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Monday, January 14, 2019

What is as an antidote to loneliness

I was called to your room in the middle of an overnight shift. There you were, breathing quickly, neck veins bulging and oxygen levels hovering despite the mask on your face. I placed my stethoscope on your back and listened to the cacophony of air struggling to make its way through your worsening pneumonia.
“We’re going to place a tube down your throat to help you breathe,” I told you.
Your eyes were pleading, scared. “We’ll put you to sleep. It’ll help you breathe more comfortably. Okay?”
You nodded. You had already told the doctors who cared for you during the day that if your breathing worsened, you would agree to intubation to allow more time to treat your pneumonia. So I called for the anesthesiologists. Minutes later, you were sedated and intubated, silenced — maybe forever.
I thought about you recently, when I read a poignant Perspective in JAMA Internal Medicine: “Saving a Death When We Cannot Save a Life in the Intensive Care Unit.” In this piece, critical care doctor Michael Wilson relates the story of a woman in the ICU who was electively intubated for a procedure and then died, without ever having had the opportunity for her loved ones to say goodbye.
Fueled by his feelings of regret over this and similar cases, Wilson argues for a different approach to intubation, which he likens to the talk a parent has with a child who is going off to war. Of course, these parents hope their children will come back safely, but they are given the chance to say what they want to say — knowing the conversation might be their last. Wilson suggests that we might build a similar pause into our protocols before intubation, lest we unwittingly deprive our patients of the opportunity for a final exchange with their loved ones. “Stealing the opportunity for meaningful last words is precisely the kind of avoidable complication that ought to be visible to us in the ICU,” Wilson writes. “My intubation checklist now includes this step.” In doing so, Wilson suggests that we might be able to “save a death” even if we are ultimately unable to save a life.
Reading this piece, I’m left with the image of Wilson’s patients — both the one who never had the chance to say goodbye, and another woman he describes who was given the chance to say “I love you” to her husband — and also of my own patients. It is too easy, in the heat of the moment, to forget that this patient before us is a person. How many times have I decided on intubation, ordered the appropriate medications, prepared for complications, but not taken pause to allow my patient to talk to a loved one?
I only took care of you for the night, as the physician on call. Though I remember your face, I do not remember your name and I don’t know what happened to you. Maybe the breathing tube came out in a day or two, and you were able to talk to your family once again. Or maybe it did not. Maybe your pneumonia worsened and you died, there in our ICU. It has been months since that night, and I can’t know. But I do wish, now, that I had paused and given you that chance.

Well, it seems as though not even a week can go by without more data on aspirin! I recently reviewed the ARRIVE trial and the implications for primary prevention — that is, trying to prevent heart attacks and strokes in otherwise healthy people. Since then, yet another large clinical trial — the ASPREE study — has come out questioning the use of aspirin in primary prevention. Three articles pertaining to this trial were published in the prestigious New England Journal of Medicine, which is an unusual degree of coverage for one trial and highlights its immediate relevance to clinical practice.

Aspirin still strongly indicated for secondary prevention

Nothing about any of the new aspirin data, including ASPREE, pertains to secondary prevention, which refers to use of aspirin in patients with established cardiovascular disease. Examples include a prior heart attack or certain types of stroke, previous stents or bypass surgery, and symptomatic angina or peripheral artery disease. In general, in patients with a history of these conditions, the benefits of aspirin in reducing cardiovascular problems outweigh the risks. Chief among these is a very small risk of bleeding in the brain, and a small risk of life-threatening bleeding from the stomach.

ASPREE study suggests no benefit from aspirin in primary prevention

ASPREE randomized 19,114 healthy people 70 or over (65 or over for African Americans and Hispanics) to receive either 100 milligrams of enteric-coated aspirin or placebo. After an average of almost five years, there was no significant difference in the rate of fatal coronary heart disease, heart attack, stroke, or hospitalization for heart failure. There was a significant 38% increase in major bleeding with aspirin, though the actual rates were low. The serious bleeding included bleeding into the head, which can lead to death or disability. Again, the actual rates were very low, but they are still a concern when thinking of the millions of patients to whom the ASPREE results apply.
Rates of dementia were also examined, and again, there was no benefit of aspirin. Quite unexpectedly, there was a significantly higher rate of death in the patients taking aspirin. This had not been seen in prior primary prevention trials of aspirin, so this isolated finding needs to be viewed cautiously. Still, with no benefits, increased bleeding, and higher mortality, at least in this population of older healthy people, aspirin should no longer be routinely recommended.
Another unexpected finding in ASPREE was a significantly higher rate of cancer-related death in the people randomized to aspirin. The prior thinking had been that aspirin might actually prevent colon cancer, though generally after many more years of being on aspirin. The ASPREE trial was terminated early due to lack of any apparent benefits. And even though five years is a relatively long period of follow-up, it may not have been long enough to find a benefit on cancer. Thus, the increase in cancer deaths may be a false finding. Nevertheless, the overall picture from this trial is not a compelling one for aspirin use for prevention of either cardiac or cancer deaths.

Should healthy people take a daily aspirin?

In general, the answer seems to be no — at least not without first consulting your physician. Despite being available over the counter and very inexpensive, aspirin can cause serious side effects, including bleeding. This risk goes up with age. So, even though it seems like a trivial decision, if you are healthy with no history of cardiovascular problems, don’t just start taking aspirin on your own.
However, there are likely select healthy patients who have a very high risk of heart attack based on current smoking, family history of premature heart attacks, or very elevated cholesterol with intolerance to statins, for example, who might benefit. Therefore, the decision to start aspirin should involve a detailed discussion with your physician as part of an overall strategy to reduce cardiovascular risk. If you are already taking aspirin for primary prevention, it would be a good idea to meet with your physician and see if you might be better off stopping.

It may not seem possible to be able to write your way to better health. But as a doctor, a public health practitioner, and a poet myself, I know what the scientific data have to say about this: when people write about what’s in their hearts and minds, they feel better and get healthier. And it isn’t just that they’re getting their troubles off their chests.
Writing provides a rewarding means of exploring and expressing feelings. It allows you to make sense of yourself and the world you are experiencing. Having a deeper understanding of how you think and feel — that self-knowledge — provides you with a stronger connection to yourself. It’s that connection that often allows you to move past negative emotions (like guilt and shame) and instead access positive ones (like optimism or empathy), fostering a sense of connection to others in addition to oneself.

Making connections is key

It’s remarkable that the sense of connection to others that one can feel when writing expressively can occur even when people are not engaged directly. Think of being at a movie or concert and experiencing something dramatic or uplifting. Just knowing that everyone else at the theater is sharing an experience can make you feel connected to them, even if you never talk about it. Expressive writing can have the same connecting effect, as you write about things that you recognize others may also be experiencing, even if those experiences differ. And if you share your writing, you can enhance your connection to someone else even more. That benefit is energizing, life-enhancing, and even lifesaving in a world where loneliness — and the ill health it can lead to — has become an epidemic.
Maybe it’s time to pay greater attention to expressive writing as one important way to enhance a sense of connection to others. Social connection is crucial to human development, health, and survival, but current research suggests that social connection is largely ignored as a health determinant. We ignore that relationship at our peril, since emerging medical research indicates that a lack of social connections can have a profound influence on risk for mortality, and is associated with up to a 30% risk for early death — as lethal as smoking 15 cigarettes a day. Social isolation and loneliness can have additional long-term effects on your health including impaired immune function and increased inflammation, promoting arthritis, type 2 diabetes, cancer, and heart disease.

How expressive writing battles loneliness

Picking up a pen can be a powerful intervention against loneliness. I am a strong believer in writing as a way for people who are feeling lonely and isolated to define, shape, and exchange their personal stories. Expressive writing, especially when shared, helps foster social connections. It can reduce the burden of loneliness among the many groups who are most at risk, including older adults, caregivers, those with major illnesses, those with disabilities, veterans, young adults, minority communities of all sorts, and immigrants and refugees.
Writing helps us to operate in the past, present, and future all at once. When you put pen to paper you are operating in the present moment, even while your brain is actively making sense of the recalled past, choosing and shaping words and lines. But the brain also is operating in the future, as it pictures a person reading the very words you are actively writing. When expressing themselves in writing, people are actually creating an artifact — a symbol of some of their thoughts and feelings. People often can write what they find difficult to speak, and so they explore deeper truths. This process of expression through the written word can build trust and bonds with others in unthreatening ways, forging a path toward a more aware and connected life.
When people tell their personal stories through writing, whether in letters to friends or family, or in journals for themselves, or in online blog posts, or in conventionally published work, they often discover a means of organizing and understanding their own thoughts and experiences. Writing helps demystify the unknown and reduce fears, especially when we share those written concerns with others.

Write for your health

As a poet, I’ve personally experienced the benefits of expressive writing. The skills it sharpens; the experience of sharing ideas, feelings, and perceptions on a page; the sensations of intellectual stimulus and emotional relief — all are life enhancing. I’d like more people to discover that expressive writing can contribute to well-being, just as exercise and healthful eating do.
I’ve documented some of the research being done in the area of healing and the arts. After reviewing more than 100 studies, we concluded that creative expression improves health by lowering depression and stress while boosting healthy emotions. So pick up a pen, and start to write creatively. For the mind and the body, writing is a strong prescription for good health.

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Leaving time for last words

For many people receiving care in a hospital or emergency room, one of the most common occurrences (and biggest fears) is getting an IV, the intravenous catheter that allows fluids and medications to flow into a vein in your arm or hand.
A trained health professional puts in an IV by sticking a needle that’s inside a thin tube (catheter) through the skin into a vein. Once inside the vein, the needle is removed. The catheter is left in the vein and taped down to keep it from moving or falling out. While IV lines are typically painless, the initial needle stick can be quite painful, especially for those who are a “difficult stick” (when the needle misses the vein, requiring multiple attempts).
IVs can be medically needed when the digestive system isn’t working well, to receive more fluids than you’re able to drink, to receive blood transfusions, to get medication that can’t be taken by mouth, and for a host of other treatments. In cases of massive bleeding, overwhelming infection, or dangerously low blood pressure, IV treatments can dramatically increase the chances of survival.

