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

Tuesday, 5 February 2019

Women and pain: Disparities in experience and treatment

Medication side effects are a big problem. It’s estimated that about half of filled prescriptions are not taken as directed, and a major reason for this is side effects. If you’ve ever had diarrhea, felt sleepy, or developed a rash after taking a new medication, you know how unpleasant side effects can be. And sometimes it’s much worse than unpleasant: drug side effects can cause permanent damage and even be deadly.
Predicting success… and side effects

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

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

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

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

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

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

The researchers divided study subjects into two groups:

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

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

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

Here’s the part where I’m obligated to mention the limitations of using genetic testing to direct drug treatment. First, in most cases, prediction isn’t perfect. Some people with a high-risk gene are fine when they take the medication; similarly, those lacking the high-risk gene can still react badly to the drug. One reason for this is that the benefits and risks of drugs are rarely determined by a single gene and many other factors matter, such as other medications taken and other medical problems. Another concern is cost. Many genetic tests are costly and it’s often unclear whether the benefits (which may be modest) are worth the expense. It’s possible that as genetic testing becomes more common and extensive, costs will come down; and as more genes are studied, the benefits of testing may become clearer (and, hopefully, more robust). Let’s face it: we are all getting older. As I write this, I am aging, and as you read this, you are, too! Today I want to talk about an aspect of aging that we don’t often think about, but which research shows we can do something about: osteoporosis, or brittle bone disease.

As we age, our bones naturally tend to become weaker. This is one reason that people often become slightly shorter as they age. Particularly for women, this process accelerates more quickly after menopause. Because bones become weaker, it is easier for them to break, sometimes with very little provocation. Hip fractures are an especially dreaded complication of osteoporosis, because they require hospitalizations and painful surgeries to repair, because recoveries can be particularly complicated, and lastly, because it sounds absolutely terrifying to break a hip! For all these reasons, the medical community worries about osteoporosis and we are constantly thinking of ways to prevent or ameliorate it.

There is a growing body of evidence that physical activity later in life (as well as earlier in life!) can help combat the effects of aging on our bones. Now, I know what you are thinking — I don’t have time to exercise! Well, I have good news for you. Just a little bit of the right type of exercise for just a few minutes a day may help.
You don’t need to train for a marathon to strengthen your bones

A recent study looked at the quantity and quality of exercise required to make a real change in bone strength, as well as how to measure that exercise. Researchers accessed pre-existing data from a large, public database in the UK in order to learn more about how exercise affects bone health in a group of healthy women at risk for brittle bones. In this study, both pre- and post-menopausal women wore accelerometers to record the intensity of their movements. The researchers wanted to see if they could learn about the patients’ movements with very brief measurements, and they found that they could.

More interestingly, what they found was that the women who had the most intense activity, recorded for what amounted to just one to two minutes each day, had a reduction in risk for brittle bones. Furthermore, they had a higher reduction than those women who did less intense activity, although those women saw some reduction in risk too. And the intensity required to achieve this? One to two minutes of running for a pre-menopausal woman and slow jogging for a post-menopausal woman.
More support for exercise and bone health

The study had some limitations. First, it measured bone health by looking at bone density in the heel by ultrasound. The best way to measure bone density is really with a special x-ray called a DEXA scan. We also care less about bone health in the heel and more about bone health in the spine and hip — places where a fracture is more dangerous. However, the general finding of better bone health in those who exercise has been seen throughout the medical literature, so I think we can still safely depend on the results of this study. Another potential limitation is that the patients they studied were all Caucasian females. However, there is no reason to presume that the research wouldn’t apply to healthy women of other ethnicities as well.

This study is so important because it really gives all of us such a reasonable goal. Can we give it our strongest effort for one to two minutes a day? I think we can. It also shows that if we make a small, measurable, but regular change, we can all dance, run, jog, jump, or hop our way to better health! The news these days is overwhelming in its awfulness. There have been horrible hurricanes, the earthquake in Mexico — and the incomprehensible shootings in Las Vegas. It’s been so awful, and so unrelenting, that it is hard to even process it.

Imagine processing it as a child?

Our first instinct is usually to shelter our children from the news and not say anything about it to them at all. That’s completely understandable, and if your child is very young or you are certain for some other reason that they aren’t going to hear about it, then not saying anything is a viable option.

But if they aren’t very young, or if you ever have the news on where they can see, or if they are ever in settings where people might have the news on or talk about it, it might not be so viable. If children are going to hear about something, they really should hear about it from you.

Also, as parents it’s important that we give our children the perspective and skills they need to navigate this scary world where, let’s be honest, bad things happen. The way you talk to children about tragedies in the news can help them cope not just now, but in the future.

