My Health - A mix of treatments may extend life for men with aggressive prostate cancer

For men diagnosed with aggressive cancer that’s confined to the prostate and nearby tissues, the overarching goal of treatment is to keep the disease from spreading (or metastasizing) in the body. Doctors can treat these men with localized therapies, such as surgery and different types of radiation that target the prostate directly. And they can also give systemic treatments that kill off rogue cancer cells in the bloodstream. Hormonal therapy, for instance, is a systemic treatment that kills prostate cancer cells by depriving them of testosterone, which fuels their growth.

Now a new study shows that a mix of different treatments, or a “multimodal” approach to prostate cancer therapy, lengthens survival in men who have this diagnosis. The study was limited to men with Gleason 9 and 10 cancers. The Gleason grading system ranks tumors by how likely they are to spread, and 10 is the highest rank on the scale.

“The takeaway finding is that men with high-grade, localized prostate cancer do better when they get multimodal care,” said Dr. Amar Kishan, an assistant professor of radiation oncology at the University of California, Los Angeles David Geffen School of Medicine, who led the study. “If they can tolerate it, then that’s what should be offered.”

Kishan and collaborators from 12 large hospitals in the United States and Norway pooled nearly 20 years of patient data from their respective institutions. The 1,809 men included in the study had each been treated in one of three different ways:

• with surgery to remove the prostate
• with a combination of external beam radiation (which directs high-energy rays at the tumor from sources outside the body) directed at the prostate, along with anti-testosterone hormonal therapy
• with hormonal therapy given together with external beam radiation and brachytherapy (which involves placing radioactive beads directly into the prostate gland).

After an average of five years of follow-up, 3% of the men given all three treatments (external beam radiation, brachytherapy, and hormone therapy) had died from prostate cancer. By contrast, 12% of the men treated with a combination of hormonal therapy and external beam radiation, and 13% of the men treated with surgery only, had died of their illness. Findings of metastatic cancer were similar, averaging 8% in the group given all three treatments, and 24% in the two other groups.

Side effects data from each group were not available.

This is the largest study yet to compare the three approaches, and importantly, it was restricted to men who began treatment no earlier than 2000. Radiation therapy has improved over time: the doses are higher and the treated areas are more precisely defined. Therefore, the evaluated approaches are consistent with the kind of treatments men would still get today.

Kishan said it’s possible that combining hormonal therapy with high-dose radiation and brachytherapy eliminates cancer in the prostate completely, so that metastases are held in check. Or, he says, radiation might stimulate the immune system to attack cancer. These hypotheses are now under investigation by researchers around the world.

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, said the study adds to growing evidence that therapies directed solely to the prostate gland, namely radiation or surgery by itself, may be improved by adding other treatments; in this case, hormonal therapy and a second form of radiation. “The study didn’t evaluate the addition of hormonal therapy to surgery, which would have been of interest,” he added. “However, the findings support multimodal therapy, though many unknowns, such as the potential for greater long-term side effects, still need to be addressed.”

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My Health - Natural Tips To Reduce Urinary Tract Infection (UTI) Which Actually Work!

Natural Tips To Reduce Urinary Tract Infection (UTI) Which Actually Work!

Health and Fitness Tips
Health is the level of functional and metabolic efficiency of a living organism. In humans it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological and social changes with environment.

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My Health - Chronic pain and childhood trauma

Recently a journalist colleague of mine put out a call for quotes from those who suffer from severe premenstrual syndrome and premenstrual dysmorphic disorder (more commonly known as PMS and PMDD, respectively) who also suffered a history of childhood abuse. Her interest was piqued by a 2014 peer reviewed article that appeared in the Journal of Women’s Health linking the disorders with early onset abuse. I answered the call, having both PMS and PMDD, as well as a history of child abuse by both my stepfather and my mother.

Yet despite having both a history of abuse and several diagnoses that contribute to chronic pain, it’s only been in the past few years that I’ve become aware of the connection between the two. It wasn’t until I started writing a collection of personal essays about my youth, and researching scientific literature about childhoods like mine, that I stumbled upon the now-famous 1998 ACE study, which explored “adverse childhood experiences.” Specifically, the study surveyed 17,000 middle-income adults who had health data stretching back to their early childhoods. The ACE research indicated that the more adversities an individual experienced as a child — whether poverty, parental death or incarceration, neighborhood violence, or abuse — the more likely that person would suffer from serious physiological disorders as an adult.

Understanding the connection

While the causality between childhood adversity and adult chronic illness has yet to be fully determined, researchers now have enough knowledge about the way chronic stress impacts physiological health to make some educated guesses about their potential link. When we are threatened, our bodies have what is called a stress response, which prepares our bodies to fight or flee. However, when this response remains highly activated in a child for an extended period of time without the calming influence of a supportive parent or adult figure, toxic stress occurs and can damage crucial neural connections in the developing brain. According to Harvard’s Center on the Developing Child, the impacts of experiencing repeated incidents of toxic stress as a child “…persist far into adulthood, and lead to lifelong impairments in both physical and mental health.”

Why addressing pain and trauma should go hand in hand

The fact that childhood adversity is so intimately intertwined with adult illness does not mean that those physiological diseases experienced by adults who had traumatic childhoods are not real or valid, or that their causes are “psychosomatic.” The biological impacts of childhood adversity are not only genuine, but can be very difficult (and sometimes impossible) to completely undo.

However, it does offer hope that psychological care for those with a history of childhood trauma may help tame their overactive stress response in the present day, and in turn provide some complementary health benefits for those also dealing with physiological diseases. In my case, while processing my traumatic childhood history in psychotherapy has not automatically cured my physical ailments (and will not), it does help me relearn how to react to stress.

Pediatric health care providers and educators should understand how far into the future the effects of childhood abuse and adversity may extend. This knowledge should serve as further motivation to help children in these situations access necessary supports as quickly as possible, to guard against some of the biological changes that could make them suffer later on in life. Likewise, those who work in the mental health field with adults who suffered childhood trauma would well do to study the link between that and chronic pain and illness, so that they can better support their patients.

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My Health - Where do you stand on bystander CPR?

Follow me on Twitter @RobShmerling

A recent survey confirmed what many have suspected: if you collapsed, there’s a good chance that the average bystander would not be prepared to perform cardiopulmonary resuscitation (CPR). And if they tried to revive you, there’s an even better chance they wouldn’t do it correctly.

Of course, there is a certain circularity to this — if you don’t know how to perform CPR, or if you know how but aren’t sure you’ll perform it correctly, you’ll be less likely to try.

So why are so few prepared?

The list of reasons is long, including:

• no prior instruction or certification
• fear of doing it wrong or being blamed for causing more harm than good
• waiting for someone else (who “knows what they’re doing”) to do it
• little faith in the effectiveness of CPR
• the victim might be sick with something the rescuer could catch
• the “ick factor,” that is, a potential rescuer is put off by the thought of having mouth-to-mouth contact with a stranger (even though current guidelines do not recommend mouth-to-mouth resuscitation).