Drip bars: IVs on demand

And this brings us to a relatively new trend: the option to receive IV fluids even when it’s not considered medically necessary or specifically recommended by a doctor. In many places throughout the US, you can request IV fluids and you’ll get them. A nurse or physician’s assistant will place an IV catheter in your arm and you’ll receive IV fluids right at home, in your office, or at your hotel room. There’s even a mobile “tour bus” experience that administers the mobile IV hydration service. Some services offering IV hydration include a “special blend of vitamins and electrolytes,” and, depending on a person’s symptoms (and budget), an anti-nausea drug, a pain medication, heartburn remedies, and other medications may be provided as well.
And no, it’s not covered by your health insurance — more on the cost in a moment.

Why would anyone do this?

When I first heard about this, that’s the question I asked. Why, indeed? People may seek out IV fluids on demand for:
  • hangovers
  • dehydration from the flu or “overexertion”
  • food poisoning
  • jet lag
  • getting an “instant healthy glow” for skin and hair
Many of the early adopters of this new service have been celebrities (and others who can afford it) including Kate Upton, Kim Kardashian, Simon Cowell, and Rihanna. Or so I’ve read.

Are IV fluids effective or necessary for these things?

Some people who get the flu (especially the very young and very old) need IV fluids, but they’re generally quite sick and belong in a medical facility. Most people who have exercised a lot, have a hangover, jet lag, or the flu can drink the fluids they need. While I’m no beauty expert, I doubt that IV fluids will improve the appearance of a person who is well-nourished and well-hydrated to start with.
And it’s worth emphasizing that the conditions for which the IVs-on-demand are offered are not conditions caused by dehydration or reversed by hydration. For example, jet lag is not due to dehydration. And while oral fluids are generally recommended for hangover symptoms (among other remedies), dehydration is not the only cause of hangover symptoms.
Finally, there’s a reasonable alternative to IV fluids: drinking fluids. If you’re able to drink fluids, that’s the best way to get them. If you’re too sick to drink and need rehydration, you should get care at a medical facility.

Is it worth going to a drip bar?

I’ll admit I’m skeptical. (Could you tell?) It’s not just that I’m a slow adopter (which is true) or that I’m dubious of costly treatments promoted by anecdotes on fancy websites (which I am). What bothers me is the lack of evidence for an invasive treatment. Yes, an intravenous treatment of fluid is somewhat invasive. The injection site can become infected, and a vein can become inflamed or blocked with a clot (a condition called superficial thrombophlebitis). While these complications are uncommon, even a small risk isn’t worth taking if the treatment is not necessary or helpful.
I can see how the idea of IV fluids at home might seem like a good idea. We hear all the time about how important it is to drink enough and to remain “well-hydrated.” It’s common to see people carrying water bottles wherever they go; many of them are working hard to drink eight glasses of water a day, though whether this is really necessary is questionable.
And then there’s the power of the stories people tell (especially celebrities) describing how great they felt after getting IV fluid infusions. If you have a friend who says they feel much better if they get IV fluids to treat (or prevent) a hangover, who am I to say they’re wrong? The same can be said for those who believe they look better after getting IV fluids as part of getting dolled up for a night on the town.

What about the cost?

While the benefits of IV fluids on demand are unproven and the medical risks are low (but real), the financial costs are clear. For example, one company offers infusions for $199 to $399. The higher cost is for fluids with various vitamins and/or electrolytes and other medications. Keep in mind that the fluids and other therapies offered can be readily obtained in other ways (drinking fluids, taking generic vitamins, and other over-the-counter medications) for only a few bucks.

The bottom line on drip bars

In recent years, more and more options have become available to get medical tests or care without actually having a specific medical reason and without the input of your doctor. MRIs, ultrasounds and CT scans, recreational oxygen treatment, and genetic testing are among the growing list of options that were once impossible to get without a doctor’s order. While patient empowerment is generally a good thing, IV fluids on demand may not be the best example. Some of these services are much more about making money for those providing the service than delivering a product that’s good for your health.
As for me, I’ll pass on the IV fluid option — unless, of course, my doctor recommends it.

Recent news reports described an “ethical lapse” by a prominent New York City cancer specialist. In research published in prominent medical journals, he failed to disclose millions of dollars in payments he had received from drug and healthcare companies that were related to his research. Why is this such a big deal? Disclosing any potential conflict of interest is considered essential for the integrity of medical research. The thinking is that other researchers, doctors, patients, regulators, investors — everyone! — has a right to know if the researcher might be biased, and that measures have been taken to minimize the possibility of bias.

Is it an advertisement or research?

One way to think about the importance of full disclosure regarding medical research is to ask: is the information I’m reading or hearing about coming from a paid spokesperson? If so, it may be the equivalent of an advertisement. Or, is it from a researcher without a financial stake in the results? The answer matters. While the information may be valid either way, the way it’s delivered, how alternative explanations for the results are considered, and the skepticism (or enthusiasm) surrounding the findings can vary a lot depending on whether the source has a vested interest in a study’s results.
One of my favorite examples of how bias can affect how medical information is delivered is the way pain relievers (such as ibuprofen or naproxen) are described in ads. There are more than 20 of them available, and for most conditions their effectiveness is about the same. And that’s exactly how a researcher with no financial ties to the makers of these drugs might describe them: in clinical trials, they are equally effective. But a company’s television ad might claim that “nothing’s proven stronger for your headaches” than their medication. Factually, both ways of presenting the information are true. But knowing the source of the information and whether it might be biased can make a big difference in how you interpret that information.

Why you should care about conflict of interest in medicine

Medical schools, hospital systems, and other institutions that employ doctors generally require disclosure of outside income. But do their patients want to know? Would it matter to you if your doctor accepted gifts, meals, or cash payments from drug companies?
There’s been enough concern about the answers to these questions that the federal government set up a website to post information about payments doctors receive from drug companies, medical device makers, and others. Perhaps you’ve heard of it. It’s called OpenPayments,* a disclosure program mandated by the Sunshine Act that posts these financial relationships online for public viewing. It’s been up and running for several years. But the impact of this program is not clear; many of my patients have never heard of it, and most people have never looked up their own doctors on the site.
*In the interest of full disclosure, my name appears in Open Payments: However, it’s for consulting with the Institute for Healthcare Improvement, an independent healthcare organization. They provided grants to encourage shared decision making and understanding of treatment options for patients with rheumatoid arthritis. A pharmaceutical company sponsored the program but has no role in promoting any particular medication.

Other ethical issues your doctor might face

Even if your doctor doesn’t accept payments from pharmaceutical companies, he or she may have to consider other ethical questions, such as:
  • Is it acceptable to own his or her own testing equipment? While it may be more convenient for patients, studies show that when a practice performs (and charges for) its own lab or imaging tests (such as a scanner for osteoporosis screening), more tests tend to be ordered.
  • Should he or she meet with representatives from pharmaceutical companies who are promoting their latest drugs? Some physicians get updates regarding new medications from drug reps (along with gifts of minor value, such as pens or lunch), but this may lead to higher rates of prescribing newer, higher priced drugs when older, cheaper options would be just as good.
  • Should your doctor attend medical meetings where drug companies sponsor the speaker (complete with dinner in a fancy restaurant)? Again, the information presented may be accurate but biased.
  • Is it reasonable for doctors to receive payments to enroll patients in a study sponsored by a drug company? This is a common practice, and it’s likely that the financial arrangement is not always disclosed to the patient.
And these are just a few of the many ethical dilemmas that many doctors face.

What do you think?

Many doctors I know are insulted by the suggestion that they “can be bought” by a charismatic drug rep bearing gifts. But a number of studies show these practices work. Large pharmaceutical companies spend millions on doctors to market, educate, and perform clinical trials. They would not invest so much money if it didn’t work.
Does any of this concern you? Do you think the case of the NYC doctor is unusual and that most doctors navigate the ethical minefields of modern medicine successfully? Let me know!
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Friday, January 4, 2019

superfoods to boost a healthy diet

When it comes to protecting brain health, you may think about exercise, diet, or engaging in activities that challenge you. Yet most of us hop into the car to travel to work, do errands, go on vacations, or drive the kids’ carpool as a matter of habit. But driving is a huge responsibility. One miscalculation on your part or the part of another driver and the results could be disastrous. Staying safe in the car not only protects your body, but also your brain. Follow these common-sense tips and recommendations, understand the law, and never take chances.
Safe driving means never drive if you are feeling woozy, overtired, or can’t see properly

Perhaps your young child has kept you awake for most of the night, and you can tell as you prepare your morning cup of coffee that you are shaky and slow. This is a good day to use public transportation (maybe you can catch a brief nap if you can grab a seat), call a friend for a ride, or use Lyft. Think about backup options for travel, and remember that being green means cutting down on your carbon footprint. If you have a long commute each day, maybe you can arrange a carpool with coworkers.
Always wear your seatbelt — and think about car “ergonomics”

A favorite story is that of a former surgeon general who tapped a taxi driver on the shoulder, and said “Sir, if you don’t buckle your seatbelt, I cannot proceed with this ride.” This should motivate us all to make sure that when we are passengers, the driver is wearing a seatbelt too. Modern cars have features to bolster safety, but they only work if you use them. Sit in your car while it’s in the driveway. Make sure the headrest as at the right height. Make sure you are close enough to reach the pedals and the wheel, but not right on top of it.

Think “defensively.” If the car stopped suddenly to avoid a crash, would your knees smash into the console? And most importantly, would your head be protected? A rapid forward-and-back head movement can bruise your brain, even without direct impact. In the case of a rear-impact collision, the brain accelerates forward and then bounces back against the skull. Even a minor accident can trigger headache and neck pain that need time and rest to recover from. So, make sure you’re positioned properly in your car, and if you share with a family member, be sure to readjust for each driver.
Kids must be buckled in the right car seat

It goes without saying that children should be carefully strapped into the proper size car seats, in the back seat of the car, and once they’re not babies, taught to behave calmly in the car. On long rides, car games and songs can make the time pass safely and are distracting and entertaining. Animals should be safely strapped in as well. Remember that in the event of a crash, an unrestrained pet is a projectile that can propel forward, hitting another passenger or the driver and potentially worsening a bad situation. Teach car safety starting with the youngest children and never put your foot on the gas unless everyone is safely strapped in.
What about a loss of consciousness or a seizure?

