Don’t take fatigue lying down

Sure, everyone gets tired sometimes, and often bounces back after a quick rest or a good night’s sleep. However, if bouts of fatigue occur more often and last longer, you shouldn’t ignore them.

“Older adults may chalk up fatigue to aging, but there is no reason you should battle ongoing tiredness,” says Dr. Suzanne Salamon, a geriatric physician with Harvard-affiliated Beth Israel Deaconess Medical Center.

Here are signs that you should take your tiredness seriously:

    inability to do activities you enjoy
    waking up exhausted, even after a good night’s sleep
    not feeling motivated to begin the day
    sudden bouts of exhaustion that go away and then return
    shortness of breath.

This type of fatigue can affect your health in many ways. You may have less energy to exercise. You may have trouble concentrating, staying alert, and remembering things. You may anger easily and become more socially isolated.
It’s worth checking in with your doctor

Fatigue also could signal a medical condition, according to Dr. Salamon, and you should consult your doctor to see if you have any of the following issues.

    Anemia. This occurs when your blood has too few red blood cells or those cells have too little hemoglobin, a protein that transports oxygen through the bloodstream. The result is a drop in energy levels.
    Heart disease. Heart disease can cause the heart to pump blood less efficiently and lead to fluid in the lungs. This can cause shortness of breath and reduce the oxygen supply to the heart and lungs, making you tired.
    Sleep problems. Sleep apnea is characterized by pauses in your breathing, often lasting several seconds, or shallow breathing while you sleep. It is common among older adults and those who are overweight. Another sleep-related issue is an overactive bladder, which forces repeated nighttime bathroom trips. Either of these can disturb your sleep enough to leave you feeling tired during the day.
    Medication. Certain medications can make you feel tired, such as blood pressure drugs, statins, antidepressants, antihistamines, nonsteroidal anti-inflammatory drugs, and cold medications. “People react to medications differently and they often end up taking more as they get older,” says Dr. Salamon. Check with your doctor, especially if you have added a new medication or recently increased your dosage. “Sometimes it helps to take certain medicines, which may cause fatigue, at night rather than in the daytime,” she says.
    Low-grade depression or anxiety. Mental health issues often drain energy levels. “You may suffer from depression or anxiety and not even know it,” says Dr. Salamon.
    Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). This is a complex disorder that causes unexplained extreme fatigue, which can worsen after physical or mental activity and does not improve with rest. Its cause is unknown, but may be linked to one or more underlying issue.

Some simple ways to boost energy levels

For regular, everyday fatigue, try these tips:

    Drink a cup of coffee or tea. A little caffeine can jump-start your day, she says. “You don’t need more than that, but it can offer a mental and physical lift, especially if you have trouble with morning fatigue.”
    Go for a 30-minute walk. “If you can’t get outside, walk around your house in bouts of 10 to 15 minutes, two to three times a day,” says Dr. Salamon.
    Take a nap. A midday nap can help overcome tiredness later in the day. Keep naps to about 20 to 30 minutes, as studies have suggested that napping for 40 minutes or longer can have the opposite effect and leave you feeling groggy rather than refreshed. “Also, don’t nap too late in the day or in the early evening, when it could interfere with your normal sleep schedule,” says Dr. Salamon.
If you Google “coconut oil,” you’ll see a slew of stories touting the alleged health benefits of this solid white fat, which is easy to find in supermarkets these days. But how can something that’s chock-full of saturated fat — a known culprit in raising heart disease risk — be good for you?

Coconut does have some unique qualities that enthusiasts cite to explain its alleged health benefits. But the evidence to support those claims is very thin, says Dr. Qi Sun, assistant professor in the Department of Nutrition at the Harvard T.H. Chan School of Public Health.

“If you want to lower your risk of heart disease, coconut oil is not a good choice,” he says. It’s true that coconut oil tends to raise beneficial HDL cholesterol more than other fats do, possibly because coconut oil is rich in lauric acid, a fatty acid that the body processes slightly differently than it does other saturated fats.
Coconut oil’s effect on cholesterol

But there’s no evidence that consuming coconut oil can lower the risk of heart disease, according to an article in the April 2016 Nutrition Reviews. The study, titled “Coconut Oil Consumption and Cardiovascular Risk Factors in Humans,” reviewed findings from 21 studies, most of which examined the effects of coconut oil or coconut products on cholesterol levels. Eight were clinical trials, in which volunteers consumed different types of fats, including coconut oil, butter, and unsaturated vegetable oils (such as olive, sunflower, safflower, and corn oil) for short periods of time. Compared with the unsaturated oils, coconut oil raised total, HDL, and LDL cholesterol levels, although not as much as butter did.

These findings jibe with results from a study by Dr. Sun and colleagues in the Nov. 23, 2016, issue of The BMJ, which examined the links between different types of saturated fatty acids and heart disease. Compared with other saturated fats (like palmitic acid, which is abundant in butter), lauric acid didn’t appear to raise heart risk quite as much. But that’s likely because American diets typically don’t include very much lauric acid, so it’s harder to detect any effect, Dr. Sun notes.
Tropical diets are different

Coconut oil proponents point to studies of indigenous populations in parts of India, Sri Lanka, the Philippines, and Polynesia, whose diets include copious amounts of coconut. But their traditional diets also include more fish, fruits, and vegetables than typical American diets, so this comparison isn’t valid, says Harvard Medical School professor Dr. Bruce Bistrian, who is chief of clinical nutrition at Beth Israel Deaconess Medical Center.

Some of the coconut oil available in stores is labeled “virgin,” meaning that it’s made by pressing the liquid from coconut meat and then separating out the oil. It tastes and smells of coconut, unlike the refined, bleached, and deodorized coconut oil made from the dried coconut meat used in some processed foods and cosmetics. Virgin coconut oil contains small amounts of antioxidant compounds that may help curb inflammation, a harmful process thought to worsen heart disease. But to date, proof of any possible benefit is limited to small studies in rats and mice, says Dr. Bistrian.
Unsaturated fats

In contrast, there’s a wealth of data showing that diets rich in unsaturated fat, especially olive oil, may lower the risk of cardiovascular disease, Dr. Sun points out. The evidence comes not only from many observational studies (like those in the aforementioned BMJ report) but also a landmark clinical trial from Spain, which found that people who ate a Mediterranean-style diet enhanced with extra-virgin olive oil or nuts had a lower risk of heart attack, stroke, and death from heart disease than people who followed a low-fat diet.

Of course, there’s no need to completely avoid coconut oil if you like the flavor. Some bakers use coconut oil instead of butter in baked goods, and coconut milk is a key ingredient in Thai cooking and some Indian curry dishes. Just be sure to consider these foods occasional treats, not everyday fare. High-grade cancer that’s still confined to the prostate is generally treated surgically. But a third of the men who have their cancerous prostates removed will experience a rise in blood levels of prostate-specific antigen (PSA). This is called PSA recurrence. And since detectable PSA could signal the cancer’s return, doctors will often treat it by irradiating the prostate bed, or the area where the gland used to be.

In February, researchers reported that radiation is a more effective treatment for PSA recurrence when given in combination with androgen-deprivation therapy (ADT). ADT interferes with the body’s ability to make or use testosterone, which is the hormone (or androgen) that makes prostate tumors grow more aggressively. It targets rogue cancer cells in the body that escape radiation.
Here’s what the study found

The newly published study randomly assigned 760 men with detectable PSA after surgery to one of two groups. One group got radiation plus ADT and the other group got radiation plus a daily placebo tablet. The study recruited patients between 1998 and 2003, and after an average follow-up of 12 years, 5.8% of men in the combined treatment group had died of prostate cancer, compared to 13.4% in the radiation-only group. Rates of metastatic prostate cancer were also lower among men treated with ADT: 14.5% compared to 23% among the placebo-treated controls.

“The take-home message is that ADT has a major and beneficial impact on the risk of death from prostate cancer when added to radiation for PSA recurrence,” said Ian Thompson, M.D., a professor of oncology at the UT School of Medicine, in San Antonio, Texas, and the author of an editorial accompanying the newly published findings.

Men in this study received a high dose of the ADT drug bicalutamide, which doctors use less frequently for PSA recurrence today, instead favoring other testosterone-suppressing medications that have since been shown to be more effective. Therefore this is an instance of a long-term study reporting results after treatment standards — in this case the selection of a specific ADT regime — have changed.
A new treatment standard

Still, some men have difficulty tolerating ADT, and not all of them should get it, particularly if they’re older and more likely to die of something other than prostate cancer. “I’d reserve ADT for younger men with a long life expectancy ahead of them who were diagnosed initially with high-grade or late-stage disease,” Thompson said. As a primary care physician at Massachusetts General Hospital (MGH), I am profoundly grateful for my 10 years in recovery from opiate addiction. As detailed in my memoir Free Refills, I fell into an all too common trap for physicians, succumbing to stress and ready access to medications, and became utterly and completely addicted to the painkillers Percocet and Vicodin. After an unspeakably stressful visit in my office by the State Police and the DEA, three felony charges, being fingerprinted, two years of probation, 90 days in rehab, and losing my medical license for three years, I finally clawed my way back into the land of the living. I was also able to return, humbled, to a life of caring for patients.

There is one question that I invariably get asked, by my doctors, colleagues, friends, family members, and at lectures and book talks: now that you are in recovery from opiates, what are you going to do when you are in a situation such as an accident or surgery, when you might need to take opiates again? I have blithely answered this question with platitudes about how strong my recovery is these days, and how I will thoughtfully cross that bridge when I come to it. In other words, I punted consideration of this difficult issue into some unknown future time.

Unfortunately, that future is now, and that bridge is awaiting my passage.

Last week I slipped on my top outside step, which was covered in ice, went into free fall, and managed to completely tear my left quadriceps tendon. This required a surgical repair in which doctors drilled three holes into my kneecap and then tethered what was left of my quadriceps muscle to the kneecap. Taking Tylenol or Motrin for this kind of pain is kind of like going after Godzilla with a Nerf gun. I was sent home with a prescription for one of my previous drugs of choice: oxycodone.

My leg was hurting beyond belief. I literally felt as if it were burning off. But, I had spent the last 13 years of my life conditioning myself, almost in a Clockwork Orange kind of way, to be aversive to taking any and all opiates.

What is a person who used to suffer from a substance use disorder (SUD) to do? There are millions of us in this country who may eventually face this choice.