A new study suggests there’s room for improvement

A new survey performed by the Cleveland Clinic asked 1,000 people about CPR. It also asked about symptoms of stroke and heart attack, since these are conditions for which bystander help can make a big difference.

The results were disappointing:

• Only 54% reported knowing how to perform CPR. While this is actually more than I would have predicted, it likely represents an overestimation, since many did not know some of the key details about it (as noted below).
• Only 17% knew that current recommendations for bystander CPR have eliminated the mouth-to-mouth part; bystander CPR now involves only chest compressions.
• Only 11% knew the proper rate of chest compressions (100 to 120 per minute). Certain songs can help you pace compressions without counting.
• Only about a quarter reported having an automated external defibrillator at work.
• About six in 10 people believed sudden numbness or weakness of the face, arm, or leg were symptoms of heart attack (when, in fact, those are more commonly symptoms of stroke).
• Thirty-nine percent thought slurred speech (a symptom of stroke) was a symptom of a heart attack.
• Less than half knew that back or jaw pain, nausea, and vomiting could represent symptoms of a heart attack.
• Only about a third of respondents knew that victims of heart attack should chew an aspirin right away (more on that in a moment).

There’s much you can do — and it’s not difficult

Whatever the reasons for these findings, there seems little justification for it. After all, CPR is much easier now that mouth-to-mouth resuscitation is no longer recommended. And while it’s true that many people don’t survive cardiac arrest — the numbers vary by study, but some studies find rates of survival for out-of-hospital cardiac arrest at less than 5% — chances for survival are higher with bystander help. Instructions regarding the appropriate use of CPR and automated external defibrillators (AEDs) are not complicated and are widely available.

But wait, there’s more!

CPR is only one way to help someone with a medical emergency. Some other things you can do to help include:

• Try to rouse the person.
• Check for a pulse and whether the person is breathing.
• Call 911 — in most cases, this is the very first thing you should do.
• If heart attack is suspected, instruct the person to chew one full strength or three baby aspirin (total of about 325 mg) over 30 seconds; people with heart disease should be carrying aspirin with them.
• Instruct others to find the nearest AED. Don’t be afraid to use it — they are designed to be used by anyone.
• Calling for help, providing reassurance, and staying with a person in need can make a big difference to someone who is critically ill and frightened.

What now?

If you never learned to perform CPR, maybe now is the time. Some of the biggest obstacles (such as having to perform mouth-to-mouth resuscitation) have been removed. So, admit it — you’re running out of excuses! Learn CPR. You could save a life. And even if you never have the opportunity to perform CPR, at least you’ll be ready to try.

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My Health - Apple cider vinegar… for heartburn?

I’ve always thought it sounded counterintuitive to use an acid to alleviate indigestion, but the number of times I’ve heard people treat their symptoms of heartburn with apple cider vinegar is too large to count. So, I decided to look into whether this strategy works, and to do some investigation about the idea behind its use. To my surprise, there is no research published in medical journals that addresses using raw apple cider vinegar to treat heartburn, despite widespread use and recommendations from blogs and websites.

What is heartburn?

Heartburn is most commonly caused by stomach acid contents traveling up into the esophagus, the pipe that connects the mouth to the stomach. Unlike the stomach, the esophagus is not used to the presence of acid. The stomach acid irritates the esophagus, leading to several symptoms including throat clearing, burning sensation in the chest and neck, sour sensation in the mouth, cough, and bloating. It is not a pleasant feeling. It’s what we call GERD, or gastroesophageal reflux disease.

There are several reasons why gastric contents move up into the esophagus instead of going down to the bowel. The relaxation of the lower esophageal sphincter (LES), a valve that sits between the esophagus and the stomach, is the most common culprit. The LES is usually closed, creating a contained system to digest food. But it opens from time to time, to let air out in the form of belching. Reflux mostly happens when the valve relaxes too much, or too often. It allows not only gas but also gastric acid to move up, causing the discomfort.

There is a theory stating that what controls the LES is the stomach’s acidity. If for some reason the stomach is not producing enough acid, the muscles around the LES would relax, resulting in more reflux. However, the mechanism that controls this valve is much more complex than the level of gastric acidity. It involves a complex network of involuntary muscles and several different hormones and neurotransmitters.

Medications for heartburn

The gold standard to treat heartburn is to take an over-the-counter class of medications called proton pump inhibitors (PPIs) that reduce stomach acidity. Using these drugs will not prevent reflux, but can reduce inflammation in the esophagus, allowing it to heal. Avoid taking these medications for more than a month, unless recommended by your doctor. It is not unusual to become used to PPIs. After taking them for a few weeks it may be hard to wean off of them, because stopping can cause rebound symptoms. PPI side effects are minimal, but long-term use can cause osteoporosis, infections, and a decrease in the absorption of nutrients.

Antacids and medications such as ranitidine and famotidine (H2 blockers) may work well and have fewer side effects, but if these strategies do not make you feel better within a few weeks, it is a good idea to consult with your doctor. Although rare, heartburn could be a sign of other serious illnesses.

Self-help measures for heartburn

Another approach that may be quite effective and free of side effects is to change specific behaviors:

• Avoid foods known to cause heartburn: coffee, chocolate, alcohol, fatty foods, tomato, spicy foods, and acidic foods.
• Avoid lying down for at least two to three hours after a meal.
• Eat small meals.
• Lose weight if you need to.
• Don’t smoke, and if you already do, try to quit.

But what about taking apple cider vinegar for heartburn? Since we have no data to support the effectiveness or safety of its use for heartburn, it’s probably a good idea to stick to drizzling this deliciousness on colorful salads for now.

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My Health - Good news: fewer teens are being bullied

Follow me on Twitter @drClaire

New data from the US Department of Education brings some really good news: fewer teens are being bullied. In 2007, 31.7% of students ages 12 to 18 reported being bullied. In 2015, that number was down to 20.8%, a drop of a third.

Other stats were also encouraging:

• In 2007, 9.7% reported being called a hate-related word, compared with 7.2% in 2015
• The percentage of teens reporting being bullied at school dropped from 6.6% in 2007 to 4.2% in 2015
• More teens are telling an adult about bullying: those numbers went from 36.1% in 2007 to 43.1% in 2015.

There are still too many kids getting bullied, so we still have more work to do, but this is a sign that the work we’ve done so far is making a difference. And we have done a lot of work, through educational campaigns, media and social media, as well as tremendous work within schools:

• Bullying has been clearly described and identified. This makes it easier for everyone to recognize bullying when they see it — and do something. There will always be some gray area, but we have much more clarity than before.
• There is a clear consensus that bullying is a bad behavior that should be stopped. This has not always been the case. In many situations, bullying behavior was normalized, thought to be part of school and life in general. Now we understand better how harmful it can be. Because of this…
• Bullying is not tolerated, or at least it is much less tolerated. Youth have learned to call it out — and many schools have strict anti-bullying policies.
• Educational efforts have given youth and adults strategies to identify and deal with bullying.