Here is where it gets tricky. Every state has different rules for when people who have experienced these situations are allowed to drive again. (Massachusetts says six months without another loss of consciousness event, such as a faint or seizure.) Your doctor must tell you this and must document that he or she has done so, but then you are responsible for reporting this to the Registry of Motor Vehicles. If your doctor is worried that you represent an ongoing danger, then he or she must follow up. Most people understand the risk of driving if there is a chance of a serious medical event, but because we all rely on our cars, it can be life-changing to be told that you are not able to drive for a certain amount of time. Think creatively about alternatives, such as carpools and public transportation. Again, if you have a seizure and lose consciousness while driving, you’re endangering not just yourself and your passengers, but every other car on the road.
Have a plan in case of an accident

Here are a few things to remember in the event of a fender-bender:

    Take photos with your phone of your car, and anyone else’s car involved.
    Take a photo of the other driver’s car insurance and license if you are able to as well.
    Make notes of exactly what happened and contact the police to file a report immediately if you are not injured.
    If you have any injury, please seek medical evaluation immediately. Sometimes, neck pain and headache will not start until the day after an accident. Check in with your PCP, who may recommend ice, medication such as ibuprofen, or further evaluation based on your symptoms.

The bottom line on safe driving

Remember, a car is a large and dangerous machine. It’s only as safe as the person driving. Speeding and tailgating have no place on the road. One moment of miscalculation can have lifelong consequences. Protect your brain — and everyone else’s brain on the road — by driving with your seatbelt buckled, and safety and good judgement — not speed — propelling your drive. Heading back to school sparks an upswing in anxiety for many children. The average child’s school day is packed with potential stressors: separating from parents, meeting academic expectations, managing peer groups, and navigating loud, crowded school hallways and cafeteria, to name just a few of many challenges. That’s why it’s typical for children to experience some anticipatory anxiety leading up to the new school year — and for parents to notice a rise in worries. For example, your child might ask questions about what her new classroom or teacher will be like, worry about having all of his school supplies ready, or have mild trouble falling asleep in the days leading up to the start of school.
Signs of back to school anxiety

But for some children — and particularly for children who already struggle with anxiety or have anxiety disorders — the return to school can be very stressful. Their behavior can reflect this. Examples of behaviors that suggest your child is experiencing above-average anxiety around the return to school include:

    Continually seeking reassurance or asking repeated, worried questions despite already receiving an answer. “What if my friends are not in my class? When will I see them? What if I don’t have anyone to sit with at lunch because I have no friends? Will I be okay?”
    Increased physical complaints, such as headaches, stomachaches, and fatigue in the absence of an actual illness.
    A significant change in sleep pattern, such as taking an hour to fall asleep when a child normally goes to sleep quickly, or waking you up with worries during the night when a child typically sleeps well.
    Avoiding school-related activities, such as school tours, teacher meet-and-greets, or avoiding school itself once the year starts (a topic that will be covered in an upcoming post).

Here is how parents can help with back to school anxiety

    Approach anxiety instead of avoiding it. It’s natural to want to allow your child to avoid situations that make her anxious, or reassure her that her worries won’t come true. However, this can actually contribute to a vicious cycle that reinforces anxiety in the long term. Instead, acknowledge your child’s emotion and then help her think through small steps she might take to approach, rather than avoid, her worries. For example, you might say, “It sounds like you’re feeling anxious about riding the school bus by yourself. Would you be up for checking out the bus stop with me this afternoon?” Give lots of attention and praise to any “brave” behaviors rather than to her anxiety. “I love how willing you were to take the bus this morning! Great job pushing back on the worry bully!”
    Practice school routines. For example, before the start of the year, you and your child might do a school day walk-through of the morning routine: waking up, eating breakfast, packing his school bag, and traveling to school. School tours or meet-and-greet days can be great opportunities to practice navigating the school environment and tolerating any anxiety in a low-stakes situation. After practice runs, debrief with your child on successes and challenges. Support your child in problem-solving around difficult points. For example, if he worries that he will have trouble finding his new classrooms, help him think through who he could ask for assistance if that occurs.
    Model behavior you’d like to see. When an anxious child refuses to get onto the school bus or has a tantrum about attending school, it’s natural to feel frustrated, harried, and anxious yourself. However, try to model the calm behavior you would like to see in your child. Take deep breaths from your belly. Remind yourself that your child’s behavior is being driven by anxiety. If necessary, step away from the situation to take a few minutes to breathe and engage in a mindfulness strategy, such as counting all of the objects of a certain color or shape in the room around you.
    Ensure enough sleep. The shift from a summer wake-up schedule to the school year wake-up time can be very challenging for many children, particularly preteens. Fatigue and crankiness from not getting enough sleep can make children much more vulnerable to anxiety. To combat this, consider moving your child’s wake-up time earlier and earlier in short increments in the weeks leading up to the start of school. Additionally, leave screens (TV, phone, computer) outside the bedroom at night.

When to seek additional help

If a child’s worries about the return to school start to interfere with his or her ability and willingness to attend school or participate in other normal activities, such as camp, beloved sports, or playdates, consider consulting with a licensed mental health professional who specializes in child anxiety. Your pediatrician, school guidance counselor, or health care plan may be able to recommend experts in your area. The Association for Behavioral and Cognitive Therapies and the American Psychological Association also offer online search tools for mental health professionals who can help.
Cannabidiol (CBD) has been recently covered in the media, and you may have even seen it as an add-in booster to your post-workout smoothie or morning coffee. What exactly is CBD? Why is it suddenly so popular?
How is cannabidiol different from marijuana?

CBD stands for cannabidiol. It is the second most prevalent of the active ingredients of cannabis (marijuana). While CBD is an essential component of medical marijuana, it is derived directly from the hemp plant, which is a cousin of the marijuana plant. While CBD is a component of marijuana (one of hundreds), by itself it does not cause a “high.” According to a report from the World Health Organization, “In humans, CBD exhibits no effects indicative of any abuse or dependence potential…. To date, there is no evidence of public health related problems associated with the use of pure CBD.”
Is cannabidiol legal?

CBD is readily obtainable in most parts of the United States, though its exact legal status is in flux. All 50 states have laws legalizing CBD with varying degrees of restriction, and while the federal government still considers CBD in the same class as marijuana, it doesn’t habitually enforce against it. In December 2015, the FDA eased the regulatory requirements to allow researchers to conduct CBD trials. Currently, many people obtain CBD online without a medical cannabis license. The government’s position on CBD is confusing, and depends in part on whether the CBD comes from hemp or marijuana. The legality of CBD is expected to change, as there is currently bipartisan consensus in Congress to make the hemp crop legal which would, for all intents and purposes, make CBD difficult to prohibit.
The evidence for cannabidiol health benefits

CBD has been touted for a wide variety of health issues, but the strongest scientific evidence is for its effectiveness in treating some of the cruelest childhood epilepsy syndromes, such as Dravet syndrome and Lennox-Gastaut syndrome (LGS), which typically don’t respond to antiseizure medications. In numerous studies, CBD was able to reduce the number of seizures, and in some cases it was able to stop them altogether. Videos of the effects of CBD on these children and their seizures are readily available on the Internet for viewing, and they are quite striking. Recently the FDA approved the first ever cannabis-derived medicine for these conditions, Epidiolex, which contains CBD.

CBD is commonly used to address anxiety, and for patients who suffer through the misery of insomnia, studies suggest that CBD may help with both falling asleep and staying asleep.

CBD may offer an option for treating different types of chronic pain. A study from the European Journal of Pain showed, using an animal model, CBD applied on the skin could help lower pain and inflammation due to arthritis. Another study demonstrated the mechanism by which CBD inhibits inflammatory and neuropathic pain, two of the most difficult types of chronic pain to treat. More study in humans is needed in this area to substantiate the claims of CBD proponents about pain control.
Is cannabidiol safe?

Side effects of CBD include nausea, fatigue and irritability. CBD can increase the level in your blood of the blood thinner coumadin, and it can raise levels of certain other medications in your blood by the exact same mechanism that grapefruit juice does. A significant safety concern with CBD is that it is primarily marketed and sold as a supplement, not a medication. Currently, the FDA does not regulate the safety and purity of dietary supplements. So you cannot know for sure that the product you buy has active ingredients at the dose listed on the label. In addition, the product may contain other (unknown) elements. We also don’t know the most effective therapeutic dose of CBD for any particular medical condition.
The bottom line on cannabidiol

Some CBD manufacturers have come under government scrutiny for wild, indefensible claims, such that CBD is a cure-all for cancer, which it is not. We need more research but CBD may be prove to be an option for managing anxiety, insomnia, and chronic pain. Without sufficient high-quality evidence in human studies we can’t pinpoint effective doses, and because CBD is currently is mostly available as an unregulated supplement, it’s difficult to know exactly what you are getting. If you decide to try CBD, talk with your doctor — if for no other reason than to make sure it won’t affect other medications you are taking.
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Home cooking: Healthy family meals

During the first year of life, naps are crucial for babies (who simply cannot stay awake for more than a couple of hours at a time), and crucial for parents and caregivers, who need breaks from the hard work of caring for an infant.

But as children become toddlers and preschoolers, naps aren’t always straightforward. Children often fight them (following the “you snooze you lose” philosophy), and they can conflict with daily tasks (such as school pick-up when there are older siblings) or lead to late bedtimes.

Here are some tips for making naps work for you and your child — and for knowing when they aren’t needed anymore.
Making naps work for your baby

Most infants will take at least two naps during the day, and early in toddlerhood most children will still take both a morning nap and an afternoon nap. Naps are important not just for physical rest and better moods, but also for learning: sleep allows us to consolidate new information. As children get older, they usually drop one of the naps, most commonly the morning nap.