Fortunately, I am not the first person who has confronted this issue. There exist safeguards one can put in place. It is important that all of your doctors know about your history of SUD. It is also helpful if you have a significant other or partner at home who can manage the pills for you, and dole out two of them every four to six hours as directed, to avoid the temptation to take more than prescribed in order to get high. (Old habits die hard.) Finally, the key to all addiction treatment is being open and honest. It is critical to check in with one’s support network about medications, cravings, and fears, and to use all of the recovery tools that are available to you, such as asking for help if you need to, and not trying to control things that can’t be controlled.

In the end, my level of pain was so great that there really wasn’t any choice but to take the oxy. My nerve receptors made the decision for me. I’m sure there are Shaolin monks somewhere who can block out high levels of pain, but that just isn’t me.

I am reassured, and even pleasantly surprised, by several aspects of having taken the oxycodone. First, it worked well for the pain. Second, I did not get high from the pills. I guess that taking two pills is different from taking (or snorting) 10 or 20, as we tend to do when we are addicted. Finally, it was very easy to stop taking them, and I have had absolutely no cravings or dreams about using since stopping.

This is a critical issue. It would be cruel and inhumane to not sufficiently treat any patient’s pain, especially after surgery, and it is important not to discriminate against people with SUDs. There are millions of people in recovery from opiates in the United States alone, and they are as deserving of pain control as anyone else.

Finally, I am grateful beyond belief to have survived my opiate addiction, and to not have become one of those all too common overdose stories we all read about in the newspapers. I am also grateful to my excellent doctors at MGH for fixing my wounded knee, and for providing me adequate pain control. Fortunately, my recovery and my pain control do not seem to have been mutually exclusive.

Read More »

A strengths-based approach to autism

You hear your spouse breathing nearby and you instantly get angry. Your 6-year-old yawns and it triggers a fight-or-flight reaction in you. You avoid restaurants because you can’t stand the sound of chewing. Sounds other people don’t even seem to notice, drive you up a wall. You might have misophonia.
What is misophonia?

People with misophonia are affected emotionally by common sounds — usually those made by others, and usually ones that other people don’t pay attention to. The examples above (breathing, yawning, or chewing) create a fight-or-flight response that triggers anger and a desire to escape. This disorder is little studied and we don’t know how common it is. It affects some worse than others and can lead to isolation, as people suffering from this condition try to avoid these trigger sounds. People who have misophonia often feel embarrassed and don’t mention it to healthcare providers — and often healthcare providers haven’t heard of it anyway. Nonetheless, it is a real disorder and one that seriously compromises functioning, socializing, and ultimately mental health. Misophonia usually appears around age 12, and likely affects more people than we realize.
What causes misophonia?

New research has started to identify causes for misophonia. A British-based research team studied 20 adults with misophonia and 22 without it. They all rated the unpleasantness of different sounds, including common trigger sounds (eating and breathing), universally disturbing sounds (of babies crying and people screaming), and neutral sounds (such as rain). As expected, persons with misophonia rated the trigger sounds of eating and breathing as highly disturbing while those without it did not. Both groups rated the unpleasantness of babies crying and people screaming about the same, as they did the neutral sounds. This confirmed that the misophonic persons were far more affected by specific trigger sounds, but don’t differ much from others regarding other types of sounds.

The researchers also noted that persons with misophonia showed much greater physiological signs of stress (increased sweat and heart rate) to the trigger sounds of eating and breathing than those without it. No significant difference was found between the groups for the neutral sounds or the disturbing sounds of a baby crying or people screaming.
The brain science of misophonia

The team’s important finding was in a part of the brain that plays a role both in anger and in integrating outside inputs (such as sounds) with inputs from organs such as the heart and lungs: the anterior insular cortex (AIC). Using fMRI scans to measure brain activity, the researchers found that the AIC caused much more activity in other parts of the brain during the trigger sounds for those with misophonia than for the control group. Specifically, the parts of the brain responsible for long-term memories, fear, and other emotions were activated. This makes sense, since people with misophonia have strong emotional reactions to common sounds; more importantly, it demonstrates that these parts of the brain are the ones responsible for the experience of misophonia.

The researchers also used whole-brain MRI scans to map participants’ brains and found that people with misophonia have higher amounts of myelination. Myelin is a fatty substance that wraps around nerve cells in the brain to provide electrical insulation, like the insulation on a wire. It’s not known if the extra myelin is a cause or an effect of misophonia and its triggering of other brain areas.
There is some good news

Misophonia clinics exist throughout the US and elsewhere, and treatments such as auditory distraction (with white noise or headphones) and cognitive behavioral therapy have shown some success in improving functioning. For more information, contact the Misophonia Association. We are in the midst of an unprecedented epidemic, with several million people currently addicted to opiates in the United States, including both prescription drugs and heroin. Much discussion has been devoted to the visible tragedy of overdoses, which are killing dozens of people every day. Less attention has been paid to a more subtle, but damaging and painful, component of this epidemic: how a person suffering from opiate addiction affects his or her family members.
The effects of substance use disorder on loved ones

Substance use disorders (SUDs) are brain diseases that can negatively affect a person’s behavior and fundamentally alter one’s personality. It is not uncommon for people suffering from SUDs to act in a way that is alienating and destructive to their friends and families. For example, a common scenario is theft of property or money to purchase drugs. Families can feel hurt and betrayed by this behavior, especially if they don’t understand that addiction is a disease. Family members can feel lied to, cheated, manipulated, and at times even threatened. With any signs of progress, with each stay in rehab, they become hopeful, only to have their hopes dashed again and again.

What can you do if you have a loved one addicted to opiates? This question has no easy answers, but does have several distinct schools of thought.
The “tough love” approach

A common belief is that a “tough love” approach will help family members avoid enabling the addiction. The thinking is that a family member can make an addiction worse by removing or cushioning the natural consequences of the addicted person’s actions, so that they do not have an incentive to recover. For example, if a person spends all his or her money on drugs, and you give them more money for food, you have enabled their addiction. Otherwise, presumably, they would go hungry, and would start to understand the connection between their drug use and their hunger.

In this example, the tough love approach suggests that the thieving offender be forced to “find their bottom,” or become miserable enough to understand the inescapable need to seek treatment. This response would also serve the purposes of protecting the family’s finances and property and setting up physical and psychological boundaries, so that the members of the family can move on with their lives.

Unfortunately, with our current opiate crisis, “finding your bottom” all too commonly can mean death from overdose, especially with our streets being flooded with fentanyl, a deadly opiate that people often mistakenly buy, looking for heroin.
Plain old love as an approach

Gradually, a more nurturing and supportive approach to substance users is supplanting the tough love approach. This is partly in response to the sheer number of overdose deaths. It is also due in part to the increasing awareness of addiction as a disease that needs to be met with empathy, rather than a moral failing that deserves scorn and punishment. Instead of tough love, people are simply using plain old love to try to coax their family member back into the fold, and hopefully encourage them to seek treatment. Each slip or relapse is met with support and patience, as families increasingly understand the chronic and relapsing nature of addiction. Many believe that this is a safer and more humane way to respond to addiction.

A tenet of 12-step ideology is that addiction is a “disease of isolation,” with its hallmarks being secrecy and disconnection. Therefore it makes sense that human connection would be an important component of treating addiction, and that a strategy of loving engagement might be more effective than one that shuns the sufferer or blames the victim. Through engagement and connection, a lifeline to treatment can be offered.
And about the suffering of family and friends…

It is essential to pay attention to the well-being of the family members themselves during all of this, as having a loved one with a substance use disorder can be profoundly stressful and disruptive, even traumatic. Every situation is different, but certain general principles apply. Psychologically, it is critical to be as open with your social community as you feel comfortable being, and to rely on the support of others. Many people find getting involved in a recovery group such as Al-Anon or Nar-Anon to be invaluable. Sometimes suffering alone can be the worst type of suffering. Family therapists and addiction specialists may also be helpful.

On a practical level, one must protect one’s finances, and you may need to change passwords or secure valuables if theft is an issue. If living with your addicted loved one is just too stressful, alternative living arrangements may be necessary. Some families may need to change their locks. Families must decide whether they truly wish to go deeply into debt to fund a second or third stint at rehab.

One of the most difficult situations that families can face is coping with a loved one who is actively abusing opiates. With our current epidemic, it is becoming distressingly common. This situation is always replete with guilt, shame, and stigma for everyone. A frequently used metaphor (borrowed from airline safety videos, yet commonly employed in recovery centers) is that it is critical that you put on your own oxygen mask before trying to help others do the same, so that you are able to remain functional in order to help. This fully pertains to addiction. We suffer alone, but we recover together. At our son’s 18-month checkup five years ago, our pediatrician expressed concern. Gio wasn’t using any words, and would become so frustrated he would bang his head on the ground. Still, my husband and I were in denial. We dragged our feet. Meanwhile, our son grunted and screamed; people said things. Finally we started therapy with early intervention services.

A few months later, after hundreds of pages of behavior questionnaires for us and hours of testing for Gio, we heard the words: “Your son meets criteria for a diagnosis of autism spectrum disorder…”

Our journey has taken us through several behavioral approaches with many different providers. Today, Gio is doing very well, in an integrated first grade in public school. He can speak, read, write, and play. His speech and syntax can be hard to understand, but we are thrilled that we can communicate with him.
The difference between typical and functional

Longtime autism researcher Laurent Mottron wrote a recent scientific editorial in which he points out that the current approach to treating a child with autism is based on changing them, making them conform, suppressing repetitive behaviors, intervening with any “obsessive” interests. Our family experienced this firsthand. Some of our early behavioral therapists would see Gio lie on the ground to play, his face level with the cars and trucks he was rolling into long rows, and they would tell us, “Make him sit up. No lying down. Let’s rearrange the cars. Tell him, they don’t always have to be in a straight line, Gio!”

To me, this approach seemed rigid. We don’t all have to act in the exact same way. These kids need to function, not robotically imitate “normal.”
Why not leverage difference rather than extinguish it?

We naturally gravitated towards Stanley Greenspan’s “DIR/Floortime” approach, in which therapists and parents follow the child’s lead, using the child’s interests to engage them, and then helping the child to progress and develop.

Mottron’s research supports Greenspan’s approach: study the child to identify his or her areas of interest. The more intense the interest the better, because that’s what the child will find stimulating. Let them fully explore that object or theme (shiny things? purple things? wheels?) because these interests help the developing brain to figure out the world.

