that the participants’ diabetes medication was being adjusted throughout the study for health and safety reasons. If the HbA1c dropped below 6.5%, then their medication was decreased, and if it stayed that low or went lower, the medication was discontinued. Likewise, if the HbA1c went above 7.5%, then the medication was increased. The lifestyle group did have more episodes of low blood sugar than the standard care side, and while that can be dangerous, it also signals that the lifestyle participants needed less medication as time went on. Many studies over several years have shown the relative safety of the flu vaccine in pregnancy. Although studies involving women in the first trimester of pregnancy are limited, those studies that did include women vaccinated in the first trimester of pregnancy did not show an association with miscarriage.

In a recent study, the data suggest an association between getting a flu shot and having a miscarriage within 28 days of the vaccine, especially in those women who were also vaccinated against the H1N1 strain in the prior year.

These results are surprising. One potential explanation is the specific inflammatory response triggered by the H1N1 vaccine, with a repeat vaccination causing an even more significant response to occur. As noted by the authors of a commentary published with the original article, “One important takeaway message from this study is that seasonal vaccine formulations are not all the same.”

Expert panels including the American Congress of Obstetricians and Gynecologists have not changed their opinion based on these study results, noting that the study included only a small number of women, and those results are not outweighed by the significant amount of existing data supporting flu vaccine safety. The current guidelines that the flu vaccine is strongly recommended in pregnancy, and is safe to be given in any trimester, remain unchanged.
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How brain science informs addiction treatment

Information is knowledge, and big tech companies know how important it is to collect and track data. When it comes to your health, it is now easy to measure and track all kinds of information. In the comfort of our homes we can check our weight, blood pressure, number of steps, calories, heart rate, and blood sugar. Recently some researchers have started to use an interesting marker for resilience and behavioral flexibility. It is called heart rate variability (HRV).

Have you ever wondered what the health impact of a stressful day was? Will you perform well during your long run tomorrow morning? Is there anything you can do today that would improve your ability to have a better day moving forward? HRV may be the piece of data that could help you answer these questions.
What is HRV?

HRV is simply a measure of the variation in time between each heartbeat. This variation is controlled by a primitive part of the nervous system called the autonomic nervous system (ANS). It works regardless of our desire and regulates, among other things, our heart rate, blood pressure, breathing, and digestion. The ANS is subdivided into two large components, the sympathetic and the parasympathetic nervous system, also known as the fight-or-flight mechanism and the relaxation response.

The brain is constantly processing information in a region called the hypothalamus. The hypothalamus, through the ANS, sends signals to the rest of the body either to stimulate or to relax different functions. It responds not only to a poor night of sleep, or that sour interaction with your boss, but also to the exciting news that you got engaged, or to that delicious healthy meal you had for lunch. Our body handles all kinds of stimuli and life goes on. However, if we have persistent instigators such as stress, poor sleep, unhealthy diet, dysfunctional relationships, isolation or solitude, and lack of exercise, this balance may be disrupted, and your fight-or-flight response can shift into overdrive.
Why check heart rate variability?

HRV is an interesting and noninvasive way to identify these ANS imbalances. If a person’s system is in more of a fight-or-flight mode, the variation between subsequent heartbeats is low. If one is in a more relaxed state, the variation between beats is high. In other words, the healthier the ANS the faster you are able to switch gears, showing more resilience and flexibility. Over the past few decades, research has shown a relationship between low HRV and worsening depression or anxiety. A low HRV is even associated with an increased risk of death and cardiovascular disease.

People who have a high HRV may have greater cardiovascular fitness and be more resilient to stress. HRV may also provide personal feedback about your lifestyle and help motivate those who are considering taking steps toward a healthier life. It is fascinating to see how HRV changes as you incorporate more mindfulness, meditation, sleep, and especially physical activity into your life. For those who love data and numbers, this can be a nice way to track how your nervous system is reacting not only to the environment, but also to your emotions, thoughts, and feelings.
How do you check your heart rate variability?