Every child is different when it comes to napping. Some need long naps, some do fine with catnaps, some will give up naps earlier than others. Even within the same family, children can be different. A big part of making naps work is listening to and learning about your child’s temperament and needs. Otherwise, you can end up fighting losing battles.

The needs of a parent or caregiver are also important: everyone needs a break. Sometimes those breaks are particularly useful at specific times of the day (like meal prep time). While you can’t always make a child be sleepy at the most convenient time for you, it’s worth a try — which leads me to the first tip:

Schedule the naps. Instead of waiting for a child to literally drop and fall asleep, have a regular naptime. We all do better when our sleep routines are regular, even adults. If you can, put the child down awake (or partially awake). Learning to fall asleep without a bottle or a breast, or without being held, is a helpful skill for children to learn and can lead to better sleep habits as they grow.

A couple of scheduling notes:

    If you need a child to fall asleep earlier or later than they seem to do naturally, try to adjust the previous sleep time. For example, if you need an earlier morning nap, wake the child up earlier in the morning. It may not work, but it’s worth a try.
    Naps later in the afternoon often mean that a child won’t be sleepy until later in the evening. That may not be a problem, but for parents who get tired early or need to get up early, it can be. Try to move the nap earlier, or wake the child earlier. If the problematic afternoon nap is in daycare, talk to the daycare provider about moving or shortening it.

Create a space that’s conducive to sleep. Some children can sleep anywhere and through anything, but most do best with a space that is quiet and dark. A white noise machine (or even just a fan) can also be helpful.

Don’t use screens before naptime or bedtime. The blue light emitted by computers, tablets, and phones can wake up the brain and make it harder for children to fall asleep.
When is it time to give up naps?

Most children give up naps between the ages of 3 and 5. If a child can stay up and be pleasant and engaged throughout the afternoon, they are likely ready to stop. Some crankiness in the late afternoon and early evening is okay; you can always just get them to bed earlier.

One way to figure it out, and ease the transition, is to keep having “quiet time” in the afternoon. Have the child go to bed, but don’t insist on sleep; let them look at books or play quietly. If they stay awake, that’s a sign that they are ready to stop. If they fall asleep but then end up staying up very late, that’s another sign that the afternoon nap needs to go.

Whether or not your child naps, having some quiet time without screens every afternoon is a good habit to get into. It gives your child and everyone else a chance to relax and unwind, and sets a placeholder not just for homework but also for general downtime as children grow — and just like naps for babies, downtime for big kids is crucial.
There is no way to meet the need for substance abuse treatment through the current healthcare system. The number of people who need treatment for drug and alcohol abuse is far greater than the number of clinicians available to treat them. In more rural areas, patients might have to spend a lot of time traveling great distances to appointments, which can be difficult to do while working or taking care of a family. And, the cost and stigma of treatment can get in the way of getting help. Moreover, even if people do get to substance abuse treatment, they often do not receive the most effective ones. As illicit drug use increases in the United States, new ways to deliver treatment are urgently needed.

Computer-guided treatments are one way to overcome the hurdles of access to evidence-based treatments, including travel and scheduling, cost, and stigma. Additionally, using computers to treat one’s own substance abuse can be empowering, giving a sense of “I did it on my own.”
How well do computer-guided treatments work compared to live counseling?

Researchers from Yale University recently developed and studied the “Computer-based Training for Cognitive-behavioral Therapy” (or “CBT4CBT”) web-based substance abuse treatment as a fully standalone intervention. CBT4CBT provides cognitive behavioral therapy (CBT) — an evidence-based treatment for substance abuse. The treatment is completely computer-guided, and does not involve interacting with a counselor or other healthcare professional. It combines online games and video vignettes with actors to teach how to manage one’s own substance use. Specifically, CBT4CBT covers: how to understand and change patterns of substance use; dealing with cravings; refusing offers of alcohol and drugs; problem-solving; noticing thoughts about drugs and alcohol and how to change them; and strengthening decision-making abilities.

Earlier research has shown that CBT4CBT can be an excellent complement to make live treatment with a counselor more effective and efficient. Recently, the research team conducted the first comparison of any standalone web-based treatment for substance abuse to “treatment as usual” — and data suggest that it may be better.
The study on CBT4CBT

The Yale team recruited 137 people seeking substance use treatment from the Connecticut Mental Health Center in New Haven; 49% African American, 34% Caucasian, and 8% Latino or Latina. Substances used were marijuana, cocaine, alcohol, opioids, and PCP. It was a real-world sample in that most participants used more than one illicit drug and most also used alcohol.

One-third of the participants were randomized to use CBT4CBT, with 10-minute in-person weekly checkups to evaluate their overall functioning, their safety, and their use of the online program. One-third of participants were enrolled in “treatment as usual,” which was either group or individual therapy, and covered topics including motivational interviewing, life skills, relapse prevention, harm reduction, mindfulness, and others. The other third were assigned to in-person CBT with a therapist who delivered the same type of content as the CBT4CBT online program.

The researchers found that drug use (measured by urine tests — which corresponded closely with self-reported use) in the CBT4CBT group was significantly less than treatment as usual, and remained lower over six months of follow-up. Persons who received live CBT had the same level of drug use as the treatment as usual group after six months. They also found that participants in the online treatment learned the CBT concepts the best, and had the highest level of satisfaction and lowest dropout rate of any of the three study conditions. Overall, after treatment the percentage of days abstinent from any drug use was 75% for the CBT4CBT group, vs. 67% of days abstinent for the treatment as usual group and 61% for the live CBT group. The study did not enroll a large enough number of participants to conduct a head-to-head comparison of CBT4CBT and live CBT. That may come later, and the results could inform how to conduct live CBT more effectively.
Getting access to computer-guided CBT

Computer-guided CBT for substance abuse should be studied further should be studied further, with different populations and in different settings, the next real challenge is to disseminate it widely across the US and beyond. According to its website, the CBT4CBT program is not yet available to the public, outside of clinical trials.

Building computer-guided treatment programs is often easier than building companies to deliver them. Barriers include acceptance by institutions, payment by insurance companies, liability, FDA approval, and resistance from healthcare providers — as well as coming up with viable business models. But if these obstacles can be overcome, the world could benefit from a highly effective and accessible treatment for drug and alcohol abuse. Family meals are beneficial for so many reasons. People who prepare meals at home tend to consume significantly more fruits and vegetables, and less sugar and fat. People who enjoy meals at home with others, sitting together and conversing, also have reduced stress and higher life satisfaction. The more frequently families with children have meals together, the more likely the children are to eat a high-quality diet, and the less likely to be overweight or obese. There are also other benefits: these children tend to have higher self-esteem and better academic performance, as well as lower risk of engaging in risky behaviors (like drug use) or developing an eating disorder.
Family meals without distraction

All those benefits go out the window if dinner is eaten in front of the television or other devices. This makes sense if we think about why the family meal has such powerful positive effects: it’s about closeness and connection. Sitting down to eat together is often the only time families can reconnect and communicate. Given our busy, technology-driven lives, the family meal is a rare (and critical) opportunity to unplug and check in. What’s even better is getting the kids involved in making dinner, which is also significantly associated with their eating a higher-quality diet.
One of my favorite family meals: Make-your-own soft tacos

The kids can get involved in preparing this simple and healthy meal, which is incredibly rich in protein and fiber, as well as calcium, iron, and potassium. Beans provide plenty of heart-healthy fiber, protein, and are associated with a lower risk of diabetes. Corn and masa (the tortilla flour made from corn) are considered whole grains and are loaded with vitamins and minerals. Avocados and olives provide heart-healthy fats, and the veggies are risk in fiber, vitamins, and antioxidants. All these easy-to-find ingredients, plus healthy veggies, the option of dairy, and protein from the pumpkin seeds, make this nutritious and fun to prepare with the family — and everyone will love that they can build their own taco!
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Thursday, January 3, 2019

steps toward a successful exercise resolution

Writing in the October 10, 2018 New England Journal of Medicine, Eve Rittenberg, MD, assistant professor at Harvard Medical School and practicing physician at Brigham and Women’s Fish Center for Women’s Health, reflects on the impact the Kavanaugh hearing and #MeToo movement have had on patients who have experienced sexual violence. Important principles of trauma-informed care—including ways to ask permission, offer control, and find support—described in her article and in Monique Tello’s post below can make a real difference to many women and health care professionals alike.

Many years ago, when I was a trainee, I helped take care of patients at a family medicine clinic.* One day, a school-aged brother and sister came in for their annual physicals. They were due for vaccines. Neither wanted any shots, and they were both quite upset. “You’ll do what the doctor tells you, is that clear?” ordered the mother. She and the nurse worked together to hold the sister’s arm down. But just as the nurse was about to deliver the injection, the young girl jerked her arm away and ran to the opposite corner of the room, crying. The brother then ran over and stood in front of her, his arm outstretched, guarding, and yelled “Get away! Leave her alone!” At first, the focus was on forcing them to have their shots, which were required for school. But it only made things worse. The young girl screamed, the boy fought, no one could calm them, and everyone was annoyed.

One of the senior doctors finally conceded: Let them go, we’ll have to work on this. But that family never returned.

Months later, we learned that the children had been removed from the home by the Department of Children and Families, for parental abuse. I could only imagine what had been happening.

*This vignette is based on a composite of several cases I have been involved with over the years. All potentially identifying details have been changed to protect patient privacy.
The prevalence of trauma

The CDC statistics on abuse and violence in the United States are sobering. They report that one in four children experiences some sort of maltreatment (physical, sexual, or emotional abuse). One in four women has experienced domestic violence. In addition, one in five women and one in 71 men have experienced rape at some point in their lives — 12% of these women and 30% of these men were younger than 10 years old when they were raped. This means a very large number of people have experienced serious trauma at some point in their lives.

Medical exams by definition can feel invasive. They often involve asking sensitive questions, examining intimate body parts, and sometimes delivering uncomfortable — even painful — treatments. So, it is important that healthcare providers are mindful of the fact that so many people come to that healthcare interaction with a history of trauma.
Could the case I described have been handled differently?