Then, use that interest as a means to engage with the child, and help them make more connections. Mottron suggests that parents and teachers get on the same level with the child and engage in a similar activity — be it rolling cars and trucks, or lining them up. When the child is comfortable, add in something more. Maybe, make the cars and trucks talk to each other.

But, don’t pressure the child to join the conversation. Let them be exposed to words, conversations, and songs, without forced social interaction. This is how early language skills can be taught in a non-stressful way, acknowledging and aligning with the autistic brain. The ongoing relationship and engagement will foster communication.

Basically, what both Greenspan and Mottron are advocating are methods of teaching autistic children to relate, adapt, and function in the world, without “forcing the autism out of them.”

The concept of accepting autistic kids as they are, and incorporating the natural ways they think into educational and therapeutic techniques, feels right to me. Gio is different from most kids, and really, he’s not interested in most kids. Our attempts to push him to participate in “fun” group activities like soccer, Easter egg hunts, and birthday parties have all been spectacular failures. Maybe the real failure was ours: by pushing him to “fit in,” we deny his true nature. Yes, the way he thinks is sometimes mysterious to us, but he clearly has great strengths: a remarkable ability to focus and persevere, to experiment with his ideas, and to follow his vision.

World-renowned autism expert and animal rights activist Temple Grandin (who is herself autistic, and very open about her preference for animal rather than human companionship!) sums up Mottron’s approach perfectly: “The focus should be on teaching people with autism to adapt to the social world around them while still retaining the essence of who they are, including their autism.”

Read More »

Tips for using this versatile piece of exercise equipment

Sodium is an essential part of our diet. It helps nerves and muscles function as well as hold onto water. Sodium in the blood is what keeps it viscous, but too much sodium means your body could retain too much liquid. This surge in volume increases blood pressure, which is the root of many serious ailments including heart and kidney disease. Experts estimate that we could save 280,000 lives in the United States if we lowered the average daily sodium intake by 40% for the next 10 years. And that’s just because lowering blood pressure protects the heart.

The average American consumes 3,409 milligrams of sodium each day, according to a new report from the Centers for Disease Control and Prevention. That’s way above the amount we should be getting per day: 1,500 mg. It means we’re ingesting 1.5 teaspoons of salt each day, when we really need only a third of that. And most of that sodium comes from prepared and processed foods — 75%, actually. Salt helps to preserve and add flavor to food, which is great when you want that strawberry Pop-Tart to taste the same whether you eat it the day after you buy it or a month after. But the CDC recently published a list of the 10 most sodium-dense foods in our diets. You know what’s at the top? Yeast bread, pizza, and sandwiches. The good stuff, the convenient stuff, the stuff like Pop-Tarts.
Dialing back the sodium

Cutting back on sodium in our prepared foods has been made easier by the increase in packaged food companies’ creating reduced-sodium versions of them, like low-sodium chicken broth. While that sounds simple, sodium lurks in some unexpected places. Kathy McManus, director of the Department of Nutrition at Brigham Health/Brigham and Women’s Hospital, says there are some ways to cut back on sneaky salt.

McManus says a good way to reduce the amount of sodium you eat is to focus on natural and whole foods. Preparing your own food, while sometimes inconvenient, can cut down on a lot of the sodium you consume. For instance, a frozen dinner of Marie Callender’s Vermont White Cheddar Mac and Cheese contains more sodium in one meal than you’re supposed to have in an entire day. But it’s not that hard to prepare a decadent mac and cheese yourself with Barilla pasta, your own white cheddar cheese, and a little cream. The sodium count comes out to around 715 mg. That is much more manageable when watching your sodium intake. It’s less convenient, but it works.

Buying low-sodium products and then adding salt to them is still better than buying the regular version. Cooking techniques can also help compensate for flavor lost when cutting back on salt. McManus suggests playing around with grilling or stir-frying with healthy oils to change the flavor. You can also add fresh or dried herbs to enhance taste. Over time, your taste buds will adjust. Your palate will change. You’ll be less accustomed to salt and less desensitized to it, so a little bit will travel farther in terms of flavor.

Restaurants remain at the top of the list for sodium-dense meals. Looking at the menu online ahead of time can help you prepare and research your options, but so can keying in on words that indicate healthier options. Look for baked, grilled, or steamed as a description for lean meats like fish or poultry. Keep an eye out for sides that are prepared simply, like vegetables. Avoid soups or pastas with sauces. Put salad dressing on the side, and definitely avoid the bread basket.
Top 10 high sodium foods

Nutrition is not a one-size-fits-all kind of science, but it does get us thinking about what we eat and how it affects us. You could never cut sodium completely out of your diet, nor would you want to, but you can be more aware of the sodium in the foods you eat. To see the complete list of high-sodium foods, check out the table below. Seasonal allergies can be frustrating. When spring crawls in, many people begin to experience all-too-familiar itchy and watery eyes, runny nose, and congestion. Symptoms of seasonal allergies are the result of an immune system in overdrive in response to pollen and other allergens. Those bothersome symptoms are intended to protect you from unwanted foreign particles, but in this situation they end up causing misery. There are quite a few options when it comes to controlling allergy symptoms, but we want to watch out for a few that can be quite dangerous when used incorrectly.
Nasal steroids

The first-line treatment for seasonal allergies is an intranasal corticosteroid such as fluticasone propionate (Flonase). These sprays are available without a prescription and you can use them as-needed. Nasal steroid sprays have been shown to help with both nasal symptoms of runny nose and congestion, as well as eye symptoms. When using these sprays, it is important to direct the spray away from the nasal septum, as there have been some cases of nosebleeds from using these sprays. If this happens, stop using the medication and let your doctor know.

To date, most studies looking at the effect of intermittent use of nasal steroids on growth in children have been inconclusive. However, a large study reported a slight reduction in the rate of growth when nasal steroids were used daily over 52 weeks by children before puberty. Therefore, it’s a good idea to discuss steroid nasal sprays with your doctor if you find your child needs it on a more regular basis.
Oral antihistamines

Antihistamines such as diphenhydramine (Benadryl), loratidine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra) can also be quite helpful. The key is to take the medicine before symptoms develop, such as early in the morning. Another important thing to remember is that some of these medications can cause drowsiness and should be used cautiously during the day, especially if you are driving.
Decongestants

Nasal decongestant sprays such as phenylephrine and oxymetazoline (Afrin) should be used cautiously. Although they may work well in the short term when used occasionally, if used regularly for more than a few days (approximately five days), you may find your nose more congested than usual. This is called rebound congestion or rhinitis medicamentosa. I usually recommend patients not use these products for more than three days. Using these sprays too often causes a biochemical change in certain receptors on your cells, resulting in a vicious cycle of dependence — the more you use it, the worse your symptoms, and the more you need to use it. If this happens, stop using the medication, and talk to your doctor about switching to another type of nasal spray (intranasal glucocorticoid spray) which has been shown to help with this condition.

Oral decongestants such as pseudoephedrine or phenylephrine may help reduce symptoms as well. You should also use these medications cautiously. They mainly work by constricting blood vessels, and may cause side effects such as increased blood pressure, palpitations, headaches, nervousness, and irritability. These medications should not be used by patients with a history of uncontrolled high blood pressure, heart rhythm problems, strokes, glaucoma, or other conditions.
Alternative therapies

Other therapies that have been shown to be beneficial include nasal saline irrigation. Irrigating the nasal passages with prepared solutions, such as with neti pots, has been shown to improve symptoms of runny nose, congestion, and itchy throat, and to improve quality of sleep in children with acute sinusitis and allergic rhinitis. When using these products, however, make sure you are using distilled, sterilized, purified, or previously boiled water, as there have been rare cases of fatal infections by amoeba when using tap water that was contaminated. Although the evidence for menthol rubs such as Vicks is limited, some patients find that rubbing a little menthol ointment under the nose can sometimes also offer congestion relief.\

Read More »

A point in the right direction, or a stab in the dark?

In 2015, motor vehicle accidents claimed the lives of more than 35,000 Americans. Sadly, the toll exacted by motor vehicle accidents has now been eclipsed. Data from the American Society of Addiction Medicine show that more than 52,000 of we Americans lost our lives to opioid overdose in 2015. Here in the Commonwealth, the story is even more grim; even accounting for differences in average age from community to community — younger people are still more likely to be affected than older people — the opioid overdose death rate has climbed to 23 per 100,000 residents as compared to 9 per 100,000 for the nation as a whole. The causes are numerous and a subject for another day. Similarly, approaches to solve the crisis are numerous and no one solution works for everyone who decides he or she has developed an opioid problem.
Medication Assisted Treatment (MAT)

One approach to treat people who are addicted to opioids is Medication Assisted Treatment (MAT) that combines medications to treat addiction with more traditional counseling approaches. One medication often used in MAT programs is buprenorphine-naloxone (trade name Suboxone, among others). This preparation — hereafter BN — combines buprenorphine, an opioid medication with partial activity that blunts cravings, and naloxone, an opioid overdose reversal medication that discourages abuse of the medication. When we compare groups of people addicted to opioids who are treated with and without BN, we see that those who receive the medication have a significantly higher rate of remaining free of other opioids. But how long should one continue the medication? A month? A year? A lifetime? And is it safe to continue the medication? We do not have the full answers yet, but early signals from the research indicate that not only is it safe but that longer treatment is better than shorter treatment.
Long-term treatment for a chronic condition

Many in the medical community have come to view addiction as a chronic disease. And, like many chronic diseases, it is one that can be managed but not yet cured. The thinking goes that just as those of us with high blood pressure take high blood pressure fighting medication each day for years, those of us with addiction would take addiction-fighting medication every day over years. The evidence shows that long-term proper treatment for high blood pressure lowers the risk for heart attack; evidence is now beginning to grow that long-term MAT can similarly decrease risk for relapse in those with addiction. As reported in a 2008 study in the American Journal on Addictions, patients who were successfully stabilized with a short course of BN could then be switched to long-term treatment with the medication. Forty percent of patients remained in treatment at two years and 20% at five years. When we remember that nearly half of people prescribed medication for blood pressure do not take their pills, we see that people on BN are not more likely to skip their medication than are people with better-studied chronic diseases. More importantly, though, greater than 90% of urine samples from those in the study remained free of opioids other than BN.