Ultimately, what all of this adds up to is a culture shift. Bullying is far from gone, and we need to keep up our efforts, especially in our current political climate, with people taking sides and some hate-related behaviors on the rise. But we think about bullying differently now than we did 10 years ago, and that’s a good thing.

Even more, the efforts against bullying have given us a blueprint for cultural change: bring the behavior out of the shadows, talk about it, educate — and give people tools and resources. Hopefully we can use this blueprint more — we are seeing it now with the #metoo movement — and help make our society a healthier, more welcoming place for all.

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My Health - Top 10 Foods How To Prevent Urinary Tract Infection (UTI)

Top 10 Foods How To Prevent Urinary Tract Infection (UTI)

Health and Fitness Tips
Health is the level of functional and metabolic efficiency of a living organism. In humans it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological and social changes with environment.

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My Health - Rethinking A1C goals for type 2 diabetes

“Treat the patient, not the number.” This is a very old and sound medical school teaching. However, when it comes to blood sugar control in diabetes, we have tended to treat the number, thinking that a lower number would equal better health.

Uncontrolled type 2 diabetes (also known as adult-onset diabetes) is associated with all sorts of very bad things: infections, angry nerve endings causing chronic pain, damaged kidneys, vision loss and blindness, blocked arteries causing heart attacks, strokes, and amputations… So of course, it made good sense that the lower the blood sugar, the lower the chances of bad things happening to our patients.

Tracking blood sugar control over time

One easy, accurate way for us to measure a person’s blood sugar over time is the hemoglobin A1c (HbA1c) level, which is basically the amount of sugar stuck to the hemoglobin molecules inside of our blood cells. These cells last for about three months, so, the A1c is thought of as a measure of blood sugars over the prior three months.

Generally, clinical guidelines have recommended an A1c goal of less than 7% for most people (not necessarily including the elderly or very ill), with a lower goal — closer to normal, or under 6.5% — for younger people.

We as doctors were supposed to first encourage diet and exercise, all that good lifestyle change stuff, which is very well studied and shown to decrease blood sugars significantly. But if patients didn’t meet those target A1c levels with diet and exercise alone, then per standard guidelines, the next step was to add medications, starting with pills. If the levels still weren’t at goal, then it was time to start insulin injections.

While all this sounds very orderly and clinically rational, in practice it hasn’t worked very well. I have seen firsthand how enthusiastic attention to the A1c can be helpful as well as harmful for patients.

And so have experts from the Clinical Guidelines Committee of the American College of Physicians, a well-established academic medical organization. They examined findings from four large diabetes studies that included almost 30,000 people, and made four very important (and welcome!) new guidelines around blood sugar control. Here’s the big picture.

Doctors and patients should discuss goals of treatment together and come up with an individual plan

Blood sugar goals should take into account a patient’s life expectancy and general health, as well as personal preferences, and include a frank discussion of the risks, benefits, and costs of medications. This is a big deal because it reflects a change in how we think about blood sugar control. It’s not a simply number to aim for; it’s a discussion. Diabetes medications have many potential side effects, including dangerously low blood sugar (hypoglycemia) and weight gain (insulin can cause substantial weight gain). Yes, uncontrolled blood sugars can lead to very bad things, but patients should get all the information they need to balance the risks and benefits of any blood sugar control plan.

An A1c goal of between 7% and 8% is reasonable and beneficial for most patients with type 2 diabetes…

…though if lifestyle changes can get that number lower, then go for it. For patients who want to live a long and healthy life and try to avoid the complications of diabetes, they will need to keep their blood sugars as normal as possible — that means an A1c under 6.5%. However, studies show that using medications to achieve that goal significantly increases the risk of harmful side effects like hypoglycemia and weight gain. To live longer and healthier and avoid both the complications of diabetes as well as the risks of medications, there’s this amazing thing called lifestyle change. This involves exercise, healthy diet, weight loss, and not smoking. It is very effective. Lifestyle change also can help achieve healthy blood pressure and cholesterol levels, which in turn reduce the risk for heart disease. And heart disease is a serious and common complication of diabetes.

Lifestyle change should be the cornerstone of treatment for type 2 diabetes. The recommendations go on to say that for patients who achieve an A1c below 6.5% with medications, we should decrease or even discontinue those drugs. Doing so requires careful monitoring to ensure that the person stays at the goal set with his or her doctor, which should be no lower than 7%, for the reasons stated above.

We don’t even need to follow the A1c for some patients

Elderly patients, and those with serious medical conditions, will benefit from simply controlling the symptoms they have from high blood sugars, like frequent urination and incontinence, rather than aiming for any particular A1c level. Who would be included in this group? People with a life expectancy of less than 10 years, or those who have advanced forms of dementia, emphysema, or cancer; or end-stage kidney, liver, or heart failure. There is little to no evidence for any meaningful benefit of intervening to achieve a target A1c in these populations; there is plenty of evidence for harm. In particular, diabetes medications can cause low blood sugars, leading to weakness, dizziness, and falls. There is the added consideration that elderly and sick patients often end up on a long list of medications that can (and do) interact, causing even more side effects.

The bottom line

There is no question that type 2 diabetes needs to be taken seriously and treated. But common sense should rule the day. Lifestyle changes are very effective, and the side effects of eating more healthfully and staying more active are positive ones. Every person with type 2 diabetes is an individual. No single goal is right for everyone, and each patient should have a say in how to manage their blood sugars and manage risk. That means an informed discussion, and thoughtful consideration to the number.

Sources

Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: A guidance statement update from the American College of Physicians. Annals of Internal Medicine, March 2018.

An overview of the management of diabetes in non-pregnant adults. MGH Primary Care Office Insite, updated June 2016.

Management of persistent hyperglycemia in type 2 diabetes mellitus. UpToDate, updated April 2017.

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My Health - What happened when I stopped saying “Be careful”

December vacation was over. The weather had finally calmed down, and kindergarten was back on, so Milo and I were walking. He was ahead of me, as usual. His eyes were on a snow mountain that would soon be climbed, and not on a patch of ice. I decided to help out, and I did. I told him, “Be careful.”

One more time.

“Be careful” is what I said.

I’m gonna brag: it’s Belichick-level genius.

And it wasn’t my first time. I’ve broken out those three syllables with digging holes, riding a bike, sitting at the table, getting out of the tub, and probably eating a bagel, and I’m gonna brag again: I don’t think it’s ever led to any carefulness.

Helping your child negotiate risk

It shouldn’t be a surprise. Dr. Joshua Sparrow, child psychiatrist and director of the Brazelton Touchpoints Center based at Harvard-affiliated Boston Children’s Hospital, says kids learn words through context. If they’re used in too many contexts, there’s no meaning. It doesn’t help that “Be careful” offers nothing to actually do.