The American Academy of Pediatrics has all sorts of resources to help parents talk with children about tragedies. Here are four simple things all parents can and should do:

1.  Tell them what happened, in simple terms. Be honest, but skip the gory details. Answer their questions just as simply and honestly. If you think — or know — that your child has already heard something, ask them what they’ve heard. That way you can correct any misinformation, and know not only what you need to explain but also what you may need to reassure them about.

2.  Be mindful of the media that your child sees. The news can be very graphic — and because the media are as much in the business of gaining viewers as of delivering news, they tend to make things as dramatic as possible and play footage over and over again. When the planes flew into the Twin Towers on 9/11, my husband and I were glued to the television, not realizing that one of our daughters, who was 3 years old at the time, thought that planes were literally flying into buildings again and again. It wasn’t until she said, “Are those planes going to come here too?” that we shut off the TV and didn’t turn it back on again until all the children were in bed.

3.  Make sure your child knows that not only are tragedies uncommon, but that you and others are always doing everything you can to keep them safe. Talk about some of the ways you keep them safe, ways that are relevant to the tragedy you are talking about. Make a safety plan as a family for things like extreme weather or getting separated. Help them think about what they might do if they are ever in a scary situation, and who they could turn to for help. Which leads me to the most important thing to do…

4.  Look for the helpers. The wonderful Fred Rogers often talked about how when he saw scary things on the news, his mother would tell him to look for the helpers, because there are always people who are helping. That may be the best thing we can do as parents: help our children look for the helpers. In all of the recent tragedies, as in all tragedies, there were so many helpers and heroes. When we concentrate on those people, not only do we give our children hope, we may empower them to one day be helpers too. In August, The New York Times published a guest op-ed by a man named David Roberts who suffered from severe chronic pain for many years before finally finding relief. The piece immediately went viral, with distinguished news journalist and personality Dan Rather posting it to his Facebook page with the addendum that it could “offer hope” to some pain patients. However, for many of us in the chronic pain community, particularly women, the piece was regarded with weariness and frustration.

The first and most prominent source of annoyance for me regarding this piece was the part when the author finally discloses his pain to his employer and it is taken with the utmost seriousness. He is immediately offered leave to find treatment, despite the lack of a definitive diagnosis. This stands in stark contrast to the experiences of many (if not most) women, where our pain is often abruptly dismissed as psychological — a physical manifestation of stress, anxiety, or depression.
Women with chronic pain may suffer more and longer than men

Consider this: women in pain are much more likely than men to receive prescriptions for sedatives, rather than pain medication, for their ailments. One study even showed women who received coronary bypass surgery were only half as likely to be prescribed painkillers, as compared to men who had undergone the same procedure. We wait an average of 65 minutes before receiving an analgesic for acute abdominal pain in the ER in the United States, while men wait only 49 minutes.

These gender biases in our medical system can have serious and sometimes fatal repercussions. For instance, a 2000 study published in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack. Why? Because the medical concepts of most diseases are based on understandings of male physiology, and women have altogether different symptoms than men when having a heart attack.

To return to the issue of chronic pain, 70% of the people it impacts are women. And yet, 80% of pain studies are conducted on male mice or human men. One of the few studies to research gender differences in the experience of pain found that women tend to feel it more of the time and more intensely than men. While the exact reasons for this discrepancy haven’t been pinpointed yet, biology and hormones are suspected to play a role.

As for Roberts, his lab tests yielded no apparent findings to explain his back pain. Eventually he enrolled in a program through the Mayo Clinic that treated chronic pain as “a malfunction in perception,” that is, a self-reinforcing addiction to and dramatization of pain.

The solution, as Robert explains, was: “…don’t dwell on the pain, and don’t try to fix it — no props, no pills. Eventually the mind should let go.”
Treatment must be individualized

This tactic may have worked for the author, but I doubt it would work as well for many of us women with clearly definable conditions like rheumatoid arthritis, multiple sclerosis, and chronic migraine, or sex-specific diseases like endometriosis. In my case, ignoring the heavy bleeding and cramping I experienced every month (often multiple times a month) and the daily gastrointestinal distress I had for years did not make the attending pain go away, despite the repeated dismissals I received from doctors. Trying to ignore the pain didn’t stop endometriosis from strangling my large intestines and adhering my ovaries and fallopian tubes to my colon. To gain actual relief from that agony, I needed surgery, and I might need it again. Likewise, ignoring my back pain does not stop the nerve compression that contributes to sporadic incidences of severe cramping and involuntary muscle twitches and jerking in my right leg. What I do need are doctors willing to listen, empathize, and work with me to identify the most appropriate treatment plan that will minimize my pain and address the underlying condition as best as possible.