Long-term treatment with BN works.
How do people do without longer-term buprenorphine-naloxone treatment?

It is one thing to say that someone on a medication has a good outcome, but it is something else to prove that without the medication the person would not do well. Many advocate short-term treatment with BN. Help a person become stable and then taper off the medication. We now have evidence that this approach, however well intentioned, may be misguided. A 2014 study reported in the Journal of the American Medical Association demonstrates that over half of people who continued on BN maintenance remained free of opioids compared to just a third of those who were stabilized on BN and then tapered off. Further, far more of those treated with maintenance BN remained in the study compared to those who were tapered, suggesting that people remain committed to treatment while receiving BN.
Is long-term MAT safe?

Even if many people can be helped by extended BN treatment, it is important to consider possible side effects. Though we do not know the effects of being on BN for many decades, the 2008 American Journal on Addictions study looked for but did not find any serious adverse effects on the people treated. Earlier concerns that BN could cause liver damage also appeared to be unfounded as blood tests did not show signs of liver problems in any of the patients in the study.

More research is needed, of course, but the early evidence suggests that BN can safely help people remain off unwanted opioids over the long term just as blood pressure medication can protect people from the effects of high blood pressure. That is good news because each day off unwanted opioids is a day a person can focus on improving his or her life. Of course, buprenorphine-naloxone maintenance is not for everyone, but when it works it can work well and can give people room to breathe and rebuild their lives. Many people do focused brain exercises to help develop their thinking. Some of these exercises work, while others do not. Regardless, the focus network in the brain is not the only network that needs training. The “unfocus” network needs training too.
The “unfocus network” (or default mode network)

Called the default mode network (DMN), we used to think of the unfocus network as the Do Mostly Nothing network. And this network uses more energy than any other network in the brain, consuming 20% of the body’s energy while at rest. In fact, effort requires just 5% more energy. As you can imagine, this network is doing anything but “resting” even though it operates largely under the conscious radar. Instead, when you turn your “focus” brain off, it will retrieve memories, link ideas so that you become more creative, and also help you feel more self-connected too. Somewhat surprisingly, although the DMN is involved in representing and understanding your self, it also helps you read the minds of others. No wonder then, with all these functions on board, this network metaphorically converts your brain into a crystal ball, allowing you to predict things more accurately too. This is the kind of sharpness that you will develop if you train the DMN.

There are many ways to activate the DMN. Below are some that will give you a good start.
Surprising ways to train the default mode network

Some simple interventions could help you engage this network, depending on your goal.

Napping: If, for example, you are dog tired in the midafternoon, and just need your mind to be clear, a 10-minute nap might be all you need for sharper thinking. But if you have a major creative project ahead of you, whether it is an innovative idea at work, or redecorating your house, you will need at least 90-minutes of napping time. This gives your brain enough time to shuttle around ideas to make the associations that it needs to make.

Positive constructive daydreaming (PCD): It’s hard to imagine daydreaming as a type of training, but it is. It has to be the right type of daydreaming. According to Jerome Singer, who has studied this for decades, slipping into a daydream is not of much use; neither is guiltily rehashing everything that makes you feel bad — like the expense you incurred when you bought the shoes you liked, or the one-too-many drinks that you had at a party. But there is a type of daydreaming that will make you more creative and likely re-energize your brain. Called positive constructive daydreaming (PCD), it is best done while you are engaged in a low-key activity, not when you are fading. And as opposed to slipping into a daydream, which is more like falling off a cliff, you must parachute into the recesses of your mind with a playful and wishful image — perhaps one of you lying on a yacht or floating on your back in a pool on vacation. Then comes the swivel of attention — from looking outside, to wandering inside. With this move, you engage your unfocus brain and all the riches that it can bring.

Physical exercise and free-walking: In the brain, thinking supports movement, and movement supports thinking. In fact, exercise improves your DMN function. It normalizes it in obese people (who have too much of it) and increases connectivity in young healthy people. Even a single session can make a difference. Aerobic exercise can help prevent atrophy of key regions within the DMN, and also help the connectivity between different regions too.

Walking does boost creative thinking, but how you walk matters. One year of walking boosts the connections between the different parts of the DMN too. In 2012, psychology professor Angela K. Leung and her colleagues tested three groups of people. One group walked around in rectangles while completing a mental test; one group walked around freely; and the last group sat down while taking the test. The free-walking group outperformed the other two groups. Other studies have shown that free-walking results in improvements in fluency, flexibility, and originality of thinking. So if you want to boost your creativity, go on a meandering hike on a safe path less traveled. Furthermore, walking outdoors may be even more beneficial than puttering around the house (unless you’re using PCD, of course!) Acupuncture is a treatment that dates back to around 100 BC in China. It is based on traditional Chinese concepts such as qi (pronounced “chee” and considered life force energy) and meridians (paths through which qi flows). Multiple studies have failed to demonstrate any scientific evidence supporting such principles. Acupuncture involves the insertion of thin needles into the skin at multiple, varying locations based on the patient’s symptoms. Once inserted, some acupuncturists hand turn the needles for added therapeutic benefit. Although there are many uses for acupuncture in traditional Chinese medicine, in Western medicine it is primarily used for the treatment of pain.
Acupuncture (im)pales in comparison to Western medicine

At a time when people are increasingly concerned about drug side effects, some consider acupuncture an attractive non-medication option. Unfortunately, many studies show that the potential benefits of acupuncture are short-lived. In my experience, I put acupuncture, massage, and chiropractic interventions in the same bucket. You may feel better for a day or two, but there is limited lasting improvement.

In one study, 249 people with migraines occurring two to eight times per month received either acupuncture, sham (fake/placebo) acupuncture, or were put on an acupuncture waiting list. The two treatment groups received treatment five days per week for four weeks. Twelve weeks after treatment, the acupuncture group had on average 3.2 fewer attacks per month, the sham acupuncture group had 2.1 fewer attacks per month, and the wait-list group had 1.4 fewer attacks per month. These results are modest at best, and carry an approximate treatment cost of $2,000 per month (estimating $100/session x 20 sessions). This figure does not include lost income from time away from work to attend appointments, travel costs, pain from the procedure, and recovery time.

In general, the effectiveness of standard treatment (medication and injectable therapies) is supported by much stronger scientific evidence than acupuncture, including large clinical trials with thousands of subjects. For those averse to medications, physical therapy is a great alternative — one based on actual human anatomy and scientific principles. My patients often complain that they do not feel significantly better after the five to 10 sessions of physical therapy that insurance companies typically approve. I advise them that the true benefit of physical therapy comes when the stretching and strengthening routines taught by the therapist are continued at home on a long-term basis. Expecting an instant and permanent cure from physical therapy is like going to the gym for a week, and expecting to lose 20 pounds — without any chance of regaining the weight. (If any readers find a gym like that, please let me know….)
Stuck with needles, then stuck with a bill

At a cost of around $100 per treatment, and with sessions that can last over an hour, acupuncture treatments can be limited by both time and cost. Some patients may confidently argue that they do not mind the cost, because their insurance plan covers acupuncture. I would caution those same patients that money does not grow on trees, especially in the health insurance forest. If money is spent on one expense, it cannot be spent on something else. A plan that covers acupuncture may include fine print about excessive co-pays or limited coverage for basic medications. In some cases, covering acupuncture or massage may affect other patients in the same pool. Imagine if everybody received free massages, but in turn a cancer patient’s lifesaving chemotherapy becomes unaffordable. Although this is an exaggerated example, it does demonstrate the economics of health insurance.
Skewer side effects?

Side effects are not just limited to medications; procedures can also have negative effects. Acupuncture is relatively safe when the practitioner uses single-use, sterile needles with a clean technique. Side effects can include skin infections, bleeding, and pneumothorax (collapsed lung) if the needles are inserted too deep in the chest. Physicians sometimes perform acupuncture, but medical training is not required, and the qualifications to secure a license to practice acupuncture vary by state. It is probably worth the added expense to have a more experienced and/or highly credentialed acupuncturist.
Needle-less to say, the procedure went well

I fondly recall meeting an elderly lady who had a good experience with acupuncture for the treatment of her migraines, but the benefit only lasted one to two days after each session. After failing multiple treatments, she tried Botox injections with physicians not named Dr. Mathew, which she found effective. Due to scheduling issues, she ended up seeing me for injections. After I explained the risks and benefits of the procedure, she asked, “Dr. Mathew, are you experienced?” I replied, “Well, I trained the other two doctors who performed your previous injections.” She replied, “Well, I guess that makes you experienced. Are you gentle?” I paused and then replied in a stern tone, “Well, I am known as the Butcher of New England.” The woman was mortified, and she actually turned a little pale. I then advised her that I was just kidding, and that I am one of the gentler injectors in the practice. We then proceeded with her treatment. After we were done, she said, “That was the gentlest set of injections I ever received, and my pain is actually better.” I then said, “Please don’t say that… you will ruin my horrible reputation as the Butcher of New England.”

Read More »

Long-term treatment for a chronic condition

In 1996 Peter D’Adamo, a naturopathic physician, published a book in which he described how people could be healthier, live longer, and achieve their ideal weight by eating according to their blood type. One’s choice of condiments, spices, and even exercise should depend on one’s blood type. Soon, the book was a best seller and people everywhere were finding out their blood type, revising their grocery lists, and changing how they ate, exercised, and thought about their health.

Here are some of the recommendations according to the “Eat Right for Your Type” diet:

    Those with type O blood should choose high-protein foods and eat lots of meat, vegetables, fish, and fruit but limit grains, beans, and legumes. To lose weight, seafood, kelp, red meat, broccoli, spinach, and olive oil are best; wheat, corn, and dairy are to be avoided.
    Those with type A blood should choose fruit, vegetables, tofu, seafood, turkey, and whole grains but avoid meat. For weight loss, seafood, vegetables, pineapple, olive oil, and soy are best; dairy, wheat, corn, and kidney beans should be avoided.
    Those with type B blood should pick a diverse diet including meat, fruit, dairy, seafood, and grains. To lose weight, type B individuals should choose green vegetables, eggs, liver, and licorice tea but avoid chicken, corn, peanuts, and wheat.
    Those with type AB blood should eat dairy, tofu, lamb, fish, grains, fruit, and vegetables. For weight loss, tofu, seafood, green vegetables, and kelp are best but chicken, corn, buckwheat, and kidney beans should be avoided.