So, I decided that for one week, I wouldn’t say those two words to my kids, Milo, 6, and Levi, 3. Instead, I’d strive for specific, possibly even helpful advice. Sparrow offered a couple of other helpful thoughts to consider before I opened my mouth.

• Assess situations and ask, What’s the worst that could happen? A skinned knee doesn’t merit much warning.
• There’s nothing wrong with eliminating unnecessary risks. e.g., standing on top of the coffee table.
• Pay attention to what kids are capable of — their skills can expand in a matter of hours.

I needed that last one. During the summer, Milo was at the beach near our house and climbing along a stretch of rocks for the first time. I was simultaneously holding my breath and firing off “Be careful”s, and what I saw (but didn’t fully accept) was that he was keeping a low center of gravity and scanning where he was going to jump before he did.

So how did I do?

The simple answer is that my experiment was a success. By being conscious of wanting to do this, I chose my words. I slowed down; I shut up more. I was calmer, and I gave Milo some room. We went out on our bikes on Saturday morning of Day Two. Milo’s a good rider and the street was quiet, so I kept quiet. He fell, but he got back up and the ride continued.

When he was standing too close to the street waiting to cross, I leaned in and said, “Take a step back toward me.” I only had to say it once. When we were walking home from school — no sidewalks — and a car was coming from behind, I asked, “What do you hear?” He turned around and stepped up onto the grass.

I don’t know if I was building his situational awareness. Dr. Sparrow doesn’t know either, but because I was talking a lot less, it’s possible that Milo had less reason to tune me out. As Sparrow says, being heard is as much about delivery, tone, curiosity, and positive intent as any words.

On the other hand…

So overall, I’d love to say that the week was Father of the Year highlight reel stuff. But it wasn’t all that straightforward. On the afternoon of Day Two, Milo, Levi and I were exploring an old cemetery in town, walking up rocks in a gentle hill. It was nothing extreme. I wasn’t saying anything and everyone was being, yes, careful. I was holding Levi’s hand and then my outside foot slipped. I came down onto Levi, forcing him onto a rock.

He got a gash on his forehead, an emergency room visit, and four stitches. I know that it was an accident, which barely kept me from feeling completely awful. But after the cookies, popsicles, a few trucks, and a respite from hair washing, I saw that Levi was all right.

And I realized that it was an accident. It was an awful one. I’m thankful it was only four stitches, and I wish that it had never happened. But it did, as will others, and my kids can’t be kept inside until graduation.

That week, we were back to school. On Monday, Milo and I walked home, which turned into running. The other days, he biked both there and back. He knows the way and he knows that he has to look around before he crosses an intersection. I was behind him, and I shut up. He didn’t need the reminder.

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My Health - Choosing the right mental health provider

When faced with mental health conditions such as depression, anxiety, or other symptoms of the mind and brain, it can be difficult to know where to find the best care. In part, the challenge of finding the right professional for you stems from the highly variable manner in which mental health concerns can emerge. One person’s depression, for example, may be very different than someone else’s, and the same can be said for anxiety, post-traumatic stress, obsessionality, attentional issues, substance use disorders, and even psychosis.

There are also lots of different kinds of mental health providers out there doing all kinds of distinct clinical work. It can be intimidating to even know where to start searching for help, but often telling your primary care doctor about your symptoms, and if necessary asking for a referral to a specialist, is a good place to begin.

If your doctor determines that specialized care is needed, you may be referred to a psychiatrist who can do a global assessment of your clinical needs. It may be the case that you will benefit most from an integrated treatment approach that features both psychotherapy and medications, or you may be referred primarily to one treatment or another. Here’s some additional information about the different kinds of mental health providers and the treatments they offer to help diagnose and treat psychiatric issues.

Psychiatrists

Psychiatrists are medical doctors who have graduated from medical school and completed at least four years of additional specialized training, through residency and often fellowship, in the medical treatment of mental disorders. Because of their advanced medical training, psychiatrists are able to prescribe medicine and also have at least basic training in most evidence-based psychotherapeutic approaches. Some choose to see patients for medication management only, while others focus on therapy and still others integrate both approaches into the same clinical sessions. Also, psychiatrists are generally the only mental health providers who can perform electroconvulsive therapy, transcranial magnetic stimulation, or other neuromodulatory treatments that use devices to noninvasively stimulate the brain in severe or medication-resistant cases.

Though some psychiatrists still practice traditional psychoanalysis involving multiple sessions “on the couch” each week, this kind of approach has become less available and less common in recent years, in part because insurances generally do not cover it, and in order to practice it providers must complete additional psychoanalytic training for several years after residency. Often, psychiatric nurse practitioners or other appropriately trained “physician extenders” can take on the traditional role of a psychiatrist, though it is important that they have access to adequate supervision, particularly for complex cases.

Therapists and counselors

Many types of professionals can provide the variety of psychotherapeutic approaches used in the treatment of mental health disorders. Therapists who have obtained PhD or PsyD degrees with a focus in clinical psychology, for example, have perhaps the most extensive training in providing talk therapy, including psychodynamic or “insight-oriented” therapy, cognitive behavioral therapy, interpersonal therapy, and others. Clinical social workers and mental health counselors may also have excellent training in particular therapeutic areas that can be very helpful to patients. Therapists and counselors may even offer some therapies, such as eye movement desensitization and reprocessing (EMDR), that psychiatrists generally have less experience with.

In each of these areas, it is important to remember that there is a spectrum of quality, and so it is essential for people with mental health concerns to find well-trained and credentialed providers that seem to be a good fit with them individually.

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My Health - Opioids in the household: “Sharing” pain pills is too common

A few years ago, I saw a patient with shoulder pain.* She’d been walking her dog; the dog had lunged at a squirrel and yanked her arm. Being a busy person, she had delayed coming in to be seen. In the course of the interview, she described how sleeping was awful, because if she rolled over onto that side, the pain was so severe it woke her up. So at the suggestion of a family member, she had sampled the pain pills prescribed to her grandfather, who was in home hospice for advanced cancer. “But don’t worry,” she assured me. “He has plenty of pain pills, and he’s very comfortable. I only used a few.”

*I’ve changed the mechanism and details of the injury to protect patient privacy.

Many people “borrow” a family member’s pain medicine; they shouldn’t

Almost every primary care physician has seen some version of this scenario. Pill sharing among friends and family is a widespread practice. Pain-pill sharing, however, can lead to misuse, abuse, and addiction. According to the Centers for Disease Control and Prevention (CDC), the number one source of abused prescription opioids is free pills from friends and family.

To study this, researchers at Johns Hopkins looked at insurance claims data from almost six million people who had received an opioid prescription, and their household members. As a comparison, they also looked at over three million people who had received an NSAID prescription (such as ibuprofen, naproxen, or celecoxib), and their household members. Over the course of a year, the household members of people who had received an opioid prescription were slightly more likely to then receive an opioid prescription themselves, 11.8%, as opposed to 11.1% in the NSAID group.