While I congratulate Roberts that he was able to put away his “props” such as his ankle braces, those of us with genuine degenerative conditions like arthritis and connective tissue disease need such aids to stabilize our joints and prevent further damage and further pain. I would implore those in the medical community for whom the Times piece resonated to understand that applying blanket solutions to chronic pain may not work for many pain patients, as the vast majority of us are women. In fact, since most studies on pain have focused on men, broadly applying their findings to everyone can be dangerous, and reinforces the same gender disparities from which they arise. The result of that would inevitably be that many more women stand to die or suffer in silence, without accessing the treatments they require and deserve in order to find adequate relief.In August, The New York Times published a guest op-ed by a man named David Roberts who suffered from severe chronic pain for many years before finally finding relief. The piece immediately went viral, with distinguished news journalist and personality Dan Rather posting it to his Facebook page with the addendum that it could “offer hope” to some pain patients. However, for many of us in the chronic pain community, particularly women, the piece was regarded with weariness and frustration.

The first and most prominent source of annoyance for me regarding this piece was the part when the author finally discloses his pain to his employer and it is taken with the utmost seriousness. He is immediately offered leave to find treatment, despite the lack of a definitive diagnosis. This stands in stark contrast to the experiences of many (if not most) women, where our pain is often abruptly dismissed as psychological — a physical manifestation of stress, anxiety, or depression.
Women with chronic pain may suffer more and longer than men

Consider this: women in pain are much more likely than men to receive prescriptions for sedatives, rather than pain medication, for their ailments. One study even showed women who received coronary bypass surgery were only half as likely to be prescribed painkillers, as compared to men who had undergone the same procedure. We wait an average of 65 minutes before receiving an analgesic for acute abdominal pain in the ER in the United States, while men wait only 49 minutes.

These gender biases in our medical system can have serious and sometimes fatal repercussions. For instance, a 2000 study published in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack. Why? Because the medical concepts of most diseases are based on understandings of male physiology, and women have altogether different symptoms than men when having a heart attack.

To return to the issue of chronic pain, 70% of the people it impacts are women. And yet, 80% of pain studies are conducted on male mice or human men. One of the few studies to research gender differences in the experience of pain found that women tend to feel it more of the time and more intensely than men. While the exact reasons for this discrepancy haven’t been pinpointed yet, biology and hormones are suspected to play a role.

As for Roberts, his lab tests yielded no apparent findings to explain his back pain. Eventually he enrolled in a program through the Mayo Clinic that treated chronic pain as “a malfunction in perception,” that is, a self-reinforcing addiction to and dramatization of pain.

The solution, as Robert explains, was: “…don’t dwell on the pain, and don’t try to fix it — no props, no pills. Eventually the mind should let go.”
Treatment must be individualized

This tactic may have worked for the author, but I doubt it would work as well for many of us women with clearly definable conditions like rheumatoid arthritis, multiple sclerosis, and chronic migraine, or sex-specific diseases like endometriosis. In my case, ignoring the heavy bleeding and cramping I experienced every month (often multiple times a month) and the daily gastrointestinal distress I had for years did not make the attending pain go away, despite the repeated dismissals I received from doctors. Trying to ignore the pain didn’t stop endometriosis from strangling my large intestines and adhering my ovaries and fallopian tubes to my colon. To gain actual relief from that agony, I needed surgery, and I might need it again. Likewise, ignoring my back pain does not stop the nerve compression that contributes to sporadic incidences of severe cramping and involuntary muscle twitches and jerking in my right leg. What I do need are doctors willing to listen, empathize, and work with me to identify the most appropriate treatment plan that will minimize my pain and address the underlying condition as best as possible.

While I congratulate Roberts that he was able to put away his “props” such as his ankle braces, those of us with genuine degenerative conditions like arthritis and connective tissue disease need such aids to stabilize our joints and prevent further damage and further pain. I would implore those in the medical community for whom the Times piece resonated to understand that applying blanket solutions to chronic pain may not work for many pain patients, as the vast majority of us are women. In fact, since most studies on pain have focused on men, broadly applying their findings to everyone can be dangerous, and reinforces the same gender disparities from which they arise. The result of that would inevitably be that many more women stand to die or suffer in silence, without accessing the treatments they require and deserve in order to find adequate relief.In August, The New York Times published a guest op-ed by a man named David Roberts who suffered from severe chronic pain for many years before finally finding relief. The piece immediately went viral, with distinguished news journalist and personality Dan Rather posting it to his Facebook page with the addendum that it could “offer hope” to some pain patients. However, for many of us in the chronic pain community, particularly women, the piece was regarded with weariness and frustration.