As mentioned, the recommendations for the blood type diets extend well beyond food choices. For example, people with type O blood are advised to choose high-intensity aerobic exercise and take supplements for their sensitive stomachs, while those with type A blood should choose low-intensity activities and include meditation as part of their routine.
But does it work?

High-quality studies about the blood type diet had not been published in peer-reviewed medical literature. Even now, a search in the medical literature for the author’s name reveals no research pertaining to this diet. Studies published in 2013 and 2014 about the blood type diets are worth noting. The 2013 study analyzed the world’s medical literature and found no studies demonstrating benefit from a blood type diet. The 2014 study found that while people following any of the blood type diets had some improvement in certain cardiometabolic risk factors (such as cholesterol or blood pressure), those improvements were unrelated to blood type.
Does it make any sense?

The theory behind this diet is that blood type is closely tied to our ability to digest certain types of foods, so that the proper diet will improve digestion, help maintain ideal body weight, increase energy levels, and prevent disease, including cancer and cardiovascular disease.

Put an end to diet disappointment with Harvard Medical School's Ultimate Guide to
Weight Loss

Click to get access to exclusive content.

Type O was said to be the original “ancestral” blood type of the earliest humans who were hunter-gatherers, with diets that were high in animal protein. Group A was said to evolve when humans began to farm and had more vegetarian diets. Group B blood types were said to arise among nomadic tribes who consumed a lot of dairy products. And since Group AB blood was supposed to have evolved from the intermingling of people with types A and B blood, type AB recommendations were intermediate between those for people with types A and B blood.

Each of these theories has been challenged. For example, there is evidence that type A was actually the first blood group to evolve in humans, not type O. In addition, there is no proven connection between blood type and digestion. So, in addition to a lack of evidence that the diet works, serious questions remain about why it should work in the first place.
So, what’s the downside?

It’s a fair question, especially since some improvements were seen in people who adopted certain blood type diets (see link above). Eating based on your blood type requires you to know your blood type and then follow a restrictive diet. Personal preferences might be a problem: a vegetarian with type O blood may struggle to stay on the assigned diet, and people who love red meat may be disappointed to learn they have type A blood. Recommended supplements are not cheap; neither are the recommended organic foods. And if you have certain health conditions, such as high cholesterol or diabetes, a nutritionist can make better evidence-based recommendations for you than those determined by your blood type.
Now what?

Advocates of blood type diets may say that while the ideal study has not yet been performed, the absence of evidence doesn’t prove they’re ineffective. And there’s also no proof that these diets are harmful. So, my guess is that interest in the blood type diets will not disappear any time soon. But there’s a reason that bookstores have rows and rows of books on diet, each claiming to be highly effective if not the best. We simply don’t know which diet is best for each individual person. And even if we did, sticking to any single diet is often challenging.
Though it seems Americans don’t agree on much, screening for cancer is an exception. Who wouldn’t support preventing or identifying cancer at an early, more treatable stage, when the alternative is pain, toxic therapies, and a shortened life? That may be why people get confused when news headlines don’t reinforce a “just do it” message. A recent example of the disconnect between public perception and medical evidence is screening for prostate cancer using the prostate-specific antigen (PSA) test. The United States Preventive Services Task Force (USPSTF), a non-governmental expert panel that produces guidelines for primary care providers, proposed new recommendations saying doctors should only order the PSA test for older men after discussing its pros and cons and eliciting preferences for screening.
Screening for prostate cancer with the PSA test: The backstory

To understand the new draft recommendation requires a brief history of this test. Introduced in the 1980s as a way to follow patients already diagnosed with prostate cancer, it began to be used to screen for new cancers. Given that the PSA is an easy blood test to perform, it was quickly adopted — without waiting for evidence that it actually worked. For many years, the USPSTF said there wasn’t enough information to recommend for or against the PSA test.

That changed in 2012 when the USPSTF released a controversial recommendation against screening. It was based in part on a large US study showing no decrease in prostate cancer deaths among men screened using the PSA test. The recommendation also reflected concern about the test causing a surge in prostate cancer diagnoses, many of which were small, low-risk cancers being treated with surgery or radiation — treatments with common side effects.

I was uncomfortable with this “don’t screen” recommendation and am happy about the proposed change. Here’s why: while the US screening trial was negative, another large study in European men showed a small decrease in prostate cancer deaths after more than 10 years of follow-up. Moreover, specialists had devised new strategies to avoid overtreating low-risk cancers.
Having a conversation about screening with the PSA test

I discuss the pros and cons of the PSA test with my patients and ask about their personal preferences for screening. I tell them that while screening can reduce death due to prostate cancer by 20%, the “bang for the buck” is small. It takes screening of over 1,000 men to prevent one death. I also highlight that the benefit of screening is years off, but the risks of treatment — impotence, incontinence, and bowel problems — occur right away.

I also emphasize the PSA test isn’t very accurate. There can be anxiety due to false positive results, meaning further testing shows no cancer. I mention the potential for diagnosing a low-risk cancer where the treatment may be worse than the disease, and that following them closely without treatment may be preferable. How much a man wants to know something like this can differ — some view it as useful information, others see it as an endless source of worry.

Finally, I share my own perspective. As a medical student in the late 1980s learning about the PSA test, my grandfather was dying from prostate cancer. He was an otherwise healthy man who had many good years left, and I wondered if the PSA test could have helped him. Because of this family history, I have decided to have the PSA test. But I’m also unsure what I would do if I didn’t have that history. The small potential for benefit must be weighed versus the risk of false positives or of finding a low-risk tumor that may never cause harm. I can see how two men without risk factors for prostate cancer could make different decisions.

So, I think the USPSTF got it right. This is a decision best made by a well-informed patient in collaboration with his doctor. The challenge in implementing this is practical: the short time I have with each patient. I could save time by simply ordering the test without a discussion. But in my role as health advisor, I need to be able to not only say when I think we should or should not do something, but also when there is a choice. And when there isn’t one right decision for everyone, my patient is the best person to make the choice that’s right for him. I can state my personal preference, but need to highlight why that may not be the right answer for him. Ever wonder what it would be like to be able to look at people’s entire adult lives? Not asking older people to remember, but starting with them as teenagers and tracking their health and well-being until they die? We’ve been lucky enough to do this for the past 78 years, starting in the late 1930s and early ‘40s with a group of men who agreed to be part of one of the longest studies of adult life ever done.

The Harvard Study of Adult Development has tracked the lives of 724 men from the time they were teenagers into old age — 268 Harvard College sophomores, and 456 boys from Boston’s inner city. Using questionnaires, interviews, medical records, and scans of blood and brains, we’ve monitored their physical and mental health, work lives, friendships, and romances.

Here are five of the big lessons we’ve learned about what contributes to a good life.
Lesson 1: Happy childhoods matter

Having warm relationships with parents in childhood predicts that you will have warmer and more secure relationships with those closest to you in adulthood. We found that warm childhoods reached across decades to predict more secure relationships with spouses at age 80. A close relationship with at least one sibling in childhood predicts that people are less likely to become depressed by age 50. And warmer childhood relationships predict better physical health in adulthood all the way into old age.
Lesson 2: Fostering the welfare of the next generation can ease the sting of difficult childhoods

People who grow up in difficult childhood environments (chaotic families, economic uncertainty) grow old less happily than those who have more fortunate childhoods. But by the time these people reach middle age (ages 50 to 65), those who mentor the next generation — guiding younger adults at home or at work — are happier and better adjusted than those who do not. The kind of maturation needed to nurture younger people also seems to reduce some of the sting of growing up disadvantaged.
Lesson 3: Coping effectively with stress has lifelong benefits

We all have habitual ways of managing stress and relieving anxiety. Some people tend to ignore uncomfortable facts, while others tend to face difficult issues and deal with what is unpleasant. For example, someone who is angry at his boss might “forget about it” but start missing important work deadlines. Alternatively, he might find a way to take up his concerns directly with that boss. We found that the people who cope with stress by engaging more directly with reality rather than pushing it away have better relationships with others. This coping style makes it easier for others to deal with them, which in turn makes people want to help them. They end up having better relationships and more social support, and this predicts healthier aging in your 60s and 70s. People who use these more adaptive coping mechanisms in middle age also end up with brains that stay sharper longer.
Lesson 4: Breaking bad habits earlier in life makes a difference

Watching people’s smoking habits across adulthood, those who quit earlier are less likely to develop lung disease as they grow old. They are also more likely to live longer than people who do not quit smoking or who quit later in life. Our findings differ from some studies that find no change in risk of disease and death once you’re tobacco-free for 15 years or more. Getting off the couch and starting to exercise earlier in life predicts that you’ll stay healthy longer in life, that your brain will stay sharper, and even that your immune system will be stronger.
Lesson 5: Time with others makes us happier

Looking back on their lives, people most often report their time with others as the most meaningful part of life, and what they’re proudest of. Time with other people makes us happier on a day-to-day basis, and time with a close partner buffers us against the mood dips that come with increased physical pain.

Read More »

Should I be eating more fiber?

High-grade cancer that’s still confined to the prostate is generally treated surgically. But a third of the men who have their cancerous prostates removed will experience a rise in blood levels of prostate-specific antigen (PSA). This is called PSA recurrence. And since detectable PSA could signal the cancer’s return, doctors will often treat it by irradiating the prostate bed, or the area where the gland used to be.

In February, Dr. William U. Shipley and his colleagues at Massachusetts General Hospital reported that radiation is a more effective treatment for PSA recurrence when given in combination with androgen-deprivation therapy (ADT). ADT interferes with the body’s ability to make or use testosterone, which is the hormone (or androgen) that makes prostate tumors grow more aggressively. It targets rogue cancer cells in the body that escape radiation.
Here’s what the study found

The newly published study randomly assigned 760 men with detectable PSA after surgery to one of two groups. One group got radiation plus ADT and the other group got radiation plus a daily placebo tablet. The study recruited patients between 1998 and 2003, and after an average follow-up of 12 years, 5.8% of men in the combined treatment group had died of prostate cancer, compared to 13.4% in the radiation-only group. Rates of metastatic prostate cancer were also lower among men treated with ADT: 14.5% compared to 23% among the placebo-treated controls.

“The take-home message is that ADT has a major and beneficial impact on the risk of death from prostate cancer when added to radiation for PSA recurrence,” said Ian Thompson, M.D., a professor of oncology at the UT School of Medicine, in San Antonio, Texas, and the author of an editorial accompanying the newly published findings.