That 0.7% seems like a small difference until you consider how many people receive an opioid prescription here in the United States. Per the CDC, there were 70 opioid prescriptions written for every 100 people in the country in 2015. This means that when we include everyone who has received an opioid prescription, we’re talking about millions of people, and all of their household members. That 0.7% risk then potentially translates to tens of thousands of people.

This study alone identified almost six million people, and even this underestimates the problems because the study excluded patients with a cancer diagnosis or who were in hospice. Off the top of my head, I can think of multiple cases where I suspected or was told outright that others were using a hospice patient’s pain pills. I asked the study author, Marissa J. Seamans, PhD, about why they excluded these patients. “Because opioids are indicated for patients diagnosed with malignancy or in hospice care, we excluded them to more easily identify comparable NSAID patients,” she explained. While this made the comparison more reliable, it also left out a large source of “borrowed” pain medication.

Maureen Dryja, RN, is one of the nurses in my practice. She has had extensive experience in home hospice agencies. “Yes, diversion of pain medication is a significant issue in home hospice care. On admission to hospice it is very openly stated that having narcotics in the house is a really big deal.” The home hospice community has developed and implemented strategies around storage, monitoring, and disposal of opioid prescriptions. Despite this, Dryja described several situations where supplies of unused opioids disappeared.

Dr. Seamans points out that regardless of why a person is prescribed opioids, “patients need to be counseled on safe storage of opioids and how unused opioids should be disposed.” She outlines some possible methods: “Safe storage suggestions include locking or latching medications, but these suggestions have not been tested.” In addition, it’s not easy to find an appropriate place to dispose of unused pain medications. “Some pharmacies have provided kiosks for safe disposal; however, safe disposal sites may be lacking in some communities.” Many communities have “drug take back” days, but only a few times a year. The Drug Enforcement Agency has a helpful website for drug disposal.

Minor surgery and dental work: Common opportunities for opioid misuse

Patients who just had dental work or surgery may also come home with large numbers of pain pills, which should also be monitored, but there are few guidelines for this situation. Physicians are generally advised to “counsel patients regarding safe storage and disposal of medications,” which can mean many different things to different people. In my primary care practice, I do sometimes prescribe opioid medications, though usually only a small amount and for a short duration. Regardless, I will counsel patients not to tell anyone, anyone, that they have the prescription, and not to store it in an obvious place where it may be seen and stolen. Most patients take this advice to heart.

Opioids have specific and limited uses for pain control, but these are often outside of the hospital or doctor’s office. And for some people, it’s tempting to “borrow” one (or more) to treat pain. As Dr. Seamans concludes, we have a long way to go, not only in developing guidelines, but in finding ways to make it easier for patients and families to comply with safe use and disposal recommendations.

Home hospice strategies around opioid medications

As Dryja explains: “The spot where the meds are going to be kept is discussed and identified. The admission nurse will assess the home situation, and he/she may suggest a locked box with only the primary caregiver (plus the primary hospice nurse) having a key.” Part of the primary nurse’s role includes a narcotic count at each visit. The primary caregiver is taught how to document the time and dose of narcotics given. This also helps monitor how pain management is going, whether dose or duration may need changing, as well as a way to be sure that the amounts given square with amounts left.

Disposal of unused pain medications is also carefully documented: “We were very clear in our instructions not to throw narcotics away, as this was something that we needed to do together, and then sign a paper that we witnessed each other discard them.” Despite this, Dryja described several situations where supplies of unused opioids disappeared, apparently disposed of prior to her arrival.

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My Health - I’m so lonesome I could cry

After only the opening chords and one or two bars of that haunting melody, you probably recognize the old song by Hank Williams — the one with the lyrics that express a feeling almost all of us have experienced:

Hear that lonesome whippoorwill
He sounds too blue to fly.
The midnight train is whining low
I’m so lonesome I could cry.

Although the song captures a common feeling, we now know it is not just a feeling, but a condition that has a very real effect on the body, and as it turns out is also a public health problem — so much so that as the new year turned in Great Britain, the issues of loneliness and social isolation were added to a ministerial portfolio. A survey study there showed that hundreds of thousands of people had not spoken to a friend or relative in a month — that’s a lot of silence in your life.

Humans are social creatures. Among ourselves we form all kinds of complex alliances, affiliations, attachments, loves, and hates. If those connections break down, an individual risks health impacts throughout the body.

The health risks of loneliness

A brief list from recent research includes:

• increased risk of cardiovascular disease
• decreased cognitive and executive function (there is initial evidence of increased amyloid burden in the brains of the lonely)
• as high as a 26% increase in the risk of premature death from all causes
• decrease in the quality of sleep
• increased chronic inflammation and decreased inflammatory control (linked to the risk of cognitive impairment and dementia)
• decreased immune function leading to vulnerability to many types of disease
• increased depressive symptoms
• increased fearfulness of social situations (sometimes resulting in paranoia)
• increased severity of strokes (with shortened survival)
• and, as you would expect, an overall decrease in the subjective sense of well-being.

As early as 1988, an important overview of multiple studies documented that social isolation was a major risk factor for mortality, illness, and injury, and in fact was as significant a risk factor as smoking, obesity, or high blood pressure. The effects and prevalence of social isolation have been confirmed in good studies many times now, as well as in the work of advocacy groups such as the AARP. In a 2010 survey study, the AARP found that in the US, 35% of adults over the age of 45 were lonely, and isolation was getting worse — 56% of the lonely had fewer friends at the time of the survey than five years before. A study in 2012 found a higher percentage of lonely people — 40%. The AARP survey found (as have other studies) that loneliness was connected to poor health.

But it is only recently that mapping out the underlying neurobiology and neuroendocrinology has become possible, using new technologies.

The effects of loneliness on the brain

Here are a few ways in which loneliness shows up in the brain:

• areas of the brain having to do with the perception of pain are activated
• gray matter density decreases in an area of the brain related to social perception
• areas of the brain having to do with “mentalization” (imagining other people’s minds) are decreased in activity
• the brain (in the all-important amygdala, for example) shows increased activity, with decreased recovery in response to negative stimuli — as Lily Tomlin on Sesame Street said about anger, this is “bad weather in the brain.”

The endocrinology is also important

The HPA axis — the feedback system across the hypothalamus, pituitary, and adrenal glands — is impacted and results mainly through the dysregulation of stress hormones, and this is associated downstream with many negative health outcomes; oxytocin (the “social hormone”) function is apparently decreased; brain derived neurotrophic factor (BDNF), one of the most abundant background facilitators of neuronal plasticity and nerve health, is decreased; and allopregnanolone, an important health-positive neurosteroid in the brain, is also decreased.

If that song, and all the health impacts of loneliness (from the cardio to the neuro to the hormonal), strike close to home, what can a person do?