The first and most prominent source of annoyance for me regarding this piece was the part when the author finally discloses his pain to his employer and it is taken with the utmost seriousness. He is immediately offered leave to find treatment, despite the lack of a definitive diagnosis. This stands in stark contrast to the experiences of many (if not most) women, where our pain is often abruptly dismissed as psychological — a physical manifestation of stress, anxiety, or depression.
Women with chronic pain may suffer more and longer than men

Consider this: women in pain are much more likely than men to receive prescriptions for sedatives, rather than pain medication, for their ailments. One study even showed women who received coronary bypass surgery were only half as likely to be prescribed painkillers, as compared to men who had undergone the same procedure. We wait an average of 65 minutes before receiving an analgesic for acute abdominal pain in the ER in the United States, while men wait only 49 minutes.

These gender biases in our medical system can have serious and sometimes fatal repercussions. For instance, a 2000 study published in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack. Why? Because the medical concepts of most diseases are based on understandings of male physiology, and women have altogether different symptoms than men when having a heart attack.

To return to the issue of chronic pain, 70% of the people it impacts are women. And yet, 80% of pain studies are conducted on male mice or human men. One of the few studies to research gender differences in the experience of pain found that women tend to feel it more of the time and more intensely than men. While the exact reasons for this discrepancy haven’t been pinpointed yet, biology and hormones are suspected to play a role.

As for Roberts, his lab tests yielded no apparent findings to explain his back pain. Eventually he enrolled in a program through the Mayo Clinic that treated chronic pain as “a malfunction in perception,” that is, a self-reinforcing addiction to and dramatization of pain.

The solution, as Robert explains, was: “…don’t dwell on the pain, and don’t try to fix it — no props, no pills. Eventually the mind should let go.”
Treatment must be individualized

This tactic may have worked for the author, but I doubt it would work as well for many of us women with clearly definable conditions like rheumatoid arthritis, multiple sclerosis, and chronic migraine, or sex-specific diseases like endometriosis. In my case, ignoring the heavy bleeding and cramping I experienced every month (often multiple times a month) and the daily gastrointestinal distress I had for years did not make the attending pain go away, despite the repeated dismissals I received from doctors. Trying to ignore the pain didn’t stop endometriosis from strangling my large intestines and adhering my ovaries and fallopian tubes to my colon. To gain actual relief from that agony, I needed surgery, and I might need it again. Likewise, ignoring my back pain does not stop the nerve compression that contributes to sporadic incidences of severe cramping and involuntary muscle twitches and jerking in my right leg. What I do need are doctors willing to listen, empathize, and work with me to identify the most appropriate treatment plan that will minimize my pain and address the underlying condition as best as possible.

While I congratulate Roberts that he was able to put away his “props” such as his ankle braces, those of us with genuine degenerative conditions like arthritis and connective tissue disease need such aids to stabilize our joints and prevent further damage and further pain. I would implore those in the medical community for whom the Times piece resonated to understand that applying blanket solutions to chronic pain may not work for many pain patients, as the vast majority of us are women. In fact, since most studies on pain have focused on men, broadly applying their findings to everyone can be dangerous, and reinforces the same gender disparities from which they arise. The result of that would inevitably be that many more women stand to die or suffer in silence, without accessing the treatments they require and deserve in order to find adequate relief.
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Monday, 28 January 2019

A rare but serious complication of… exercise

Sore throats happen all the time in childhood — and most of the time, it’s nothing to worry about. Most of the time, they are simply part of a common cold, don’t cause any problems, and get better without any treatment.

Sometimes, though, a sore throat can be a sign of a problem that might need medical treatment. Here are four examples:

Strep throat. This infection, caused by a particular kind of streptococcus bacteria, is quite common. Along with a sore throat, children may have a fever, headache, stomachache (sometimes with vomiting), and a fine, pink rash that almost looks like sandpaper. All of these symptoms can also be seen with a viral infection, so the only way to truly know if it’s strep throat is to swab for rapid testing and/or a culture. Strep throat actually can get better without antibiotics, but we give antibiotics to prevent complications, which, while rare, can include heart problems, kidney problems, and arthritis.

Peritonsillar or retropharyngeal abscess. This is a collection of pus either behind the tonsils (peritonsillar) or at the back of the throat (retropharyngeal) and can be dangerous. Redness and swelling on one side of the throat, or a bad sore throat with fever and neck stiffness, can be signs.

Stomatitis. This is caused by viruses, and leads to sores in the mouth and throat. It gets better by itself, but it can make eating and drinking very uncomfortable, which is why some children with stomatitis (especially very young children) end up with dehydration. There are medications that can help coat the sores and make drinking easier, to help prevent dehydration.