Men in this study received a high dose of the ADT drug bicalutamide, which doctors use less frequently for PSA recurrence today, instead favoring other testosterone-suppressing medications that have since been shown to be more effective. Therefore this is an instance of a long-term study reporting results after treatment standards — in this case the selection of a specific ADT regime — have changed.
A new treatment standard

Still, some men have difficulty tolerating ADT, and not all of them should get it, particularly if they’re older and more likely to die of something other than prostate cancer. “I’d reserve ADT for younger men with a long life expectancy ahead of them who were diagnosed initially with high-grade or late-stage disease,” Thompson said.

“This important study confirms that combined therapy is superior to radiation alone and should be viewed as the standard treatment for PSA relapse,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “High dose bicalutamide has been associated with cardiovascular side effects, but ongoing and future research is clarifying how best to use ADT in this particular setting.” The prescription retinoid that my dermatologist suggested sounded like a great idea. It was a topical vitamin A-based cream, which has been shown to help reduce fine lines and wrinkles. Now that I’m a middle ager, I thought I’d give it a try. Then I got to the drugstore, and found that the little tube had a huge price: $371! I didn’t want to shell out that much for a mere face cream, so I didn’t fill the prescription.

But my case was only skin-deep. What about people who can’t — or don’t want to — pay for prescription medications to treat chronic or serious illness? “It’s a real problem. Medications only work if people take them, and you can’t take them if you can’t afford them,” says Dr. Joshua Gagne, a pharmacist and epidemiologist with Harvard-affiliated Brigham and Women’s Hospital.

According to a National Center for Health Statistics survey, about 8% of adults in the United States don’t take prescribed medications because they can’t afford them.

Even if cost is not affecting your medication regimen, the following ideas may save you some money.

    Try generics. Generic drugs have the same active ingredients as brand-name medications, but generics are substantially less expensive. For example, the cholesterol-lowering drug Lipitor retails for about $390 for a 30-day supply. The generic version, atorvastatin, is about $10 for a 30-day supply. Always ask your doctor if a generic is available. “If a generic isn’t available, ask if there’s a similar drug with a generic version,” suggests Dr. Gagne.
    Go to a big-box store. Many pharmacies in grocery stores and big-box chains offer hundreds of generic medications for just $4 (for a 30-day supply) or $10 (for a 90-day supply). Ask for the list when you’re at the pharmacy or look it up on the Internet, and bring a copy to your doctor. Don’t be discouraged if your medication isn’t on the list; check a different store. “Different chains have different lists,” says Dr. Gagne.
    Get a bigger dose. Some prescription medications can be divided with a pill splitter. Ask your doctor if that’s the case with your medication, and if it’s possible to get a double dose. For example, you might get 10-milligram (mg) pills that can be split into 5-mg pills. Some medications cannot be split, such as capsules or tablets that are enteric-coated, or those that release medicine over time. “As a general rule, extended-release or slow-release medications should not be split,” says Dr. Gagne. These include drugs like metformin ER (Glucophage XR) for diabetes and pantoprazole (Protonix) for heartburn.
    Get a larger supply. Instead of getting a prescription that lasts for 30 days, and making an insurance copay each time, ask for a 90-day supply so you can make just one copay every three months. This works for medications you take long-term.
    Apply for assistance. There are many kinds of prescription assistance programs, offered by state and local governments, Medicare, nonprofit groups, and even drug makers. The programs typically have income requirements. Nonprofit organizations include: Needy Meds and Partnership for Prescription Assistance. Other resources include state assistance programs and Medicare Extra Help. Another option is to call the manufacturer of your medication directly. You can look up your medication on this Medicare website.
    If you’re on Medicare, consider updating your plan. Medicare plans can change from year to year, including the medications they cover, and the copays and deductible amounts. You have an opportunity to switch Medicare plans during the annual enrollment period from October 15 to December 7. Review the options using Medicare’s personalized plan search on its website.
    Shop around. Medication retail prices vary. Some pharmacies buy directly from drug makers; others use a middleman, which can drive up prices. Call pharmacies in your area to compare prices, or use a computer or smartphone app to do the work for you, such as WeRx or GoodRx. The attorney general’s office in your state may also have a website that provides similar information.

This last strategy is the one that worked for me. My dermatologist directed me to a pharmacy that sold the retinoid cream for less (because of a deal with the drug maker). It wasn’t free by any means, but the price was enough to get me to fill the prescription. Do I look younger yet? Not quite. But thanks to the discount, my wallet is looking a little better. Imagine a chronic medical condition in which the treatment itself has serious side effects. Examples of this are plentiful in medicine. For example, in diabetes, giving too much insulin can cause hypoglycemia (low blood sugar), a dangerous and potentially life-threatening condition. That doesn’t happen very often, but imagine that it was a common complication of treating diabetes because doctors couldn’t really tell how powerful a given dose of insulin actually was. And suppose that doctors and patient safety experts advocated for places where patients with diabetes could be carefully monitored when taking their insulin. Would you be opposed to this idea? Would you blame the patient for developing diabetes, or for needing this carefully supervised medical treatment in order to live? I suspect that the answer is “of course not!”

Now, let’s shift gears and discuss opioid addiction, specifically people who use illicit drugs like heroin and black-market fentanyl. Heroin is the strong opioid substance derived from the poppy seed that has been used for thousands of years. Fentanyl is a synthetic opioid that can be hundreds of times more powerful than morphine or heroin. Increasingly, illicit heroin is adulterated with fentanyl and similar chemicals, which public health experts believe is the reason for the continued rise in opioid-related deaths despite aggressive measures to decrease opioid prescriptions, increase substance use disorder treatment facilities, and widely distribute naloxone, the antidote to opioid overdose.
Saving lives in the face of increased risk for dying of a heroin overdose

People who use heroin are now at significant risk for overdose death, mainly because the opioid content can vary considerably from dose to dose. Previously, a little too much could have caused a decrease in respiratory rate and a high dose could lead to overdose. Now, with the variability of potency from the synthetic opioids, the strength of each dose can be markedly different. Furthermore, the uptake of fentanyl in the brain is so rapid that a fatal overdose can occur much more quickly than with heroin alone.

If we, as a society, are truly serious about saving lives, we have no choice but to allow people who use injectable opioids to do so in safe, monitored locations without fear of negative repercussions (e.g., being arrested). If you had asked me about this several years ago, I never would have believed that I could write the preceding sentence. I would have said, “Why empower junkies to abuse illegal drugs? Why make it easier on them instead of harder? Why should society condone this activity?”

However, I was wrong — dead wrong.
Good reasons for a change of heart

It turns out that addiction (called substance use disorder or, more specifically here, opioid use disorder in medical jargon) is a disease that can affect any one of us, just like diabetes or high blood pressure. It does not discriminate and does not represent a moral failure on the part of the individual who develops it. It is a condition that no one chooses, but when it attacks, it changes the brain of those with the disease. We can actually visualize those changes with tests like functional MRIs. It leads people to make choices that destroy their lives and the lives of others, such as loss of job, isolation and loss of relationships, incarceration, and even death. We also now know that this is a treatable disease, but the window for successful treatment depends on the psychological state of the person. We must be ready to engage them in treatment at that moment when they are ready.

My opinions changed drastically after a visit to a local needle exchange facility. By current law, individuals can’t inject inside the building. They have to take their chances outside and then they can come inside to be monitored after injecting. I initially envisioned the facility to be sterile, dirty, and depressing. Instead, I was surprised to see that it looked like a living room. There were sofas and a television. There was a warm light, and it appeared to be a welcoming place. Across from the sofas were two desks where staff members sat. Their job is to watch for any signs of overdose (a person who is too sleepy or who is breathing too slowly) and then rapidly respond by providing a nasal dose of naloxone to reverse the overdose. More importantly, they are there to help people right when they are open to treatment for substance use disorder. The staff will help connect them to treatment resources, whether it is group therapy or medical treatment like buprenorphine (Suboxone) or methadone.

If that moment of opportunity in which the individual is receptive to treatment passes, the consequences can be deadly.

Furthermore, the facility is all about harm reduction. There are boxes of free supplies: needle kits so that people do not share needles, condoms for safe sex, kits to help treat small skin infections, even little clean cups to freebase injectable drugs. Naloxone kits are also provided free of charge. There is no judgment there. It is only about reducing a person’s risk of serious, life-threatening infections like HIV and hepatitis C, or the risk of death. And it makes sense. If we are going to agree that opioid use disorder is just another medical condition that needs to be treated, then the compassionate thing to do is to remove the stigma associated with it and reduce associated harms while a person is suffering with substance use disorder. Plain and simple: people with this disease are going to use drugs. Is it better for them to use in the shadows, risking transmission of serious infectious diseases, or monitor them when they are using and be there for them to get them treatment at the moment they are ready?

Currently it’s still illegal in the US to allow people to inject in these supervised environments, but the tide is turning. The city of Ithaca, NY is contemplating a safe injection space, as is Seattle. Multiple studies have confirmed that they work. In Vancouver, Canada, where such facilities were implemented in 2003, they concluded: “Vancouver’s safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts.” Massachusetts is also contemplating a similar pilot supervised injection facility program. With the crises of the opioid epidemic now claiming more than 30,000 lives every year in the US, it’s time to change our biases and old ways of thinking — people’s lives depend on it.

Read More »

Eat only every other day and lose weight?

The alternate-day fasting thing is very popular right now. This gist of it is, basically, feast and famine. You starve one day, then feast the next. Proponents claim that this approach will lead to weight loss, as well as a number of other benefits.

As a physician researcher, this annoys and alarms me. I preach sensible intake of real foods as part of a lifelong approach to health. I also depend on scientific evidence to guide my counseling. So, I welcomed this yearlong study comparing alternate-day fasting with more common calorie restriction.
Some data on alternate-day fasting

Researchers divided 100 obese study volunteers (mostly African-American women, without other major medical issues) into three groups:

    one group followed an alternate fasting plan, which meant on the fasting day they would eat only 25% of their caloric needs and on the non-fasting day they’d eat a little bit more (125% of their caloric needs per day)
    a second group ate 75% of their caloric needs per day, every day
    a third group ate the way they typically did, for six months.

The two diet groups received counseling as well as all foods provided. This “weight loss” period was followed by another six months of “weight maintenance” and observations.