Understand that people are a medicine

Sigmund Freud, in a chapter on anxiety in his Introductory Lectures on Psychoanalysis, relates a lovely story about a young boy who was afraid of the dark, except when his aunt talked to him. The boy said, “When someone speaks, it gets lighter.”

So, people are anxiety relievers. And people are antidepressants, as well as blood pressure reducers (mostly). People, in general, are good for you. So, find ways to be around and be with people; let people accompany you on your travels through life.

Ways to do this are more common than you might think.

• People from a distance: go to a library reading room to read the papers and take in the crowd.
• People closer up: volunteer at a hospital, or a local food bank, or another organization that needs help.
• People with engagement: join a congregation of worship; take up a hobby that you can share with others, such as a sport, or a game club (chess, mah-jongg, cards, Scrabble).
• People with even more engagement: renew old friendships that may have withered on the vine; you will be surprised what a difference just having tea or coffee with an old friend regularly will make. The AARP found that having even one supportive relationship decreased perceived loneliness (and by implication, the health impact) from 76% for those with none to 36%.
• If you feel introspective (Mark Twain said, “The worst loneliness is to not be comfortable with yourself”), seek out a therapist with whom you can think about your situation.

People are complicated. People can be difficult. But it is only within the complex and gratifying and sometimes challenging ecology of human relationships that we can truly thrive. See you at the coffee shop.

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My Health - Does your child need a tonsillectomy?

Follow me on Twitter @drClaire

Tonsillectomies are one of the most common surgeries performed on children — but the decision to do one should not be taken lightly.

In 1965, there were about a million tonsillectomies (with or without adenoidectomy, a surgery often done at the same time) performed on children younger than 15 years old. By 2006 that number had dropped by half, and by 2010 it had dropped by half again.

Why the drop? Well, complications are common. In fact, one in five children who have a tonsillectomy has a complication. The most common is breathing difficulty, which can affect one in 10. Bleeding affects one in 20, and can happen days after the surgery, after a child has gone home. While the complications are treatable and death is very rare, it’s clearly an operation that should only be done when truly necessary.

There are two main reasons to do a tonsillectomy, but neither is black and white. Each patient and each situation is different. It’s important to understand the gray area (there is a lot of it) in order to make the best decision.

The first reason for tonsillectomy: obstruction

Tonsils (and adenoids) can grow large enough to block the airway, making it difficult to breathe. This can be especially noticeable when a person is lying down, such as during sleep, when gravity brings the tonsils down onto the airway. This leads to a condition called obstructive sleep apnea (OSA), which can be serious and lead to health and behavioral problems in children.

Snoring during sleep isn’t enough to diagnose OSA. “Apnea” means that the person actually stops breathing — so what parents should listen for is not just snoring but pauses in breathing. It can sound like a choking noise followed by silence. Parents whose children suffer from this often find themselves getting up during the night to adjust their child’s position in bed.

Sometimes the story is so clear (smartphone videos from parents can be very helpful), and the tonsils so large, that the decision to do surgery is straightforward, and the surgery is very helpful. But often it’s not so clear, especially when the tonsils (or adenoids) aren’t that large. When it’s not clear, very often the doctor will order a sleep study, called a polysomnogram (PSG). During this study, the child is monitored during sleep to get a better sense of exactly what is happening.

These studies are very helpful, but they aren’t perfect. Not only are they a measure of just one night, which may or may not be typical, but they don’t always predict whether or not a child will have the health and behavioral problems we worry about, or whether they will get better after surgery. This can be especially true when a child is overweight, as being overweight can cause or worsen apnea, and the apnea may or may not get better with a tonsillectomy. Also, PSGs are expensive and not always widely available. That’s why doctors differ in how often they order PSGs and how they use the results.

There are other ways to manage OSA besides surgery, including continuous positive airway pressure (CPAP) machines and other devices, medications, and positioning. When it’s not clear that a tonsillectomy is needed, when parents prefer not to do it, or there are other reasons not to do it (like known bleeding problems or other medical problems that make surgery risky), these other measures can be tried.

Another reason for tonsillectomy: recurrent infection

Children who are severely affected by recurrent throat infections (more than seven episodes in one year, five in each of two years, or three in each of three years) may be helped by a tonsillectomy. However, just having a sore throat doesn’t count. To meet criteria, there needs to be fever, enlarged lymph nodes, pus on the tonsils, or a positive strep culture — and the child should have been seen and all the details confirmed and documented.

In cases where children are severely affected, tonsillectomy can reduce the number of infections — but when this has been studied, children who don’t get tonsillectomies have fewer infections over time too. That’s the thing: either way, children get better. “Tincture of time,” or just waiting it out, can work too.

Making a decision about tonsillectomy

So if you are thinking that your child might need a tonsillectomy, or if your doctor has suggested one, talk it over carefully with your doctor. Ask lots of questions. Spend some time understanding both the risks and benefits. It’s certainly true that for some children tonsillectomy makes a huge difference, especially those with obstruction — but for many others, just giving it some time, perhaps with some medication or other treatments, can do the trick too.

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My Health - When dying is a rebirth

Follow me on Twitter @1111linno

My life is extraordinary. Such a hyperbolic-sounding statement and yet, in so many ways, so very true.

Extraordinary because a decade ago I was told I had three to five months left to live. Diagnosed with non-small cell lung cancer (NSCLC) three years earlier, the removal of most of my left lung followed by chemotherapy had done little to slow down the cancer. Too diffuse for radiation, we had run out of options.

And so, I did what the dying do. Grieving as preparations began. I bid adieu to friends and family, held my children even closer, and sought the help of a thoracic social worker. The day I walked through her door, my first words were, “I need you to help me learn how to die.”

Life can be so strange, so surprising. I never thought I’d be diagnosed with lung cancer at the age of 45 and that I’d be facing death at 48. But the biggest surprise was yet to come.

Obviously, I didn’t die. Just in the nick of time, medical science intervened as I was found to have a newly identified driver in lung cancer, an ALK (anaplastic lymphoma kinase) mutation. On October 1, 2008 I became the fourth person in the world with NSCLC to enroll in a first in-human trial targeting ALK. And, to all of our surprise, I had an amazing response.

In the years hence, I have returned to chemotherapy, but also enrolled in two more phase I clinical trials. And life has gone on. My youngest child was only seven when I was diagnosed; two years ago I had the immense privilege of seeing him graduate cum laude from Phillips Exeter Academy. He is now in his second year at MIT and my other two adult children are thriving in both their relationships and careers.

Four years ago, own marriage ended, in no small part because of the differences in the way we approached my cancer, which, though still considered terminal, had also become a chronic illness.

Living alone has had its challenges, but I can truly say that I have never been happier. For the first time since my early 20s, I am focusing on my own goals. Upon leaving our marriage, I moved to a converted mill housing a community of creatives. I call it the art dorm, and my loft — the art fort. I recently had my first solo art show, and it was a big success. It is safe to say I’m on a creative roll. I am also working on a book (or two), a DIY MFA (that’s another blog), and I devote more time than ever to patient advocacy, with a focus on clinical trial participation and medical research.