The gold standard is to analyze a long strip of an electrocardiogram, the test we frequently do in the medical office where we attach wires to the chest. But over the past few years, several companies have launched apps and heart rate monitors that do something similar. The accuracy of these methods is still under scrutiny, but I feel the technology is improving substantially. A word of caution is that there are no agencies regulating these devices, and they may not be as accurate as they claim. The easiest and cheapest way to check HRV is to buy a chest strap heart monitor (Polar, Wahoo) and download a free app (Elite HRV is a good one) to analyze the data. The chest strap monitor tends to be more accurate than wrist or finger devices. Check your HRV in the mornings after you wake up, a few times a week, and track for changes as you incorporate healthier interventions.
The bottom line

Tracking HRV may be a great tool to motivate behavioral change for some. HRV measurements can help create more awareness of how you live and think, and how your behavior affects your nervous system and bodily functions. While it obviously can’t help you avoid stress, it could help you understand how to respond to stress in a healthier way. There are questions about measurement accuracy and reliability. However, I am hoping an independent agency eventually identifies which devices and software provide data we can trust. In the meantime, if you decide to use HRV as another piece of data, do not get too confident if you have a high HRV, or too scared if your HRV is low. Think of HRV as a preventive tool, a visual insight into the most primitive part of your brain.
Stomachaches are incredibly common in children. Most of the time they are nothing serious at all. Most are just from a mild stomach bug, or some constipation, or hunger — or are a child’s way of getting out of something they don’t want to do. But a stomachache can sometimes be a sign of a more serious problem.
A stomachache worries doctors when…

1.  The pain is severe. By severe, I mean that the child cannot be distracted from it, and is crying or otherwise showing that they are extremely uncomfortable. Any severe pain warrants a trip to the doctor, whether it’s unrelenting or it comes and goes.

2.  There is blood in the stool. Most of the time, we see blood in the stool with constipation, which is usually not serious and can be easily treated. But a bad stomachache with blood in the stool can be a sign of a serious infection, inflammatory bowel disease, or another intestinal problem. So any time your child has a stomachache and blood in the stool, give your doctor a call to be on the safe side.

3.  The child vomits blood. As with blood in the stool, this isn’t always a sign of something serious. Children who have been vomiting a lot can sometimes vomit some blood, and children who have nosebleeds, or bleeding from a lost tooth or some other problem of the mouth, may vomit that blood back up. But as with blood in the stool, any stomachache with vomiting blood requires a call to the doctor.

4.  There is green vomit. Green vomit can be a sign of a blockage in the intestine. Sometimes people vomit some yellow-green material when they have vomited up everything else, but stomach pain and green vomit should never be ignored.

5.  The child has hives, looks pale, complains of dizziness, or has swelling of the face. Anaphylaxis, the most serious kind of allergic reaction, can cause stomach pain, often with vomiting. For this one, you should call 911. If your child has a known allergy and you have epinephrine at home, give it while you wait for the ambulance to arrive.

6.  The stomach pain is in the right lower side of the belly. That’s where the appendix is. Early on, the stomachache of appendicitis is usually around the belly button, but then it moves to what we doctors call “the right lower quadrant.” Constipation can cause pain there, and girls who get periods can have pain there when they ovulate, but we don’t like to miss appendicitis. So, any pain in that part of the belly should get checked out.

7.  The child has a fever and a bad cough. Pneumonia can sometimes cause a stomachache. Now, many viruses can cause a stomachache along with a cough, but if the cough is particularly bad, or the stomachache is getting worse, or the child seems to be breathing quickly or otherwise differently, call the doctor.

8.  The child says it hurts to urinate. Sometimes a stomachache can be a sign of a urinary tract infection.

9.  The child has a high fever or seems much sleepier than usual. Stomachaches can be seen in serious infections — and being very sleepy when you are in pain can be a sign not just of infection but of low blood pressure or blood loss. High fevers and extra sleepiness should always be checked out, but especially if there is a stomachache too.

10.  The child is losing weight. It’s not uncommon for a child to lose a little weight from vomiting or diarrhea. Usually they gain it back once they feel better. But if a child who gets stomachaches is steadily losing weight — for example, their clothes no longer fit — they should be thoroughly checked out by the doctor.
What to do if none of the above is true

This doesn’t mean that every other stomachache is fine — but if none of the above is true, it’s less likely to be something serious. Try rest, fluids, and a bland diet (or extra fiber in the diet if your child is constipated). If your child isn’t getting better, especially if your child has vomiting or diarrhea that isn’t getting better, call your doctor. If your child has recurrent stomachaches, it’s incredibly helpful when parents keep a diary of the stomachaches, along with details of things like what they ate that day, what their stool was like, how they acted, etc. This information can go a long way toward helping the doctor figure out what is going on, and how to help.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diet and lifestyle changes are powerful medicine. Even if your blood pressure is normal now, you can help to prevent it from becoming elevated starting today. Eat more fruits, veggies, and whole grains, and limit foods high in sodium and unhealthy fats. Be as physically active as possible.