Ingestion. Little children are curious and don’t have the best self-preservation skills. If they drink something that is a strong acid or alkali, it can burn the mouth and throat as it goes down. Household products such as bleach, drain cleaners, toilet bowl cleaners, some detergents, and even some beauty products such as hair straighteners, can do terrible damage. If an adult didn’t witness the ingestion, all they might know is that the child is suddenly complaining of mouth and throat pain.
There are few subjects that can stir up stronger emotions among doctors, scientists, researchers, policy makers, and the public than medical marijuana. Is it safe? Should it be legal? Decriminalized? Has its effectiveness been proven? What conditions is it useful for? Is it addictive? How do we keep it out of the hands of teenagers? Is it really the “wonder drug” that people claim it is? Is medical marijuana just a ploy to legalize marijuana in general?

These are just a few of the excellent questions around this subject, questions that I am going to studiously avoid so we can focus on two specific areas: why do patients find it useful, and how can they discuss it with their doctor?

Marijuana is currently legal, on the state level, in 29 states, and in Washington, DC. It is still illegal from the federal government’s perspective. The Obama administration did not make prosecuting medical marijuana even a minor priority. President Donald Trump promised not to interfere with people who use medical marijuana, though his administration is currently threatening to reverse this policy. About 85% of Americans support legalizing medical marijuana, and it is estimated that at least several million Americans currently use it.
Marijuana without the high

Least controversial is the extract from the hemp plant known as CBD (which stands for cannabidiol) because this component of marijuana has little, if any, intoxicating properties. Marijuana itself has more than 100 active components. THC (which stands for tetrahydrocannabinol) is the chemical that causes the “high” that goes along with marijuana consumption. CBD-dominant strains have little or no THC, so patients report very little if any alteration in consciousness.

Patients do, however, report many benefits of CBD, from relieving insomnia, anxiety, spasticity, and pain to treating potentially life-threatening conditions such as epilepsy. One particular form of childhood epilepsy called Dravet syndrome is almost impossible to control, but responds dramatically to a CBD-dominant strain of marijuana called Charlotte’s Web. The videos of this are dramatic.
Uses of medical marijuana

The most common use for medical marijuana in the United States is for pain control. While marijuana isn’t strong enough for severe pain (for example, post-surgical pain or a broken bone), it is quite effective for the chronic pain that plagues millions of Americans, especially as they age. Part of its allure is that it is clearly safer than opiates (it is impossible to overdose on and far less addictive) and it can take the place of NSAIDs such as Advil or Aleve, if people can’t take them due to problems with their kidneys or ulcers or GERD.

In particular, marijuana appears to ease the pain of multiple sclerosis, and nerve pain in general. This is an area where few other options exist, and those that do, such as Neurontin, Lyrica, or opiates are highly sedating. Patients claim that marijuana allows them to resume their previous activities without feeling completely out of it and disengaged.

Along these lines, marijuana is said to be a fantastic muscle relaxant, and people swear by its ability to lessen tremors in Parkinson’s disease. I have also heard of its use quite successfully for fibromyalgia, endometriosis, interstitial cystitis, and most other conditions where the final common pathway is chronic pain.

Marijuana is also used to manage nausea and weight loss, and can be used to treat glaucoma. A highly promising area of research is its use for PTSD in veterans who are returning from combat zones. Many veterans and their therapists report drastic improvement and clamor for more studies, and for a loosening of governmental restrictions on its study. Medical marijuana is also reported to help patients suffering from pain and wasting syndrome associated with HIV, as well as irritable bowel syndrome and Crohn’s disease.

This is not intended to be an inclusive list, but rather to give a brief survey of the types of conditions for which medical marijuana can provide relief. As with all remedies, claims of effectiveness should be critically evaluated and treated with caution.
Talking with your doctor

Many patients find themselves in the situation of wanting to learn more about medical marijuana, but feel embarrassed to bring this up with their doctor. This is in part because the medical community has been, as a whole, overly dismissive of this issue. Doctors are now playing catch-up, and trying to keep ahead of their patients’ knowledge on this issue. Other patients are already using medical marijuana, but don’t know how to tell their doctors about this for fear of being chided or criticized.

My advice for patients is to be entirely open and honest with your physicians and to have high expectations of them. Tell them that you consider this to be part of your care and that you expect them to be educated about it, and to be able to at least point you in the direction of the information you need.