There have been some recent news articles about a relatively new (and improved) way for health professionals to approach patients. This is called trauma-informed care. Dr L. Elizabeth Lincoln is a primary care physician at MGH who has trained medical professionals and students about approaching patient care with an understanding of trauma. She explains: “Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. A medical office or hospital can be a terrifying experience for someone who has experienced trauma, particularly for childhood sexual abuse survivors. The perceived power differential, being asked to remove clothing, and having invasive testing can remind someone of prior episodes of abuse. This can lead to anxiety about medical visits, flashbacks during the visit, or avoidance of medical care.”
What does trauma-informed care look like?

The first step is to recognize how common trauma is, and to understand that every patient may have experienced serious trauma. We don’t necessarily need to question people about their experiences; rather, we should just assume that they may have this history, and act accordingly.

This can mean many things: We should explain why we’re asking sensitive questions. I might say, “I need to ask you about your sexual history, so I know what tests you may need.” We should explain why we need to perform a physical exam, especially if it involves the breasts or genitals. If someone is nervous, we can let them bring a trusted friend or family member into the room with them. I’ve had many female patients hold someone’s hand during a pelvic exam. We can tell them that if they need us to stop at any time, they can say the word. If someone refuses outright to have a certain exam or test, or if they’re upset about something (like having vaccinations), we can respond with compassion and work with them, rather than attempting to force them or becoming annoyed.

For someone who has experienced trauma, the hospital or doctor’s office can be a scary place. Dr. Lincoln explains: “Patients often do not volunteer such information about prior experiences, because of guilt or shame. Medical professionals often ask about safety in a patient’s present relationships, but few ask about past experiences. A simple question such as, “Is there anything in your history that makes seeing a practitioner or having a physical examination difficult?” or, for those with a known history of sexual abuse, “Is there anything I can do to make your visit and exam easier?” can lead to more sensitive practices geared to developing a trusting relationship. Patients can advocate for themselves by explaining to physicians their anxiety about medical visits, why this is so, and what they have found helpful or harmful in prior healthcare encounters.”
Trauma comes in many forms

It is also important to note that there are many types of trauma. A colleague of mine has a child who survived a life-threatening illness. Prior to his ICU stay, he never flinched at vaccines; since his hospitalization, any needle sticks make him extremely anxious. Another colleague describes how after years of invasive infertility treatments, and despite becoming a mother, she sobbed uncontrollably at her simple routine gynecologic exam, because it touched such a nerve of helplessness and failure. Trauma-informed care is the open-mindedness and compassion that all patients deserve, because anyone can have a history that impacts their encounter with the medical system.

We as providers need to recognize that many, many patients have a history of physical, sexual, and/or emotional abuse, as well as serious illnesses and negative experiences in the medical setting, and we need to learn to respond with empathy and understanding.All too many women recognize the signals of a urinary tract infection, or UTI: pain and burning when urinating, coupled with a frequent urge to do so. A simple change in behavior could help prevent a common UTI known as recurrent cystitis in women, according to a randomized controlled study published in JAMA Internal Medicine in October 2018. The study showed that drinking more water daily led to fewer episodes of recurrent cystitis and less need for antibiotics.
What is cystitis and what causes UTIs?

Cystitis refers to an infection in the bladder, which most women know as a urinary tract infection. Cystitis is extremely common among women, partly because female anatomy increases the risk of infection due to the proximity of the urethra to the anus. Additional risk factors for cystitis include sexual intercourse, diaphragm use, spermicides and spermicide-coated condoms, and a prior history of cystitis. Women with diabetes and those who have abnormalities of the urinary tract are also at increased risk for cystitis.

The vast majority of infections (up to 95%) are caused by one bacteria, E. coli. Signs and symptoms of an infection include pain with urination, increased frequency of urination, and an increased urge to urinate.
What is the treatment?

Cystitis is treated with antibiotics for three to five days, depending on the antibiotic used.
Can UTIs be prevented?

If you’ve ever had cystitis, you may have heard suggestions that are mostly based on anecdotal evidence. To decrease risk for cystitis, women are advised to urinate after intercourse, drink cranberry juice, drink more fluids in general, and keep the perineal area that lies between the urethra and the anus clean. Evidence is mixed on whether these steps may help prevent cystitis. This study sought to provide direct evidence of the benefits of drinking extra fluids.
What did the study tell us?

The study participants were 140 premenopausal women who experienced three or more episodes of cystitis in one year and reported that they drank less than 1.5 liters of fluids daily, which is about 6 1/3 cups. The average amount participants drank daily was a bit over a liter (1.1 liters, or about 4 1/2 cups).

The women were randomized to one of two groups. Every day, one group drank their usual amount of fluids plus an additional 1.5 liters of water. The control group drank just their usual amount of fluids. The women kept journals recording the type and amount of fluids they drank in a day. Their urine was periodically measured for volume and tested for hydration status. The study discovered that women who drank an additional 1.5 liters of water had 50% fewer episodes of recurrent cystitis, and required fewer antibiotics than women who did not drink additional fluid.
Is it safe to drink this much fluid?

While the amount of extra fluids tested in the study may seem like a lot, the Institute of Medicine recommends that women have 2.2 liters daily, which is about 9 cups. Not all of this needs to come just from water — or even fluids. Fruits and vegetables, which are part of a healthy diet, contain a lot of water.

This study used a rigorous scientific method to evaluate the benefits and risks of an inexpensive and safe anecdotal treatment. While it has been suggested that substances in cranberry juice can decrease the risk of urinary tract infection, no studies have conclusively demonstrated its benefits. Water may be the best means to increase hydration because it is inexpensive and has no calories. Although this study focused on women who had recurrent cystitis, its results could be extrapolated for a lower-risk population as well.

If you’re a woman with symptoms of cystitis, such as pain or burning with urination, increased urgency and frequency, try to drink more fluids, but also call your health care team for evaluation. A simple urine test in conjunction with the symptoms you describe may provide enough information for your health care provider to confirm an infection and start you on a brief course of antibiotics.

Better still, going forward, you may be able to decrease the chance that you will develop an infection by drinking more water daily. It’s a simple solution readily available for prevention — and now supported by evidence!6 steps toward a successful exercise resolution
Many people have decided to try the ketogenic diet for weight loss. The most recent evidence shows that reducing your carbohydrate intake to a minimum may help you shed a few pounds, at least in the first few weeks to months. However, we don’t really know whether, over the long term, achieving and maintaining ketosis is better for weight loss than other diets. Almost any intervention can cause undesirable consequences, and the ketogenic diet is no different. One of the most well-publicized complications of ketosis is something called “keto flu.”
What is keto flu?

The so-called keto flu is a group of symptoms that may appear two to seven days after starting a ketogenic diet. Headache, foggy brain, fatigue, irritability, nausea, difficulty sleeping, and constipation are just some of the symptoms of this condition, which is not recognized by medicine. A search for this term yields not a single result on PubMed, the library of indexed medical research journals. On the other hand, an internet search will yield thousands of blogs and articles about keto flu.

It is tricky to describe exactly what happens after the diet change, because we are left with only our own observations and experiences. These symptoms may not even be unique to the ketogenic diet; some of my patients describe similar symptoms after they cut back on processed foods, or decide to follow an elimination or an anti-inflammatory diet.
What causes keto flu?

Well, we don’t really know why some people feel so bad after this dietary change. Is it related to a detox factor? Is it due to a carb withdrawal? Is there an immunologic reaction? Or is this a result of a change in the gut microbiome? Whatever the reason is, it appears the symptoms attributed to the keto flu may happen, not to everyone but to some people, after “cleaning up” their diet.
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A soaring maternal mortality rate: What does it mean for you?

A new guideline from the World Health Organization (WHO) aims to help reduce steadily rising rates of caesarean sections around the globe. While crucial at times for medical reasons, caesarean births are associated with short-term and long-risks health risks for women and babies that may extend for years.

In June 2018, Serena Williams told Vanity Fair about her journey to motherhood, including the story of how she nearly died a few days after giving birth. In September, Beyoncé punctuated her Vogue cover with the story of how she developed a life-threatening pregnancy condition called preeclampsia, which can lead to seizures and stroke. Throughout the summer, headlines like “Dying to Deliver” and “Deadly Deliveries” and “Maternal Mortality: An American Crisis” popped up on newsfeeds and streamed on screens across America.

As a professor who studies safety in pregnancy, I was quoted in many articles and media features. I explained what the harrowing stories indicate about our health systems, our public policies, our society at large. But as an obstetrician, I’ve been puzzling over how to explain to my patients what this means for them individually. And my pregnant wife, who is due any day, has been noticing the headlines too.
What is maternal mortality?

Typically, deaths that occur due to complications of pregnancy or childbirth, or within six weeks after giving birth, are recorded as maternal mortality.
What do the statistics tell us?

In 1990, about 17 maternal deaths were recorded for every 100,000 pregnant women in the United States. While relatively rare, this number has risen steadily over the last 25 years, indicating a worsening safety problem. In 2015, more than 26 deaths were recorded per 100,000 pregnant women. This means that compared with their own mothers, American women today are 50% more likely to die in childbirth. And the risk is consistently three to four times higher for black women than white women, irrespective of income or education.

Additionally, for every death, pregnancy-related conditions, such as high blood pressure or blood clotting disorders, result in up to 100 severe injuries. For every severe injury, tens of thousands of women suffer from inadequately treated physical or mental illnesses, as well as the broader disempowerment mothers face in the absence of paid parental leave policies and other social support.
Are the statistics misleading?

The root cause of these startling statistics is often misunderstood. The public image of maternal death is a woman who has a medical emergency like a hemorrhage while in labor. However, very few deaths counted in maternal mortality statistics occur during childbirth. Rather, four out of five of these deaths happen in the weeks and months before or after birth. So, they occur not in the hospital, but in our communities. And they represent many failures — not just unsafe medical care, but also eroding social support necessary for women to recognize medical warning signs, like abnormal bleeding or hopelessness about the future, and to seek timely care.