There is a lot more in the very long, detailed executive summary, including specific guidance for various populations, myriad diseases, and special circumstances, but this is the gist of it. The document is free, and available here. But, it’s also one of the first things to fall by the wayside in times of stress, especially for those who are primary caregivers. This includes parents, people caring for elderly relatives, healthcare providers, and first responders. These are the people who often put the well-being of others above themselves.

This is a big problem.
Why is self-care important?

Well, we can’t function very well if we aren’t very well. If it is important to us to be able to take care of others, then we must pay attention to our own well-being.

My favorite analogy for this is clichéd, but accurate. When you get on an airplane and the flight attendant gives that safety spiel, when they get to the part about the oxygen masks, the first thing they tell you is: “If you’re traveling with children or others who need assistance, put your oxygen mask on first.”

Think about it. Let’s say you don’t do that and you fall unconscious due to lack of oxygen, then no one gets the help they need. Lose/lose situation there. It’s the same deal in everyday life. When we don’t take care of ourselves, no one wins.

And yet there is a pervasive cultural pressure to keep pushing ourselves, to ignore the physical needs of our bodies and the emotional needs of our souls, which invariably leads to chronic stress, burnout, depression. Data show that burned-out healthcare providers provide crappy service, depressed parents can’t effectively parent, and the list goes on.

When I talk with my patients about self-care, I often hear things like “But I don’t have time!” or “I’ll feel like I’m being selfish!”

As one of two working parents with two small children, I can empathize greatly with these patients. So, the advice I give is the same advice that I follow.

I know that it can be difficult to fit in self-care when time is at a premium and demands on you are high, but here are four easy things you can consider.
4 things to help revive and nourish body and soul

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

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

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

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

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

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

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

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

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

Here are examples of newer approaches:

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

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

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

To me, this means my brain-mechanic work looking under the hood of the brains of rats exposed to drugs is essential to the ultimate process of helping people suffering from SUDs, but only if I take the time to look up and discuss my findings with clinical colleagues. Likewise, the clinicians’ overwhelming job of helping people with immediate, life-threatening needs is essential, but only if they pause periodically to listen to our new brain discoveries that might revolutionize SUD treatments.
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Monday, 4 February 2019

Things parents and teachers need to know about ADHD

The blood left over in the umbilical cord and placenta after a baby is born has special cells in it that can treat and even cure some serious diseases. The blood can be collected and stored — and that’s what many private cord blood banking companies encourage parents to do, in case their child (or someone else in the family) develops one of those diseases in the future.

The American Academy of Pediatrics wants parents to collect that cord blood. But instead of keeping it for themselves, they would like them to give it away to a public cord blood bank.

Cord blood contains cells called hematopoietic stem cells. These cells can turn into any kind of blood cell and can be used for transplants that can cure diseases such as blood disorders, immune deficiencies, metabolic diseases, and some kinds of cancers. Research is revealing more and more ways it can save lives. It is precious — almost magical — and absolutely worth keeping. Doing so is completely safe for the baby, and doesn’t affect labor or delivery.

The diseases that cord blood treats are not very common, so the chances of any given child developing them are low — but worldwide they affect millions of children. That’s why public blood banks are used 30 times more often than private ones. If a family has a known genetic problem that puts them at risk of developing an illness that could be treated with cord blood, then it makes sense to keep it for family use. But if that’s not the case, it makes more sense to donate it, because it’s much more likely to be needed by another family than by the baby’s family.

Giving to a public blood bank is free, but banking through a private bank costs money: $1,000 to $2,000 initially, and then a yearly fee of $100 to $200. That’s a lot of money, which means that most families who end up needing cord blood don’t have a personal supply banked for them. Private cord blood banks also don’t have to meet the same accreditation standards as public ones, which means that the cord blood may end up being less useful if it’s needed.

It is only recently that we realized how precious cord blood is; before then, we threw it out. We still throw it out heartbreakingly often. There is some advanced planning involved to collect it, which is why we need to get the word out to everyone who is or might be an expectant parent, or anyone who might know an expectant parent and can tell them about cord blood donation. 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.
Attention deficit hyperactivity disorder is a childhood disorder that affects as many as one out of 10 children in the United States. Even though it’s fairly common, many misconceptions still persist. So here are five important things you should know if you are a parent or a teacher of a child with ADHD.