Both diet groups lost about 5.5% of their body weight (12 pounds) by month six, and both regained about 1.8% (four pounds) by month 12, and had significant improvements in blood pressure, blood sugar, insulin, and inflammatory proteins when compared to the people who ate their normal diets.

At the end of the 12 months, there was only one difference between the two diet groups: the alternate fasting day group had a significant elevation in low density lipoprotein (LDL), an increase of 11.5 mg/dl as compared to the daily calorie restriction group. LDL is known as a risk factor for heart attacks and strokes, so that’s not good.
And how would this work in real life?

This was a very small study to begin with, and, more importantly, there was a fairly significant dropout rate. Only 69% of subjects stayed to the end, which decreases the power of the findings. Twelve people quit the alternate-day fasting group, with almost half citing dissatisfaction with the diet. By comparison, 10 people quit the daily calorie restriction group, and none cited dissatisfaction with diet, only personal reasons and scheduling conflicts (eight quit the control group for the same reasons).

It’s not surprising that people disliked alternate-day fasting. Previous studies have reported that people felt uncomfortably hungry and irritable on fasting days, and that they didn’t get accustomed to these discomforts. Interestingly, in this study, over time people in the fasting group ate more on fasting days and less on feasting days. So basically by the end of the study they were eating similarly to the calorie restriction group.

The authors note more limitations. The control group did not receive food, counseling, or the same attention from the study personnel, potential factors that could affect their results, besides how they ate. And this study can’t tell us about the potential benefits for people who have high blood pressure, high cholesterol, or diabetes because the study didn’t include individuals with those conditions.
The bottom line

Usually at this point we say something like “more studies of this approach are needed,” but I won’t. There’s already plenty of evidence supporting a common-sense lifestyle approach to weight loss: ample intake of fruits and veggies, healthy fats, lean proteins, and plenty of exercise. From apples to zucchini, there are over a hundred “real” foods you can eat endlessly, enjoy, and yes, still lose weight.

I would advise against spending any more money on fad diet books. Or processed carbs, for that matter. Rather, hit the fresh or frozen produce aisle, or farmer’s market, and go crazy. Then go exercise. Do that, say, for the rest of your life, and you will be fine. No one got fat eating broccoli, folks. (That said, if you tend to binge or stress-eat sugary or starchy foods, and you feel like you can’t control your habit, talk to your doctor, because that is a separate issue to be addressed.)
In 2012, the US Preventive Services Task Force (USPSTF) took the unprecedented step of recommending against prostate cancer screening for all men, regardless of age, race, or family history. Now this influential group of independent experts is reassessing its position based on more recent data. Instead of discouraging screening altogether, the UPSTF is urging doctors to discuss its potential benefits and harms with men 55 to 69 years of age. The same recommendation applies to all men in this age group, including those at higher risk of prostate cancer, such as African Americans and men with a family history of the disease. The USPSTF continues to recommend against screening men older than 70, since they’re unlikely to experience a survival benefit from treatment during their expected lifespans. The USPSTF was silent on men younger than 55, because Task Force members don’t believe there is sufficient information for them to make a recommendation.

Screening is usually done with a blood test that measures levels of a protein released by the prostate gland called prostate-specific antigen, or PSA. Elevations in PSA may be due to prostate cancer, but other conditions can also cause levels to rise, such as inflammation or an enlarged prostate. PSA levels also vary from man to man and can be unusually high in men who are otherwise healthy. To confirm or rule out a cancer diagnosis, doctors will typically order a biopsy of the prostate. However, prostate biopsies can lead to complications like infection, bleeding, and pain, and they often detect slow-growing, low-risk cancers that may never cause a man any harm during his lifetime. Treating low-risk cancers can leave men impotent and incontinent for years without extending their survival.

The USPSTF recommended against screening five years ago because its members felt the harms of treatment outweighed the benefits. However, newer data make the tradeoffs between potential harms and benefits too close to call. A European study published in 2014 found that PSA tests can prevent three cancers from spreading, and prevent one to two prostate cancer deaths, for every 1,000 men screened over 13 years. Then a study published last year found no difference in 10-year survival among men who were monitored or treated for low-risk prostate cancer. Monitoring, which is also called active surveillance, entails periodic PSA tests and biopsies to check for cancer growth, and thus allows men with low-risk prostate cancer to avoid the harms of treatment, at least temporarily.

It’s important to emphasize that the Task Force is not recommending that men in the 55-69 age group be screened, only that they talk about it with their doctors and then decide personally if it’s something they want to do, in accordance with their own values and preferences.

“Even the most serious student of prostate cancer and prostate cancer screening can appreciate the enormous endeavor that the Task Force undertook,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “Patients should consider shared decision making with their health provider when it comes to screening. But as in 2012, the ability to show an overall survival benefit from any screening recommendation still eludes us, and the cancer-specific survival benefit, if one exists at all, is at best very modest.”
In April, scientists reported encouraging results from a pilot study of men with metastatic prostate cancer, or cancer that has spread beyond the prostate gland. Long considered incurable, these advanced cancers are usually treated by giving men systemic drugs that target new tumors forming in the body. The scientists who led this new study took a more aggressive approach. In addition to giving systemic therapy, they surgically removed the prostate gland and affected lymph nodes, and also treated visible cancer in the bones with radiation. By throwing everything but the kitchen sink at these cancers, they achieved a stunning result: some of the treated men are still cancer-free after four years, and one has lived without evidence of cancer for five years. “If these remissions persist long enough, then we have to ask whether some of these men have been cured of their disease,” said the study’s lead author, Dr. Matthew O’Shaughnessy, a urologic oncologist at the Memorial Sloan Kettering Cancer Center, in New York.
How the study was conducted

The small pilot study enrolled 20 men, and O’Shaughnessy emphasized that follow-up with a larger group is needed to confirm the results. Five of the men had cancer that had spread to lymph nodes in the pelvis, and 15 of them had cancerous lesions in their bones. All the men were treated for between six and eight months with hormonal therapy, which blocks testosterone (the male sex hormone that makes prostate cancer cells grow faster). As noted previously, they also had their prostates and lymph nodes removed, and bone lesions were treated with radiation as needed. What the researchers were aiming for is a complete absence of prostate-specific antigen (PSA) in blood for a minimum of 20 months after the start of hormonal therapy. Prostate cancer cells will shed PSA into blood, but if the gland has been removed and all traces of cancer removed from the body, the levels should drop to zero and stay there, even after testosterone levels return to normal.

Overall, five men had undetectable PSA at 20 months and counting, although that number is too small to draw any conclusions about who might benefit most from the approach. According to O’Shaughnessy, when used together hormonal therapy, surgery, and radiation all contributed to prolonged remissions that would not have been possible if only one treatment was used. A study employing the same methods is planned for later this year.
What this means for treating advanced prostate cancer

Until recently, taking out the prostate and lymph nodes in men with advanced prostate cancer would have been unthinkable. Doctors worried that surgery could release cancer cells into the bloodstream, but newer studies show it can safely lengthen survival. Researchers have also been combining hormonal therapy and radiation with encouraging results, and now giving all three treatments is “consistent with a trend of doing more for advanced prostate cancer than doing less,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. Still, Garnick cautions that cures for advanced prostate cancer can take decades to confirm. “Hopefully follow-up research will support this transformative approach,” he said.

Read More »

Safe injection sites and reducing the stigma of addiction

It’s the end of the school year, the time of graduation speeches, of looking back at accomplishments and making plans for new ones. It’s a time when many parents think about their hopes and dreams for their children, whether they are graduating or just learning to walk.

As parents, we tend to think about getting good grades, excelling at athletics, being popular, getting into good schools, and getting good jobs. All of this is great, of course. But there is something that children need if they are going to truly succeed in life, and that’s resilience.

Resilience is the ability to overcome hardship and be okay. It’s the ability to navigate life’s inevitable bumps and still be happy and healthy and stay on track. What worries me sometimes is that our current parenting culture of achievement and obsessing over safety — and the way that electronic devices have become so ubiquitous — may get in the way of learning resilience.

According to Harvard University’s Center on the Developing Child, there are four factors that help children develop resilience. They are:

    Supportive adult-child relationships. This is crucial. All it really takes is one supportive, nurturing relationship to make all the difference. This gives children a buffer, and helps them know that they aren’t alone and that they matter to someone. While all parents want to have a good relationship with their child, the demands of daily life can get in the way. Try to spend regular time with your child when they have your undivided attention. Ask about their day, get involved in activities they enjoy, spend time doing things together. Make sure your child knows that no matter what, you have their back — and you will love them.
    A sense of self-efficacy and perceived control. Basically, you want to help a child learn that they can manage, and that even if things go wrong, they can figure a way through. You can’t do this just by telling your child that he is smart and capable; he needs to learn it himself. Bit by bit, giving independence, letting children make decisions and take risks helps them learn to weather life’s storms. It’s not always easy to let children take risks —we never want them to be hurt, emotionally or physically — but with you at their back, and in a gradual way, most children can and do manage just fine. Learning this also involves shutting off the screens and being active. Learning to be physically capable is important. In being active, in running and climbing and other such activities, children learn not just their strengths and limitations but how to plan and troubleshoot.
    Strong adaptive skills and self-regulatory capacities. This is what we call “executive function.” It’s like the air traffic controller functions of life: the ability to prioritize, not get distracted, make a plan, negotiate, get along with others, and manage emotions. These are not easy tasks, and there is no way to learn them without practice. One of the best ways for children to practice is through unstructured playtime, either alone (so they can find ways to entertain themselves) or with others (so they can learn how to work with others). Consistent discipline, not giving in to tantrums, and helping children manage sadness or frustration rather than just fixing things for them, can also help. The Center on the Developing child also has suggestions on activities to support executive function at different ages.
    Being able to mobilize sources of faith, hope, and cultural traditions. It helps to be part of something bigger, to have community, to have traditions that help you through difficult times. This doesn’t mean that you need to join a faith if you don’t belong to one. But if you do, maybe you could go to services a bit more often. If you don’t, spending time with extended family, joining a community group, taking part in service opportunities together… these activities can help give your child a perspective on life, as well as strategies for handling challenges. Because ultimately, the ability to keep perspective and handle challenges is what gets us through and helps us succeed.
When I was a kid, my summer sport of choice was baseball. Every day I played in marathon neighborhood games until it was too dark to see the ball. It was about fun and not fitness. But now that I’m older, and my Louisville Slugger has been officially retired, I need a summertime sport that recaptures the playfulness of my youth, but also works to keep my physical and mental skills sharp.