A few days after having a baby, American women are sent home from the hospital, infant in hand. More often than not, mother and family are left on their own until a cursory 15-minute visit with a healthcare provider several weeks later. During long gaps between checkups, mothers experience deep worry for their infants. They struggle with rapidly accelerated responsibilities, extreme sleep deprivation, and relentless pressure to return to work. And all while recovering from pregnancy and adjusting to parenthood — a transition that marks one of life’s greatest physiological endurance tests. Too often, this experience is isolating, disempowering, and mortally dangerous.  And over time, these risks are getting increasingly severe.
What can we do to help?

Undoubtedly, clinicians and hospitals can do more to ensure the safety of women giving birth. For example, they can issue health guidelines and run simulations to better prepare to handle emergencies. Policymakers can do more, too, including tracking maternal mortality so that failures like delays in lifesaving care can be identified and fixed.

In some cases, moms can do more to take care of themselves, including by eating well and exercising to stay healthy. The challenge, of course, is that most new moms are exhausted because motherhood is exhausting. And in general, society expects moms to put themselves last in order to put their families first.

So, I would say a major responsibility to address the well-being of mothers actually lies with the rest of us. If rising maternal mortality is fundamentally a failure of social support, we all need to step up: birth partners, grandparents, friends, neighbors, professional colleagues — all of us. All people are vulnerable during the period surrounding the birth of their child. But in the United States, we forget to advocate for ourselves and for each other. We need to listen to moms. And we need to support them. After distilling all the data, and reading all the headlines, I believe saving their lives is as simple as that. While we know that breastfeeding has many health benefits for mothers and babies, the studies have been a bit fuzzy when it comes to the link between breastfeeding and preventing obesity in children. Some studies show a clear link, but in others that link is less clear. A new study published in the journal Pediatrics may help explain the fuzziness. It showed that what really helped prevent obesity was getting breast milk directly from the breast.

That’s not to say that drinking expressed breast milk from a bottle isn’t healthy. After all, it’s the food that was explicitly designed for infants — and in the study, babies that got breast milk from a bottle did have lower rates of obesity at 12 months. Some of that benefit is thought to be related to the microbiome that breast milk helps create. Babies who drink breast milk are more likely to have certain bacteria in their digestive tracts that help prevent obesity.

But the babies that had the lowest risk of obesity in the study were those that got only breast milk directly from the breast for the first three months of life. Why would that be?

To be able to breastfeed directly from the breast for three months, you have to be able to be with your baby constantly for three months. Mothers who can do that either have access to paid maternity leave or have enough resources to take an unpaid leave — or to stay at home with their babies and not work outside the home at all. Studies have shown that mothers who breastfeed longer are more likely to have higher incomes, more education, and private insurance.

These, then, are mothers who are also more likely to have access to and be able to afford healthy foods, to live in areas where there are safe places to exercise — and to be able to pay for sports and other forms of exercise as their children grow. It’s not just about how these babies are fed, but also about the context in which they are born and raised.

The way in which they are fed, though, is important. Babies who feed directly from the breast are less likely to be overfed. When they are full, they stop sucking, or switch to a “comfort” kind of sucking that doesn’t produce milk. When babies are fed from bottles, parents and caregivers are more likely to push them to finish the bottle; feeding becomes a bit less about appetite and more about volume and schedule.

Learning to eat only when you are hungry and stop when you are full is a really good skill when it comes to preventing obesity. That’s why the American Academy of Pediatrics has encouraged parents to learn and use “responsive feeding,” that is, responding to the cues of babies and children of both hunger and being full. The motto is, “You provide, your child decides.”

What this study helps us see is that the link between breastfeeding and obesity prevention is part of a bigger picture we need to pay attention to if we want to fight the obesity epidemic. It shows us that we need to:

    Do everything we can to help mothers stay at home with their babies for at least three months, which will require paid maternity leaves. The United States is way behind the rest of the world in this.
    Help all parents, regardless of how they feed their infants, learn about responsive feeding, and thus help their babies learn to eat when they are hungry and stop when they are full.
    Understand obesity risk as part of a bigger societal issue — truly, as a social justice issue. All children need — and deserve — access to healthy foods and exercise, and there is more we can do to make this happen.
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Self-care for the caregiver

Dividing cells face daunting challenges when replicating the billions of letters of DNA in their genomes. For instance, DNA letters in new cells can get mixed up, and then the affected genes don’t function correctly. To fix that problem, healthy cells can deploy so-called mismatch repair (MMR) genes that put scrambled DNA letters back in the correct order. But when those genes are themselves defective, then this repair system breaks down. And as a result, cells develop a progressive condition called microsatellite instability that leaves them vulnerable to cancer.

Those sorts of defects are shared by many different tumor types. The good news is that they are susceptible to the killing effects of an immunotherapy drug called pembrolizumab. The FDA approved that drug last year for all MMR/MSI-positive metastatic cancers, regardless of where they originate in the body. Pembrolizumab works by prompting the immune system’s T cells to recognize and destroy cancer cells bearing this genetic biomarker.

Earlier this year, scientists reported new findings with pembrolizumab in men with prostate cancer. Of the 839 men they evaluated, 2.5% had MMR defects and high levels of microsatellite instability. In about a quarter of the men, those defects were somatic, meaning they had been acquired after conception and were localized to the cancer. In the rest of the men, the defects were inherited and expressed by all the cells in their bodies.

This was the first study to investigate how the drug performs in men with MMR/MSI-positive prostate cancer, and the results were encouraging: Among half the treated men, PSA levels dropped by 60% to 80%. Since prostate cancer cells release PSA, a decline in the level of that hormone shows the drug is working. Moreover, tumors also shrank in as many as 40% of the men whose PSA levels were responding to treatment.

The authors of this study recommended that all metastatic prostate cancer patients be tested for these defects, since pembrolizumab might also work for them. Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, agrees. “This is an exciting development as it opens up therapeutic possibilities that would have never been considered previously,” he said. “Moreover, our own personal experiences in testing for MMR mutations and treatment with pembrolizumab have been remarkable. Testing will likely become mandatory as more experience is gathered.” You may have heard melasma referred to as “the mask of pregnancy,” because it is sometimes triggered by an increase in hormones in pregnant women. But while the condition may be common among pregnant women, you don’t have to be pregnant to experience melasma.

“It’s not only associated with pregnancy, but can affect women at all stages of life,” says Dr. Shadi Kourosh, director of the Pigmentary Disorder and Multi-Ethnic Skin Clinic at Harvard-affiliated Massachusetts General Hospital. And it may last for many years. “Women who develop melasma in their teens or 20s or 30s may see it stay around for decades,” says Dr. Barbara Gilchrest, senior lecturer on dermatology at Harvard Medical School.
Melasma can be hard to treat

While melasma isn’t painful and doesn’t present any health risks, it can cause significant emotional distress. The condition can be difficult to treat, and there’s a lot of misinformation out there about what causes it, says Dr. Kourosh.

You’re more likely to get melasma if you have a darker skin type, probably because your skin naturally has more active pigment-producing cells, according to the American Academy of Dermatology. Melasma appears when these cells become hyperactive and produce too much pigment in certain areas of the skin. Melasma is more common in women, but it can also affect men. It may have a genetic component, as it often runs in families.
Causes of melasma

Melasma has a lot of different causes, says Dr. Kourosh. Two in particular stand out:

    Hormones (including hormonal medications). Fluctuations in certain hormones can cause melasma, which is why it commonly occurs during pregnancy. Melasma may also occur when you either start or stop hormonal contraception, including birth control pills, or when you take hormone replacement therapy, says Dr. Gilchrest.
    Sun exposure. The sun is the big culprit in triggering melasma. “Underlying factors such as hormonal changes may not manifest until a person goes on vacation to a southern location like Florida, or during the summertime when she spends more time in the sun,” says Dr. Kourosh. “The sun is the major exacerbating factor, whatever the underlying cause.” Melasma can be caused or worsened by not only the sun’s rays, but also heat and visible light. This means that even sunscreens that protect against skin cancer aren’t enough to ward off melasma, says Dr. Kourosh. This makes treating melasma a challenge, particularly in the summer months.

Finding the cause of melasma

The first step is to confirm that the darkened skin patches are indeed melasma and try to identify the cause. Treating melasma is unlikely to be effective if the underlying cause isn’t addressed, says Dr. Kourosh. “Even the oral treatments that now exist for severe cases of melasma are really pointless to do if there are still triggers in place,” she says. “We take a thorough medical history to find out what’s causing the melasma,” says Dr. Kourosh. Then adjustments are made. If a hormonal contraceptive is causing the problem, a woman might consider switching to a nonhormonal option, such as a copper intrauterine device.
Medications and topical treatments

Some commonly used options are topical retinols and retinoid treatments, which are applied to the skin to help speed your body’s natural cell turnover process. This may help dark patches clear more quickly than they would on their own. In addition, some doctors may prescribe bleaching agents, such as hydroquinone, which works by blocking melanin production. But while products with hydroquinone can be purchased over the counter, they should only be used under a doctor’s care — and only on the darkened areas of the skin. “Higher concentrations of hydroquinone can cause white spots to develop on the skin,” says Dr. Gilchrest. The medication may even cause a darkening of the skin in some cases. Other topical lightening agents (like kojic acid or azelaic acid) may be recommended. Other treatment options may include chemical peels, laser treatments, and skin microneedling. But at this point they’re not reliably effective, says Dr. Gilchrest.
A critical part of treatment: protect skin from the sun

It is critical to prevent the sun from aggravating the condition. This may require extreme diligence. “The sun is stronger than any medicine I can give you,” says Dr. Kourosh. The most important way to clear up melasma is by using a strict sunscreen regimen. But keep in mind that not all sunscreens are created equal. To prevent against melasma, you need a sunscreen that blocks not only the sun’s rays, but also its light and heat, such as one that includes zinc or titanium dioxide. Chemical sunscreens don’t offer the same protection for melasma, and in some instances, they may even trigger allergic reactions that can make melasma worse, she says. As men get older, their prostates often get bigger and block the flow of urine out of the bladder. This condition, which is called benign prostatic hyperplasia, causes bothersome symptoms. Since men can’t fully empty their bladders, they experience sudden and frequent urges to urinate. Treatments can relieve these symptoms, but not without troubling side effects: pharmaceutical BPH treatments cause dizziness, fatigue, and retrograde ejaculation, meaning that semen gets diverted to the bladder during orgasm instead of being ejected from the body. Surgical treatments such as transurethral resection of the prostate, or TURP, can relieve symptoms for many years. But they also take weeks or months to recover from, and men can experience permanent retrograde ejaculation, and in some instances, long-term impotence.