1. The hallmark symptoms of ADHD are inattention, hyperactivity, and impulsivity. Most kids are inattentive, impulsive, and hyperactive at times. But for a diagnosis of ADHD, these symptoms must interfere significantly in multiple places, such as at school and at home. This is a childhood disorder, meaning the symptoms must be present before adolescence. The symptoms can start in preschool, but most kids aren’t diagnosed until later in childhood. The symptoms may change over time, with hyperactivity and impulsivity being more pronounced in young children, while high-schoolers and young adults often display more difficulty with attention. Many children (perhaps as many as half) will outgrow their symptoms but others do not, so ADHD can affect a person into adulthood.

2. There are different types of ADHD: predominantly hyperactive/impulsive presentation; predominantly inattentive presentation; combined presentation. Most children with ADHD have a combination of inattention, impulsivity, and hyperactivity and would be diagnosed with ADHD-combined presentation. Other children who struggle most with hyperactivity and impulsivity would get the diagnosis of ADHD-hyperactive/impulsive presentation. A third group has predominantly problems with attention. While you often will hear these children described as ADD (attention deficit disorder), the correct term is ADHD-predominantly inattentive presentation. Girls tend to have inattentive symptoms more than boys.

3. ADHD is a brain-based disorder. Kids can’t overcome symptoms of ADHD by “trying to concentrate harder” or by willing themselves to “pay attention.” Brain imaging studies have shown that people with ADHD have structurally different brains than people without ADHD. It also runs in families. Children whose parents have ADHD have a 40% to 60% chance of also having ADHD. Sometimes a child’s diagnosis can be the first clue that a parent may have ADHD.

4. The symptoms of ADHD can make school, family, and social relationships difficult. School requires attention and organizational skills, things that can be difficult for kids with ADHD. They may lose homework, have difficulty organizing their thoughts, and have problems thinking ahead and planning. In addition, it’s common for children with ADHD to also have learning disabilities, such as dyslexia, that make schoolwork even more challenging. While kids with ADHD don’t generally have a specific problem with social skills, difficulty with emotion regulation and impulsivity can interfere with personal relationships, and so it can be hard for them to keep and maintain friendships. It can also be hard for them to follow social rules, control their emotions, or say the appropriate thing. Finally, problems with organization, planning, and focusing on what’s being said to them can make many aspects of home life quite difficult. Relationships with parents and siblings can take a lot more work.

5. There are great treatments available for children with ADHD. There are a variety of research-backed therapies that can help relieve symptoms of ADHD. Some of the most effective approaches combine several therapies, for example:

    Medication: Many parents are fearful of trying medication, but ADHD medications are some of the most well-studied across all areas of medicine. Stimulant medications (such as Ritalin, Adderall, or Concerta) are the most commonly prescribed. These drugs stimulate the parts of the brain that are understimulated. These parts of the brain are related to thinking and attention. The goals of these medications are to reduce hyperactivity/impulsivity and increase focus/attention.
    Behavior therapy: Behavior therapy teaches the child to be aware of, monitor, and eventually modify disruptive behaviors. The therapist will teach social skills, such as waiting your turn, reading facial expressions, sharing, asking for help, and reacting appropriately when teased. Cognitive behavioral therapy emphasizes mindfulness, and teaches a child to be aware of her thoughts and emotions as a way of improving attention and focus.
    Education and training: Knowing oneself, or one’s child, can help parents understand how ADHD and its symptoms affect the family unit. Parents and teachers can learn tools that can help the child learn new, pro-social, and positive behaviors. Adults can learn how to cope with inappropriate behaviors and encourage positive ones. This can help reduce ADHD symptoms.
    ADHD coaching: A coach can help students with ADHD work toward goals, see change as a positive thing, improve productivity and functioning, and keep a student accountable. This is particularly useful for older kids.
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Taking an anticlotting drug? If you need a procedure, be prepared

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In addition to the procedure itself, other factors that affect anticoagulant decisions include a person’s age, any other health problems or medications they take, and whether they’re taking warfarin (which stays in the body for days) or a NOAC (which may lose some of its effect after about 12 hours). Because of all these variables, the best strategy is to make sure that the doctor slated to perform your procedure talks directly with the doctor who prescribed your anticoagulant, says Dr. Piazza. “If that conversation doesn’t take place, patients can have problems with either bleeding or clotting,” he says. Many physicians who do procedures aren’t as familiar with NOAC prescribing guidelines, so they may mistakenly keep people off these medications for a week or more, putting them at risk for a clot.
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Sunday, 3 February 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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