Last year a little white Shiba Inu came into my life — a rescue that I actually helped rescue — and we walk several miles every day. Five months ago I also started online dating and, contrary to the experience of many, I’m having a blast. I attribute that to my extraordinary (yes) self-confidence and my willingness to go all in, without regard to being hurt. These are qualities that I did not possess prior to my diagnosis with cancer.

It’s such an odd and unexpected paradigm — living with a terminal illness. The downsides are obvious and yet, I have learned so very much. Forced to face my greatest fears, I have become far more courageous; in fact, there is little I fear now. This means my anxiety has gone way, way down and my ability to enjoy life, way, way up. Because I have learned to sit with uncertainty, I am no longer married to outcomes. It’s all good. I liken this to loving/living life unconditionally; I simply cannot be disappointed. Each new morning is opened like a present — a gift I simply did not expect to receive.

Perhaps it is this awareness that has sharpened both my perception and my appreciation; I refuse to waste a moment. And although I would prefer to not have an illness that is terminal, I would wager that I am infinitely more alive than many who do not.

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My Health - The story of your life and the power of memoir

I play poker in a weekly game hosted by an 80-year-old man named Mort. During a recent game, I noticed a stack of composition books, scribbled-over yellow pads, and Bic pens spread over his dining table.

What was he up to? Mort said he had lost his sense of purpose and identity, so he turned to something he knew a lot about — his life story — and began to write his memoirs.

Mort’s reaction is quite common among older adults, as is his response. As people age, they may begin to feel irrelevant to those around them, especially their families, which often leads to low self-esteem, greater isolation, and a higher risk of depression.

But engaging yourself in an endeavor like writing your memoirs can be rewarding for you and others.

“You would be surprised at how interested your peers and family members are in your stories and personal history,” says Brendan Kearney, Vitalize 360 Wellness Coach at Harvard-affiliated Hebrew SeniorLife. “You have a unique firsthand account of your culture and history that others don’t, and leaving a recorded history of your life can be an important gift to both you and your descendants.”

Words of wisdom

Writing your memoirs offers many benefits beyond simple storytelling. For instance, they can be an opportunity to pass along specific wisdom and life lessons. “Even if you write about parts of your life that you have never told anyone because they were unhappy or painful memories, revisiting them can show others the strength it takes to overcome life barriers when they face their own,” says Kearney.

The actual writing aspect also can be a therapeutic tool as you explore issues that may still trouble you. A study published in the March 2018 JAMA Psychiatry found that writing about a specific upsetting memory was just as effective as traditional cognitive processing therapy in treating adults with post-traumatic stress disorder.

A walk down memory lane

Where should you begin your life story? You don’t have to follow a straight year-by-year account. Instead, Kearney recommends creating a timeline of your life based on the places you have lived. “Begin with writing about your homes,” says Kearney. “Think about the house you grew up in, or the first house you owned. The places you’ve lived often invoke a wealth of visual memories and long-forgotten stories that are tied to those places.”

Another way to trigger ideas is to look through photo albums. Focus on a single picture and write about the story behind it. Or use writing prompts, by asking yourself questions such as, “One of my fondest memories of my best friend was …”; or “The time I was happiest or most scared was …” Or write about your favorite hobbies or sports.

Mort’s first chapter? His love of poker.

The write stuff

Writing can be tough for some people. Here are some strategies to help you find your rhythm.

• Write at the same time each day to establish a routine. Choose a specific time to write, whether it’s in the morning while you drink coffee, or before bed, or any time in between.
• Write for a set period. In the beginning, set a timer and write for 10 to 15 minutes. Gradually extend the time to 20 minutes or longer.
• Don’t worry about spelling and grammar. Your writing is about record keeping and not publication, so write the way you speak, and don’t focus on correcting mistakes.
• Use a recorder. If you aren’t comfortable writing, then record your stories on a tape recorder or your smartphone. There are many speech recognition programs that can convert audio into text documents, such as Sonix, InqScribe, and Dragon NaturallySpeaking.
• Try writing longhand. Research has found that handwriting, especially in cursive, can activate parts of the brain associated with short- and long-term memory. The slower process also can help improve attention and information processing, since you have to focus on forming letters and words.
• Look for writing groups. Some community centers offer memoir-writing workshops that can offer further support and give you a chance to share your writing with other people. Or reach out to friends about forming your own writing group.

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My Health - What patients — and doctors — need to know about vitamins and supplements

A recently published clinical guideline on vitamin and mineral supplements reinforces every other evidence-based guideline, research review, and consensus statement on this topic. The bottom line is that there is absolutely no substitute for a well-balanced diet, which is the ideal source of the vitamins and minerals we need.

The brief article, co-authored by nutrition guru Dr. JoAnn Manson, cites multiple large clinical trials studying multiple nutritional supplements’ effects on multiple end points. The gist of it is, our bodies prefer naturally occurring sources of vitamins and minerals. We absorb these better. And because commercially available vitamins, minerals, herbs, etc. are lumped together as “supplements,” the FDA doesn’t regulate them. When we ingest processed, concentrated, and artificially packaged “supplements,” we may be doing ourselves harm. They may be toxic, ineffective, or contaminated (all of which are not uncommon).

In other words: Most people who eat a healthy diet are unlikely to benefit from nutritional supplements.

Note the very important qualifiers. We’re talking about most people (not all) who eat a healthy, well-balanced diet.

Does anyone need vitamin and mineral supplements? Well, yes

There are medical conditions that put people at high risk for certain nutritional deficiencies, and there are medical conditions that can be treated with certain nutritional supplements. This is important, and is why the authors support targeted supplementation. But who needs what and where to acquire these are important discussions to have.

There are guidelines for specific groups, such as pregnant women. Folic acid is especially important for healthy fetal development, and a deficiency can cause spina bifida, a neurologic condition. I advise my patients to start either a prenatal vitamin with folic acid, or at the very least folic acid itself, ideally before they begin trying to conceive. As pregnancy advances, mom needs to provide her growing fetus with everything, and so she will benefit from a prenatal vitamin (either by prescription or a well-vetted over-the-counter one) which contains things like iron and calcium.

Older adults can have difficulty absorbing vitamin B₁₂, and I have a low threshold when checking this level; if someone is taking an acid-reducing medication, it is very likely that they will become deficient in B₁₂, as well as iron, vitamin D, and calcium, among other things. These folks may very well benefit from a quality multivitamin.

Of course, there’s a long list of medical issues that predispose people to vitamin deficiencies. For example, people who have had weight-loss surgery may require a number of supplements including A, D, E, K, and B vitamins, iron, calcium, zinc, copper, and magnesium, among other things. People with inflammatory bowel disease (like Crohn’s or ulcerative colitis) may have similar requirements. People who have or are at risk for osteoporosis may greatly benefit from vitamin D and, depending on the quality of their diet and other factors, possibly also calcium supplements.