My advice for doctors is that whether you are pro, neutral, or against medical marijuana, patients are embracing it, and although we don’t have rigorous studies and “gold standard” proof of the benefits and risks of medical marijuana, we need to learn about it, be open-minded, and above all, be non-judgmental. Otherwise, our patients will seek out other, less reliable sources of information; they will continue to use it, they just won’t tell us, and there will be that much less trust and strength in our doctor-patient relationship. I often hear complaints from other doctors that there isn’t adequate evidence to recommend medical marijuana, but there is even less scientific evidence for sticking our heads in the sand. 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.
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Friday, 4 January 2019

Preterm birth and heart disease risk for mom

When I’m dragging and feeling tired during the occasional low-energy day, my go-to elixir is an extra cup (or two or three) of black French press coffee. It gives my body and brain a needed jolt, but it may not help where I need it the most: my cells.
The cellular basis of being tired

What we call “energy” is actually a molecule called adenosine triphosphate (ATP), produced by tiny cellular structures called mitochondria. ATP’s job is to store energy and then deliver that energy to cells in other parts of the body. However, as you grow older, your body has fewer mitochondria. “If you feel you don’t have enough energy, it can be because your body has problems producing enough ATP and thus providing cells with enough energy,” says Dr. Anthony Komaroff, professor of medicine at Harvard Medical School. You may not be able to overcome all aspects of age-related energy loss, but there are ways to help your body produce more ATP and replenish dwindling energy levels. The most common strategies revolve around three basic concepts: diet, exercise, and sleep.

Diet. Boost your ATP with fatty acids and protein from lean meats like chicken and turkey, fatty fish like salmon and tuna, and nuts. While eating large amounts can feed your body more material for ATP, it also increases your risk for weight gain, which can lower energy levels. “The excess pounds mean your body has to work harder to move, so you use up more ATP,” says Dr. Komaroff. When lack of energy is an issue, it’s better to eat small meals and snacks every few hours than three large meals a day, according to Dr. Komaroff. “Your brain has very few energy reserves of its own and needs a steady supply of nutrients,” he says. “Also, large meals cause insulin levels to spike, which then drops your blood sugar rapidly, causing the sensation of fatigue.”

Drink enough water. If your body is short on fluids, one of the first signs is a feeling of fatigue. Although individual needs vary, the Institute of Medicine recommends men should aim for about 15 cups (3.7 liters) of fluids per day, and women about 12 cups (2.7 liters). Besides water and beverages like coffee, tea, and juices, you can also get your fluids from liquid-heavy fruits and vegetables that are up to 90% water, such as cucumbers, zucchini, squash, strawberries, citrus fruit, and melons.

Get plenty of sleep. Research suggests that healthy sleep can increase ATP levels. ATP levels surge in the initial hours of sleep, especially in key brain regions that are active during waking hours. Talk with your doctor if you have problems sleeping through the night.

Stick to an exercise routine. Exercise can boost energy levels by raising energy-promoting neurotransmitters in the brain, such as dopamine, norepinephrine, and serotonin, which is why you feel so good after a workout. Exercise also makes muscles stronger and more efficient, so they need less energy, and therefore conserve ATP. It doesn’t really matter what kind of exercise you do, but consistency is key. Some research has suggested that as little as 20 minutes of low-to-moderate aerobic activity, three days a week, can help sedentary people feel more energized.
When being tired warrants a visit to your doctor

You should see your doctor if you experience a prolonged bout of low energy, as it can be an early warning of a serious illness. “Unusual fatigue is often the first major red flag that something is wrong,” says Dr. Komaroff. Lack of energy is a typical symptom for most major diseases, like heart disease, many types of cancer, autoimmune diseases such as lupus and multiple sclerosis, and anemia (too few red blood cells). Fatigue also is a common sign of depression and anxiety. And fatigue is a side effect of some medications.
If you delivered a baby early, you may want to pay closer attention to your heart health. A study published in the journal Hypertension shows that a history of preterm birth (defined as a birth before the 37th week of pregnancy) may bring health risks for not only for baby, but for mom, too.

The study found that women who delivered a baby preterm were more likely to experience rising blood pressures later, compared to women who delivered closer to term. If they had this pattern, they were also more likely to show signs of coronary artery disease, which is associated with an increased risk of heart attack and stroke.

Because of the unique demands that pregnancy places on a woman’s body, it may serve as a stress test for a woman’s heart, says Dr. JoAnn E. Manson, the Michael and Lee Bell Professor of Women’s Health at Harvard Medical School. Pregnancy-related conditions (for example, gestational diabetes and pre-eclampsia) are known to raise a woman’s risk of developing cardiovascular disease. Preterm birth should now join that list, says Dr. Manson.