So, I picked up a racket.

It turns out that racket sports are not only fun, but they may help me live longer. A study published online by the British Journal of Sports Medicine examined the link between six different types of exercise and the risk of early death. Researched looked at racket sports, swimming, aerobics, cycling, running, and soccer. Study volunteers included 80,306 people, who ranged in age from 30 to 98. Over the course of the study’s nine years, those who regularly played racket sports were 47% less likely to die of any cause and 56% less likely to die of cardiovascular disease.

“In many ways, racket sports like tennis, squash, badminton, racquetball, Ping-Pong, and other variations are the ideal exercise for many older adults,” says Vijay A. Daryanani, a physical therapist and personal trainer with Harvard-affiliated Spaulding Outpatient Center. “Besides offering a good cardiovascular workout, they can help with both upper- and lower-body strength at one time. They can be played at any age, can be modified to fit most fitness levels, and do not involve a lot of equipment.”
Body and mind games

Racket sports offer something other fitness sports do not — lateral movement. “Most of our lives are spent moving forward, and that includes our exercise,” says Daryanani. “Racket sports force you to move both back and forth and side to side. This helps improve balance and weight shifting, which can lower your risk of falls.”

This kind of activity also exercises your mind. From a cognitive standpoint, it sharpens your planning and decision-making skills, as you must constantly anticipate and execute your next shot.

Racket sports also serve up a strong social component. You play against other people — either as a single or part of a doubles team — while other exercises like running, swimming, and cycling are more isolated activities. Frequent social contact is essential for a long and healthy life. In fact, a 2012 study in the Archives of Internal Medicine found that loneliness was associated with functional decline and an increased risk of death among adults older than age 60.
Pick up pickleball

While there are many types of racket sports to try, one of the fastest-growing among older adults is “pickleball.” It’s a hybrid sport that blends tennis, table tennis, and the backyard childhood game of Wiffle ball.

The paddle is between a table tennis paddle and a tennis racket in size and made of lightweight composite material, such as aluminum or graphite, which cuts down on fatigue. The plastic pickleball resembles a larger Wiffle ball and travels about one-third the speed of a tennis ball, so it is easier to see and hit.

Pickleball is played both indoors and outdoors. The court is 20 by 44 feet, or about the size of a double badminton court. The net is shorter than a tennis net, which makes it easier to hit over. Here are the basic rules:

    The ball is served underhanded and must land in the opposite diagonal court just beyond a 10-foot area by the net called the “kitchen.”
    The ball must bounce once before being returned, and again before being returned by the serving team.
    Once the ball has bounced and been returned by each team, volleying may continue with or without bounces, only if participants are outside of the kitchen.
    Games are played to 11 points, with points scored only by the serving team.
    A two-point spread wins the game.
The United States was declared free from ongoing measles transmission in 2000. So why are we still having measles attacks? An outbreak of measles is currently raging in Minnesota. In 2015, 125 cases of measles occurred in California, and in 2014, 383 people were infected with measles in an Amish community in Ohio.
How measles outbreaks happen

There are several reasons why we are still at risk for measles outbreaks. Travelers may get infected overseas, and bring the measles virus back into the country with them unawares. The 2015 measles outbreak in Ohio began when two infected members of the Amish community returned home from typhoon relief work on the Philippines. The California measles outbreak in 2014 started at two Disney theme parks, perhaps after the virus was brought there by a foreign tourist.

In measles, there is an unusually long delay between infection and the development of the rash and other symptoms, typically about two weeks. Measles virus is also highly contagious; patients start to spread the virus to other people about four days before the rash develops. These features make it possible for measles to spread quickly through an unsuspecting population.

The final component to measles outbreaks is inadequate immunity. Many American adults have only received a single dose of the measles, mumps, and rubella (MMR) vaccine, which is only 93% effective at preventing measles. Since 1989, the recommendation has been to give two doses of MMR, which is 97% protective against measles. Vaccination rates have been low among patients in recent US outbreaks. In the current outbreak in Minnesota, most measles cases have occurred in unvaccinated Somali-American children, probably due to the success of anti-vaccine activists in pushing a debunked connection between autism and the MMR vaccine.
Measles infection can still be lethal

So, what’s the big deal about measles? For most people, measles makes for a miserable week of high fever, cough, runny nose, watery eyes, and an impressive total body rash. But for others, it can be a life-threatening, even fatal, condition. One out of every 20 measles patients develops pneumonia, which may be severe. Infection of the brain, or encephalitis, occurs in one out of 1,000 cases. Brain damage, deafness, intellectual disability, or death may result. Before the measles vaccine was available, measles killed 500 people in the US every year, most of them children, and led to 1,000 cases of brain damage per year.

Measles has an especially horrifying late complication known as subacute sclerosing panencephalitis (SSPE). In SSPE, children recover from their initial measles infection, only to develop progressive brain infection with a mutated form of measles virus in their teenage years, leading to a persistent vegetative state.

Many outbreaks of measles could probably be prevented if more travelers received MMR prior to foreign travel. According to a study done in US travel clinics, 16% of pre-travel patients were eligible for measles vaccine, but only a minority of patients received it. The authors of the study cited many reasons that patients didn’t receive the vaccine, with patient refusal being the most common. Next time you plan to travel overseas, think about protecting your community by asking your doctor if you are a candidate for the MMR vaccine before you leave. Imagine a chronic medical condition in which the treatment itself has serious side effects. Examples of this are plentiful in medicine. For example, in diabetes, giving too much insulin can cause hypoglycemia (low blood sugar), a dangerous and potentially life-threatening condition. That doesn’t happen very often, but imagine that it was a common complication of treating diabetes because doctors couldn’t really tell how powerful a given dose of insulin actually was. And suppose that doctors and patient safety experts advocated for places where patients with diabetes could be carefully monitored when taking their insulin. Would you be opposed to this idea? Would you blame the patient for developing diabetes, or for needing this carefully supervised medical treatment in order to live? I suspect that the answer is “of course not!”

Now, let’s shift gears and discuss opioid addiction, specifically people who use illicit drugs like heroin and black-market fentanyl. Heroin is the strong opioid substance derived from the poppy seed that has been used for thousands of years. Fentanyl is a synthetic opioid that can be hundreds of times more powerful than morphine or heroin. Increasingly, illicit heroin is adulterated with fentanyl and similar chemicals, which public health experts believe is the reason for the continued rise in opioid-related deaths despite aggressive measures to decrease opioid prescriptions, increase substance use disorder treatment facilities, and widely distribute naloxone, the antidote to opioid overdose.
Saving lives in the face of increased risk for dying of a heroin overdose

People who use heroin are now at significant risk for overdose death, mainly because the opioid content can vary considerably from dose to dose. Previously, a little too much could have caused a decrease in respiratory rate and a high dose could lead to overdose. Now, with the variability of potency from the synthetic opioids, the strength of each dose can be markedly different. Furthermore, the uptake of fentanyl in the brain is so rapid that a fatal overdose can occur much more quickly than with heroin alone.

If we, as a society, are truly serious about saving lives, we have no choice but to allow people who use injectable opioids to do so in safe, monitored locations without fear of negative repercussions (e.g., being arrested). If you had asked me about this several years ago, I never would have believed that I could write the preceding sentence. I would have said, “Why empower junkies to abuse illegal drugs? Why make it easier on them instead of harder? Why should society condone this activity?”

However, I was wrong — dead wrong.
Good reasons for a change of heart

It turns out that addiction (called substance use disorder or, more specifically here, opioid use disorder in medical jargon) is a disease that can affect any one of us, just like diabetes or high blood pressure. It does not discriminate and does not represent a moral failure on the part of the individual who develops it. It is a condition that no one chooses, but when it attacks, it changes the brain of those with the disease. We can actually visualize those changes with tests like functional MRIs. It leads people to make choices that destroy their lives and the lives of others, such as loss of job, isolation and loss of relationships, incarceration, and even death. We also now know that this is a treatable disease, but the window for successful treatment depends on the psychological state of the person. We must be ready to engage them in treatment at that moment when they are ready.

My opinions changed drastically after a visit to a local needle exchange facility. By current law, individuals can’t inject inside the building. They have to take their chances outside and then they can come inside to be monitored after injecting. I initially envisioned the facility to be sterile, dirty, and depressing. Instead, I was surprised to see that it looked like a living room. There were sofas and a television. There was a warm light, and it appeared to be a welcoming place. Across from the sofas were two desks where staff members sat. Their job is to watch for any signs of overdose (a person who is too sleepy or who is breathing too slowly) and then rapidly respond by providing a nasal dose of naloxone to reverse the overdose. More importantly, they are there to help people right when they are open to treatment for substance use disorder. The staff will help connect them to treatment resources, whether it is group therapy or medical treatment like buprenorphine (Suboxone) or methadone.

If that moment of opportunity in which the individual is receptive to treatment passes, the consequences can be deadly.

Furthermore, the facility is all about harm reduction. There are boxes of free supplies: needle kits so that people do not share needles, condoms for safe sex, kits to help treat small skin infections, even little clean cups to freebase injectable drugs. Naloxone kits are also provided free of charge. There is no judgment there. It is only about reducing a person’s risk of serious, life-threatening infections like HIV and hepatitis C, or the risk of death. And it makes sense. If we are going to agree that opioid use disorder is just another medical condition that needs to be treated, then the compassionate thing to do is to remove the stigma associated with it and reduce associated harms while a person is suffering with substance use disorder. Plain and simple: people with this disease are going to use drugs. Is it better for them to use in the shadows, risking transmission of serious infectious diseases, or monitor them when they are using and be there for them to get them treatment at the moment they are ready?

Currently it’s still illegal in the US to allow people to inject in these supervised environments, but the tide is turning. The city of Ithaca, NY is contemplating a safe injection space, as is Seattle. Multiple studies have confirmed that they work. In Vancouver, Canada, where such facilities were implemented in 2003, they concluded: “Vancouver’s safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts.” Massachusetts is also contemplating a similar pilot supervised injection facility program. With the crises of the opioid epidemic now claiming more than 30,000 lives every year in the US, it’s time to change our biases and old ways of thinking — people’s lives depend on it.

Read More »