Still, it’s important to treat BPH to avoid even worse problems later. Left untreated, men can develop urinary retention, which is an acute inability to urinate without a catheter, and their bladder health can also deteriorate over time.
An alternative

Now a newer BPH procedure, called prostatic urethral lift, or UroLift, provides another option. And unlike drugs and older BPH surgeries, it spares sexual functioning.

During a UroLift procedure, doctors use tiny implants and sutures to pull the prostate away from the bladder so that urine flows more freely out of the body. The procedure can be performed in a doctor’s office, and most men go home the same day without a catheter. Clinical studies have shown that symptomatic improvements hold up for at least five years, which is comparable to study results with TURP.

The FDA approved UroLift for enlarged prostates in 2013, and the American Urological Association began recommending it as a standard of care option this year. Urologists around the country are getting up to speed on the procedure, which is now becoming increasingly available. Readers should be aware that the AUA gave UroLift a “C” grade, in part because the long-term data in support of the procedure aren’t as plentiful as they are for TURP and other more invasive surgeries, which received a grade of “B.”

For more information, we spoke to Daniel Rukstalis, M.D., a professor of urology at Wake Forest School of Medicine in Winston-Salem, North Carolina. Dr. Rukstalis led the clinical trials behind UroLift’s approval by the FDA, and he’s performed the UroLift procedure on over 350 BPH patients. (For full disclosure, Dr. Rukstalis is a clinical investigator for NeoTract, the company that developed UroLift).

Q: Dr. Rukstalis, thank you for joining us. Why would a man consider UroLift offer over other BPH treatments?

Rukstalis: Well, all the available therapies can lessen obstructive urinary symptoms and minimize long-term risks to the bladder. But UroLift is at this moment the only BPH treatment that completely spares erectile and ejaculatory functioning.

Q: How good is it at improving BPH symptoms overall?

Rukstalis: Our clinical trial led to a 12-point drop on average in International Prostate Symptom Scores (IPSS). [The IPSS is an eight-question screening tool that scores the severity of symptoms such as incomplete bladder emptying, urinary frequency, and weak streams. Men treated for BPH usually have IPSS scores of at least 20.] The trial had 206 participants. And at five years, their IPSS scores were still improved by about a third and their quality of life scores were also about 50% higher than when they had the procedure.

Q: Who is eligible for a UroLift?

Rukstalis: It’s FDA-approved for men 45 and older with prostates up to 80 grams in size (a normal prostate in a man ranges between 7 to 11 grams). But my view is that UroLift works best in prostates ranging from 25 to 60 grams. About a third of men with BPH also have what’s called a “median lobe,” or a bit of prostate tissue that protrudes up into the bladder. We just completed a clinical trial showing that UroLift works well for these men too. On the basis of that study, the FDA approved UroLift for men with median lobes in early 2018. We’ll typically evaluate potential candidates with a pelvic ultrasound, which provides a lot of information about the health of the bladder and the size and shape of the prostate.

Q: What can a man expect going into the procedure?

Rukstalis: We’ll put him to sleep with intravenous propofol, which is the same anesthetic used during a colonoscopy. The UroLift implants get delivered into the prostate with a rigid metal scope that goes directly through the penis. By pulling excess prostate tissue out of the way, the implants create a channel through which urine can flow. (This YouTube video provides a good overview.) We do this as an outpatient procedure.

 Q: What will he experience after the procedure is done?

Rukstalis: He can expect some transient blood in the urine and a burning sensation when he pees, but this all clears up within about three days. About 2% to 4% of the men I treat spend a few days using a catheter.

Q: Why doesn’t UroLift work for larger prostates over 60 grams?

Rukstalis: Because beyond a certain size threshold, the implants don’t open the channel well enough. Also you wind up needing too many implants, and they’re very expensive — anywhere from $700 to $1,000 each. The procedure is optimized for four to six implants and you really don’t want to use more than seven of them.

Q: This is a new procedure. How important is the doctor’s experience?

Rukstalis: UroLift is a judgment-based procedure in terms of the number of implants used and where in the prostate a doctor puts them. What I would say is that you’re looking for a doctor who’s comfortable with a cystoscope [which is a hollow metal rod with a lens used for prostate examinations]. If a doctor is comfortable with cystoscopy equipment, then he or she can adopt quite readily to the technology. And there are excellent UroLift training programs around the country for any urologist who wants to do it.

Q: What about long-term prospects? Do men need repeat treatments?

Rukstalis: We know that most men still benefit from treatment at five years. But we can’t say whether those results predict benefits at 10 years or longer. We haven’t done those studies yet, but they haven’t been for TURP and the other surgical procedures either. My view is that it depends on prostate size. Men with smaller prostates will benefit for longer durations.

Q: Does having had a UroLift complicate things for a man who might need a TURP later?

Rukstalis: Not in my experience. I’ve performed TURPs, prostatectomies, and laser prostate surgeries in people who had a UroLift with no trouble.

Q: Do you have any criticisms of the procedure?

Rukstalis: It’s too expensive. We need to find ways of doing UroLift at lesser cost. And some men find it doesn’t work as well as they had hoped, even though in these men, the procedure goes a long way toward protecting bladder functioning.

Q: Thanks very much! I’m sure our readers will appreciate your insights.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org also commented on the UroLift: “This is one of many emerging options for non-pharmacologic BPH treatment that can now be offered to the proper patient matched to the appropriately trained urologist. As with many procedures, longer-term outcomes are needed to determine its proper role in treating this very common problem.”
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How to have a safe Halloween

Alcohol is embedded in our society, and it is difficult to be in a public space without seeing a reference to alcohol or being offered a drink. Alcohol is broken down in the liver by an enzyme called alcohol dehydrogenase. People with a variant in this enzyme have issues with metabolizing alcohol and can develop total body flushing or reddening of the skin.

Alcohol consumption has been associated with pregnancy defects, liver disease, pancreatitis, high blood pressure, coronary artery disease, stroke, cancer, addiction issues, and physical injury (trauma to self/others with acute intoxication). The health benefits of alcohol may be up for debate. However, moderate alcohol consumption may have some beneficial effects, which was appreciated in 1992 based on the observation that populations in France had high dietary intake of saturated fats, but a relatively low incidence of cardiovascular disease. This phenomenon was labeled as the “French paradox,” and has been thought to be due in part to the consumption of red wine.
Quit your wine-ing?

Alcohol has long been associated with the development of headache, with about one-third of patients with migraine noting alcohol as a trigger. Based on this association, population studies show that patients with migraine tend to drink alcohol less often than people without migraine. Wine in particular is an alcoholic beverage that has been linked to headaches dating back to antiquity, when Celsius (25 B.C.–50 A.D.) described head pain after drinking wine. Despite this commonly held belief, there is very little scientific evidence to support the belief that wine is a more common trigger of headaches than other forms of alcohol.

The studies that have been conducted suggest that red wine, but not white and sparkling wines, trigger headache independent of how much a person drinks in less than 30% of people. Lower quality wines may cause headaches due to the presence of molecules known as phenolic flavonoid radicals, which may interfere with serotonin, a signaling molecule in the brain involved in migraines. In one study, the odds of a person citing red wine as a trigger of headache were over three times greater than the odds of indicating beer as a headache trigger. In some studies, it was observed that spirits and sparkling wines were associated with migraines significantly more frequently than other alcoholic beverages.
Here is the advice of one wine expert

I turned to Barb Gustafson, a sommelier (certified wine professional) for some insight on the qualities of wine that might be associated with headache.

(Barb works at Paul Mathew Vineyards — and yes, there is actually a winemaker in California that bears a name spelled identically to my own, but there is no relation.)  “Legumes” sounds like such a fancy word.  Let’s clarify that we’re talking about beans, folks. Beans, lentils, peas, chickpeas, it’s all good… and good for you.  Legumes are amazingly nutritious, high in protein and fiber, low in fat, and low in glycemic load.
Legumes for heart health

Scientific studies have definitively linked a diet high in legumes with a lower risk of developing obesity, diabetes, high blood pressure, high cholesterol, heart disease, or strokes. As a matter of fact, eating legumes every day can effectively treat these diseases in people who already have them. In one randomized controlled clinical study of over 100 people with type 2 diabetes, consuming at least one cup of legumes (beans, chickpeas, or lentils) every day for three months was associated with significant decreases in body weight (2.7 kilograms, about 6 pounds); waist circumference (a 1.4 centimeter decrease); blood sugar (a 0.5% decrease in HbA1c); cholesterol (an 8-point decrease in LDL, measured in mg/dl); and blood pressure (a 4.5-point decrease in systolic and a 3.1-point decrease in diastolic blood pressures, measured in mm Hg). All of these improvements are impressive! We’re talking about beans, not medicines with all those side effects, right? Right: you can check out the entire study here.

Similar findings have been reported from other studies. An analysis of eight randomized controlled clinical trials including data from over 550 participants with a wide variety of medical problems found that participants who consumed about a cup of legumes every day for 10 weeks had a significant decrease in systolic blood pressure (average 2.25 points). In another study, researchers combined data from ten randomized controlled trials representing over 250 participants who had been prescribed legumes every day for at least three weeks. The legumes varied: pinto beans, chickpeas, baked beans, lentils, and peas in amounts ranging from 1/2 cup to 2 cups. None of the participants was taking cholesterol-lowering medication, and yet the legume diets resulted in an average 8-point decrease in LDL cholesterol (that’s the low-density lipoprotein, the “bad” cholesterol). This is better than many people can achieve with pills! You can check out this study here.
How can beans have all of these benefits?

Legumes are high in fiber, specifically viscous soluble fiber, which not only slows their absorption in the small intestine, but also binds up certain molecules having to do with cholesterol. This makes legumes very low in glycemic index and load, meaning they result in lower blood sugars and less insulin released after eating them. This fiber also lowers cholesterol levels.