“I think this study adds to the mounting evidence that preterm birth is yet another complication of pregnancy that indicates a higher risk of cardiovascular disease in the mother,” she says.
The association between early birth and heart disease risk

The study looked at data from more than 1,000 mothers in several major US cities. Researchers divided the women into three categories — “low stable,” “moderate,” and “moderate increasing” — based on how their systolic blood pressure (the first number in a reading) changed over time. Women who had what was defined as “moderate increasing” blood pressure were 19% more likely to have delivered a baby early than women with “low stable” blood pressure. In addition, more than 38% of the “moderate increasing” group developed coronary artery calcifications (a marker for higher risk of future heart attack), seen on CT heart scans, compared with 12.2% of the “low stable” group. Women who had both a preterm delivery and “moderate increasing” blood pressure had more than double the risk of developing arterial calcifications, compared with women who delivered at term and had a lower blood pressure pattern.

The associations researchers found were stronger in women who experienced high blood pressure conditions during pregnancy, but were also found in women who did not. Interestingly, women who had a “moderate increasing” blood pressure pattern but delivered a full-term baby didn’t seem to have excess risk for artery calcifications.

But not all preterm births bring the same potential heart risks. The study authors found that a preterm birth alone wasn’t enough to raise risk. That happened only when women had both a preterm birth and a pattern of increasing blood pressure in the years that followed. This may be the case because there are other factors that can result in a preterm birth, such as carrying twins or other multiples, or having a physical problem with the cervix, says Dr. Manson. For women with such conditions, a preterm delivery would not be expected to reflect higher cardiovascular risks, says Dr. Manson.
If you gave birth early, pay attention to all heart disease risk factors

Having a preterm birth or other pregnancy-related complications doesn’t mean you are doomed to develop cardiovascular disease. Steps you can take to reduce your risk include the following:

    Discuss your pregnancy history with your doctor. Your doctor should be aware that you delivered preterm and should also know about any other pregnancy-related complications you had, such as gestational diabetes or pre-eclampsia — and should understand that it may raise your risk for future heart disease.
    Track your blood pressure. “Your blood pressure should be monitored closely, at least once a year, and preferably more often,” says Dr. Manson. Self-monitoring using a blood pressure machine monthly at home might also help you spot troubling trends early. Blood pressure should ideally remain below 120/80 mm Hg. If it rises above that level, discuss it with your doctor.
    Maintain a healthy diet and lifestyle. It’s been said a million times before, but eating a well-balanced diet rich in fruits, vegetables, and whole grains can help head off cardiovascular disease. Avoid excess sodium, red meat, and heavily processed foods whenever possible. And of course, don’t smoke, and make time to squeeze in regular exercise.
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Saturday, 22 December 2018

Interesting Facts on Umbilical Cords

Too many chronic ailments are on the rise and there is no health care to counter the spread of all these diseases. The result is that every individual is plagued with a plethora of problems and in their haste to keep up with everyday life; they end up popping too many pills. The health system that presently exists has a very mechanical approach towards patients and their problems, for them suppressing a problem is better than completely eradicating the root cause of it.

Though there is a system of medicinal science that has been in existence for centuries and takes a very holistic approach towards dealing with any health issue. It takes measures to prevent any diseases along with curing the existing ones. Though of course there are some diseases that do require allopathic medicines in order to be cured but that doesn't lessen the importance of Ayurveda. This ancient system of treating diseases with herbs and natural products originated in India and is highly practiced and recommended. Many countries in the west after the advent of Yoga and other eastern esoteric methods, are taking up the ayurvedic route to a better health. Ayurveda is a highly spiritual and traditional way of curing a disease and there are a variety of reasons why you must choose to use Ayurvedic medicines:

Provides A Complete & Holistic Cure:
Many people suffering from chronic health issues get tired of popping pills but have to keep up with those medicines in order to suppress their ailment. Often times they develop other health issue due to constant intake of pills such as liver or other digestive problems. Ayurvedic medicines on the other hand deal with permanently healing the person. It doesn't offer just temporary relief but ensures the complete eradication of the root cause of the problem.

Cost Effective:
More than the actual disease that they are suffering from, people fear the medical bills they incur. Taking constant insurance policies and yet taking up more loans to finally pay off the medical bills can actually induce more mental health problems. Ayurvedic medicines on the other hand do not burn a hole in the pocket and are available at very affordable prices.