But wait — there’s more: not only are legumes high in fiber, they are also high in protein, making them very filling and satisfying, so people tend to eat less of other things. And they contain plenty of potassium, magnesium, folate, and other plant nutrients that are associated with lower blood pressure and improved cardiovascular health.

Despite all of this good evidence, people in the United States tend not to eat a lot of legumes. Given how healthy and economical beans, lentils, chickpeas, and peas are, we aim to help with some suggestions: A highly effective psychotherapy called cognitive behavioral therapy (CBT) focuses on how our thoughts, beliefs, and attitudes can affect our feelings and behavior. Traditional CBT treatment usually requires weekly 30- to 60-minute sessions over 12 to 20 weeks. A faster option now emerging is intensive CBT (I-CBT), which employs much longer sessions concentrated into a month, week, or weekend — or sometimes a single eight-hour session.

CBT helps people learn tools to reframe different types of thinking, such as black-and-white thinking (I can’t do anything right) and emotional reasoning (I feel you dislike me, so it must be true) and other potentially harmful thought patterns that fuel mental health problems and undermine relationships, work, and daily life. Once learned, the coping strategies taught during CBT or I-CBT sessions can help people deal with a variety of problems throughout life.
Can intensive CBT help people with anxiety, depression, and other issues?

I-CBT has been used to treat many people suffering from mood and anxiety disorders, trauma-related disorders, and other issues. Some programs treat children or teens who have mild autism spectrum disorder (mild ASD), selective mutism, or prenatal alcohol exposure, or who are struggling with school refusal.

There are I-CBT programs that focus in specific areas, such as:

    attention deficit hyperactivity disorder (ADHD)
    anxiety disorders, including agoraphobia, generalized anxiety disorder (GAD), social anxiety, specific phobias, panic attacks and panic disorder, and separation anxiety
    obsessive-compulsive disorder (OCD)
    post-traumatic stress disorder (PTSD), sexual trauma, and traumatic brain injury (TBI).

Is intensive CBT effective?

Research on effectiveness — or whether or not I-CBT works — is relatively new. Studies suggest it is effective for treating OCD. Children and adults who have this condition make similar, long-lasting gains with traditional or intensive CBT. It’s also effective for treating panic disorder in teens, anxiety symptoms in children with mild autism spectrum disorder, and severe mood disorders.

Additionally, fewer people drop out of treatment with I-CBT compared with traditional CBT.
Who might benefit from the short time span?

People with full-time jobs who find it difficult to take time off during the work week for weekly appointments might be able to commit to a weekend of intensive treatment. Teenagers busy with academics and activities during the school year may benefit from intensive sessions for a week during the summer. Families juggling multiple schedules can benefit from I-CBT because it allows them to focus on treatment without feeling their time is split among several other commitments. And people who live in areas without easy access to mental health services or specialists may be able to travel for a weekend for intensive treatment.

I-CBT may also help people who have tried traditional CBT, but have not found it feasible or successful. Alternatively, I-CBT sessions may introduce people to this form of psychotherapy, and its benefits, thus serving as a catalyst for traditional CBT treatment.
What are the drawbacks?

Most importantly, the effectiveness of I-CBT is still being evaluated. Intensive treatment requires specialized therapists who are trained to deliver I-CBT. It may not be possible to find a well-qualified program or therapist nearby, which would add to the cost and time commitment of treatment. Most insurance companies do not cover intensive treatments such as I-CBT, so it can be expensive.
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Do I need orthotics? What kind?

Here’s why parents need to know about e-cigarettes. First, many more teens are using them. In 2017, 3% of middle school students and 12% of high school students reported using them, and while that may not sound like a lot, since 2011 use has gone up about 500% in middle school and 800% among high school students. And, e-cigarettes can be dangerous.
How e-cigarettes work

E-cigarettes are basically delivery devices for nicotine, the addictive chemical in tobacco. The hope of the Food and Drug Administration (FDA) is that they might possibly decrease smoking — which would be great, as smoking is the leading preventable cause of death in the United States. It’s the smoke itself that causes the vast majority of the health risk, so the idea was that perhaps if you gave people a way to inhale nicotine that didn’t involve burning tobacco, you might get them away from tobacco, especially if you were able to gradually decrease the amount of nicotine they inhale.

The problem is that not only did it turn out that these devices don’t really help people quit, they are being marketed to youth, and youth are buying them.
Why e-cigarettes are especially dangerous for young people

This is where the danger comes in. E-cigarettes are dangerous for youth in at least three ways:

    Nicotine can affect developing brains, putting young users at higher risk of addiction and mental health problems.
    Inhaling the vapor itself can cause breathing problems.
    E-cigarette use makes it more likely that youth will start smoking tobacco.

This is a big enough concern that the FDA is launching an effort to curb e-cigarette use in youth. They have targeted the major manufacturers (JUUL, Vuse, blu E-Cig, MarkTen, Logic) and are not only examining their marketing practices, but asking them to come up with “robust” plans to curb youth use of their products. They are also looking at other ways to curb use, including education and regulation. Many states have laws regulating the sale of e-cigarettes to youth, and others are considering them.
Here’s what parents need to do

    Get educated. Learn about e-cigarettes and their health risks.
    Talk to your kids about them. Ask about what they know, ask if they have tried them, ask if their friends have tried them. Ask if they see others using them at school. Make sure they understand the dangers.
    Advocate! Talk to your elected officials about better laws to protect our children. Talk to your school and community about education and outreach.
Localized prostate cancer that is diagnosed before it has a chance to spread typically responds well to surgery or radiation. But when a tumor metastasizes and sends malignant cells elsewhere in the body, the prognosis worsens. Better treatments for men with metastatic prostate cancer are urgently needed. In 2018, scientists advanced toward that goal by sequencing the entire metastatic cancer genome.

The newly revealed genomic landscape includes not just the active genes that make proteins, but also the vast stretches of DNA in between them that can also be functionally significant. Most of the genomic alterations were structural, meaning that DNA letters in the cells were mixed up, duplicated, or lost. A major finding was that the androgen receptor, which is a target for hormonal medications used when cancer returns after initial treatment, was often genetically amplified. That could explain why patients often become stubbornly resistant to hormonal therapies: if the androgen receptor is hyperactive, then the treatments can’t fully block its activity.

The research revealed many other sorts of alterations as well. For instance, DNA-repair genes such as BRCA2 and MMR were often defective. Cells rely on these genes to fix the genetic damage that afflicts them routinely every day, but with their functional loss, cancerous changes can follow. Cancer-driving oncogenes such as MYC were common, as were “tumor-suppressor” genes such as TP53 and CDK12, which ordinarily work to keep cancer at bay.

Metastatic prostate cancer differs from one man to another, and likewise, the frequency of these alterations varied among the more than 100 men who provided samples for analysis. By exploring the data, scientists can now develop new hypotheses for testing, and refine personalized treatment strategies to help men with this life-threatening disease. Many people come to my office complaining of foot pain from conditions such as bunions, hammertoes, a pinched nerve (neuroma), or heel pain (plantar fasciitis). I perform a thorough evaluation and examination, and together we review the origin, mechanics, and treatment plan for the specific problem or issue. The patient usually asks if they need an orthotic and, if so, which type would be best.

I recommend a foot orthotic if muscles, tendons, ligaments, joints, or bones are not in an optimal functional position and are causing pain, discomfort, and fatigue. Foot orthotics can be made from different materials, and may be rigid, semirigid, semiflexible, or accommodative, depending on your diagnosis and specific needs.
Different types of orthotics

Most of my discussions center around three types of foot orthotics: over-the-counter/off-the-shelf orthotics; “kiosk-generated” orthotics; and professional custom orthotics. Over-the-counter (OTC) or off-the-shelf orthotics are widely available and can be chosen based on shoe size and problem (such as Achilles tendinitis or arch pain). Kiosk orthotics are based on a scan of your feet. A particular size or style of orthotics is recommended for you based on your foot scan and the type of foot problem you are experiencing. They may help with heel pain, lower back pain, general foot discomfort, or for a specific sport.

For custom prescription orthotics, a health professional performs a thorough health history, including an assessment of your height, weight, level of activity, and any medical conditions. A diagnosis and determination of the best materials and level of rigidity/flexibility of the orthotics is made, followed by an impression mold of your feet. This mold is then used to create an orthotic specifically for you. The difference between OTC/kiosk and custom orthotics may be likened to the difference between over-the-counter and prescription reading glasses.
Which type of orthotic is right for you?

A person of average weight, height, and foot type, and with a generic problem such as heel pain, usually does well with an over-the-counter or kiosk orthotic. They are less expensive, and usually decrease pain and discomfort. However, you may have to replace them more often. Someone with a specific need, or a problem such as a severely flat foot, may benefit from custom prescription orthotics. While more expensive and not usually covered by insurance, they generally last longer than the OTC/kiosk type.

Before investing in orthotics, I recommend spending your hard-earned money on quality, properly fitted shoes specific for your work or athletic activities. You may be surprised to learn that many people have not had their feet professionally measured at a shoe store in years. As we age, our foot length and width changes. And sizing may not be consistent between brands; the same size 9-1/2 narrow shoe may differ significantly from one manufacturer to another.

If your pain or discomfort does not improve with new shoes, try over-the-counter or kiosk orthotics for a period of time. If you see improvement, fine. If not, see a health care professional for an evaluation for custom prescription orthotics.

In my experience, certain groups of people benefit from an examination performed by a health care professional, and a prescription for custom orthotics. These include people with diabetes who have loss of feeling in their feet, people with poor circulation, and people with severe foot deformities caused by arthritis. In fact, Medicare has a program that covers 80% of the cost of diabetic shoes and orthotics, because studies have shown that they decrease the chance of developing an open sore that can lead to amputation.

In summary, if you feel you know what is causing your foot pain, you don’t fall into any of the groups that benefit from professional custom orthotics, and you already wear a properly fitted pair of shoes, go ahead and try the OTC or kiosk orthotics. For most people, these will provide relief. After taking these steps, if you notice no improvement in your condition, then seek out the advice of a health care professional.
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