It's Natural:
You can always trust Mother Nature to provide you with the best and the healthiest things. Just like the fruits and vegetables that we eat, everything that is used in Ayurvedic medicines is made of natural substance and possesses no strong side effects. All the more reasons to take up ayurvedic medicines.People often question that how come the Japanese are so fit and slim despite eating rice and noodles on a daily basis? While there are numerous reasons behind their physical dexterity, one vital fact is that they don't consume the regular white rice but parboiled rice. Parboiled rice, also known as converted rice, is the grain that is partially boiled in the husk in order to augment its nutritional profile for added benefits. But what benefits? While there are various kinds of rice grains ranging from white rice to brown rice to black rice, every specific variety has its own advantages. Parboiled Rice though stands a cut above them. Although it isn't yet officially declared as the healthiest rice (considering there are thousands of categories), it is certainly the most effective one for the following reasons: -

1. Increases Metabolism

Parboiled rice is a great source of vitamin B-9, or Folate. Since our body is dependable on the specified vitamin and amino acids, the compound helps increase the rate of metabolism. Half-cup cooked parboiled rice incorporates approximately 100 micrograms of Folate which is near thirty percent of the daily required quantity for both the men and the women.

2. Amplifies Levels Of Oxygen

Converted rice is also an excellent source of Iron. Half-cup serving of the grain incorporates approximately 1.4 milligrams of the element which is around 20 percent of the daily required quantity for both the men and the women. According to a study, Iron helps our body in sensing the levels of oxygen present in the tissues and furthermore distributes oxygen through our bloodstream.

3. Regulates The Activities Of Thyroid Gland

Utmost advantage of boiled rice is that it provides us with Selenium, a chemical element which help in regulating the thyroid gland via controlling the activities of thyroid hormones and thus, resulting in prevention of chubbiness or getting underweight. Half-cup of serving of cooked parboiled rice incorporates approximately 7.3 micrograms of Selenium radicals which is near 15 percent of the daily required quantity for both men and the women.

4. Prevents Cardiovascular Risks

Parboiled rice also contains Niacin i.e. Vitamin B3 which not only supports the metabolism of the body but also helps the cells in carrying out the necessary chemical reactions to breakdown fats, proteins, and carbohydrates into energy and thus keeps the cholesterol levels under control. Half-cup serving of parboiled rice incorporates approximately 1.8 micrograms of Niacin which is near fifteen percent of the daily required quantity for both the men and the women.

So, instead of believing in the half-authentic fact that eating rice regularly can make you obese, remember that daily consumption of parboiled rice is favorable for your body as it helps in maintaining good health. Converted rice is available for purchase mostly everywhere albeit it's a bit expensive as compared to white rice.Ever wondered if there is a relationship between your umbilical cord and the belly button? Of course there is! When you have your little one inside your womb, it needs a life-support system to survive the pregnancy gestation period. This support is comprised of the placenta, the umbilical cord and the amniotic sac filled with amniotic fluid. "The baby's life hangs by a cord", as said by Ian Donald, aptly tells the importance of the umbilical cord.

The umbilical cord plays the essential role of attaching your baby to the placenta and keeps feeding your baby. During delivery, the placenta is expelled from your uterus through a process known as the after-birth. The umbilical cord, once your baby is delivered is clamped and cut. The remaining section of the cord heals and later becomes the baby's belly button.

Nevertheless, most are aware of these common facts. But there are some really fun insights that you probably never thought about:

Umbilical Cords Vary in Length

The lengths of the umbilical cords in babies are variable. However, there is no concrete evidence to ascertain why the length varies at all. Within the full gestation period of 28 weeks, the cord may reach its full length which usually is between 45-60 centimetres in length. In a small percentage of pregnancies, the cord is less than 45 centimetres in length and investigative studies have shown that placenta retention and C-section is usually higher in such instances.

Tangles, Knots, and Loops

Babies in the womb are constantly moving around. A common game that they indulge in is playing 'loop the loop' with the cord. If the baby is healthy and the cord remains intact, it does not really pose any risk to the baby. Approximately 35% of the babies born have the umbilical cord wrapped around their necks and 1% of them have the cord in a true knot.

It stops working when needed.

In the womb, the stem cell remains in a temperature controlled environment. Post the baby's birth, the cord is exposed to cooler air and the 'Wharton's Jelly' within it starts to harden and shrink. Natural clamping occurs that squeezes and closes the blood vessels inside the cord. Depending on the temperature outside of the mother's body, natural clamping takes approximately between 3 and 20 minutes.

The Umbilical Cord Tissue is full of potential.

Most of us have heard about cord blood stem cells but the new research that has everyone's attention is on umbilical cord tissue. Many ongoing clinical trials have brought significant evidence forward that the cord blood tissue also contains stem cells that possess the potential to multiply and transform into various cell types, like cartilage, bone, fat, etc. This essentially means that the cord tissue with more stem cells can potentially be used in treating more conditions and disorders.

As Nancy Reagan rightfully said, "Now science has presented us with a hope called stem cell research, which may provide our scientists with many answers that have for so long been beyond our grasp."
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