There are other medical conditions that can be treated with supplements. One that immediately comes to my mind is inflammatory arthritis (or other inflammatory conditions) and turmeric. While quality scientific studies are lacking, there are plenty of smaller studies as well as historical experience suggesting that turmeric has anti-inflammatory properties, and I see some of our rheumatologists routinely recommending this to patients for pain relief. Then there’s prediabetes/diabetes and cinnamon, which has blood sugar-lowering properties. With these compounds, I advise that people use the regular spice in normal culinary amounts, not a processed/concentrated packaged supplement.

Not all vitamins are created equal

And here is another key point that bears repeating: Manson suggests choosing vitamins that have been tested by independent labs such as US Pharmacopeia, Consumer Lab, and NSF International, and certified to have the labeled dosage of the correct ingredient, and not have toxins or contaminating organisms. Many commercially available supplements here in the US will bear a label from one of these labs.

On that point, gummy vitamins are often not certified and often do cause cavities. Yes, everyone loves them, because they’re basically candy. I do not recommend gummy vitamins for anyone, but especially not for pregnant women.

I’ll also add in a warning: I often hear about providers who are selling supplements or other products directly to their patients. This is a conflict of interest, and it’s unethical, as well as fraught with all sorts of potential problems. Please use caution if purchasing anything directly from the provider who is prescribing it.

The bottom line

In summary, enjoy a varied, colorful, healthy diet, consider supplements when they may be needed or helpful, and choose your sources carefully.

Sources

Vitamin, Mineral, and Multivitamin Supplements for the Primary Prevention of Cardiovascular Disease and Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine, April 2014.

Dietary supplements and disease prevention — a global overview. Nature Reviews: Endocrinology, May 2016.

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My Health - FDA approves new drug for men at high risk of prostate cancer spread

A newly approved drug called apalutamide is giving hope to thousands of men confronting a tenacious problem after being treated for prostate cancer. Prostate-specific antigen (PSA) levels should plummet to zero after surgery, and to near zero after radiation therapy, but in some men, they continue rising even when there’s no other evidence of cancer in the body. Doctors typically respond to spiking PSA with drugs that block the production of testosterone, which is the male sex hormone that fuels prostate cancer. However, this type of medically induced castration, called hormonal therapy, doesn’t always reduce PSA. Moreover, prostate cancer cells can become resistant to hormonal therapy, after which PSA resumes its upward march. This is called non-metastatic castration resistant prostate cancer (nmCRPC), and it often precedes the appearance of metastatic tumors that show up later.

The dearth of approved treatments for nmCRPC has long frustrated patients and their doctors alike. But in February, the US Food and Drug Administration approved apalutamide for men who have nmCRPC after results from the SPARTAN clinical trial showed the drug could delay metastases by up to two years. “Based on these clinical trial results, apalutamide should be considered the new standard of care for nmCRPC,” said Dr. Matthew Smith, a medical oncologist at Massachusetts General Hospital who led the study. “The drug addresses a great clinical need and holds the promise of longer survival for men whose cancer defies hormonal therapy.”

The SPARTAN trial enrolled 1,207 men whose PSA levels doubled within 10 months or less after initial treatment despite ongoing hormonal therapy. Enrolled men were assigned to either daily apalutamide tablets combined with hormonal therapy, or to hormonal therapy combined with placebo. Doctors usually stick with hormonal therapy even after PSA levels rise, since it prevents the body from recovering its ability to make testosterone. Men continued on the study until the first metastases were detected, and then they were given other drugs used for treating metastatic prostate cancer.

According to the results, those taking apalutamide avoided metastases for a median of 40.5 months (meaning half were free of metastases for longer than that, and the other half for less). The placebo-treated men, meanwhile, remained free of metastases for a median of 16.2 months, about two years less. Furthermore, apalutamide treatment “delayed symptomatic progression, pain, and other symptoms that patients experience as a consequence of their cancer,” Smith said. But apalutamide, which prevents testosterone from interacting with its receptor on cancer cells, was also associated with more frequent significant side effects, such as fatigue, rash, weight loss, falls, and skeletal fractures.

Based on accumulating evidence, Smith anticipates that longer freedom from metastases equates with longer overall survival in men with nmCRPC. However, whether that’s true remains to be seen. “So far, outcomes suggest men will live longer on apalutamide,” 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. “The anxiety most patients experience when PSA increases after what was thought to be curative is significant. Continuing with this new therapy should be considered between appropriately selected patients and their doctors after a full discussion of the potential benefits and risks.”

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My Health - Eating well to help manage anxiety: Your questions answered

Does diet affect anxiety? If so, what should I eat, and which foods should I try to avoid?

People who suffer with anxiety should remember a few simple rules:

• Low blood sugar, poor hydration, use of alcohol, caffeine, and smoking can also precipitate or mimic symptoms of anxiety.
• Eating regular meals and preventing hypoglycemic states are therefore important.
• Adequately hydrating with plain water is best, at least 6 to 8 glasses a day.
• While nicotine does not cause anxiety, withdrawal from nicotine can mimic anxiety, and people with anxiety may smoke to soothe themselves. It may become a problematic behavior, as nicotine can also raise blood pressure and heart rate, which are also symptoms of anxiety.
• People who feel anxiety may lean on alcohol to calm their nerves, but excessive drinking can lead to its own set of emotional and physical problems.
• Many sodas contain caffeine and have a high sugar content. Being aware of these factors and substituting plain water or sparking water for soda can be a healthier option.
• Working toward a well-balanced diet with adequate fruits, vegetables, lean meats, and healthy fats remains a good recommendation for those who struggle with anxiety. Avoiding processed foods and foods high in sugar means the body experiences fewer highs and lows of blood sugar, which helps to further reduce feelings of anxiety. Very simply put, a sugar rush can mimic a panic attack.

For example, eating a frozen dinner and ice cream will affect you differently than eating chicken and broccoli with a pasta made from whole grains or quinoa. The second meal includes whole, unprocessed foods, and you control the amount of sugar, if any, added to the meal. It takes longer for your body to metabolize these foods, which helps you feel fuller for longer and keeps blood sugar levels steady, rather than yo-yoing up and down.

Does sugar increase anxiety symptoms?

Yes! And there are many hidden sugars in the foods we eat, including savory foods. Many people don’t realize this. One example is a popular store-bought Tomato Basil Sauce. One half-cup serving (and very few people would eat just half a cup at a meal) contains 12 grams of sugar, which is 3 teaspoons (4 grams sugar = 1 teaspoon). Food labels in the US use grams, and many people do not really know how to interpret these. Recipes use ounces, pounds, teaspoons, and tablespoons, so this conversion becomes important for the consumer. So, if you used 1-1/2 cups of the pasta sauce, you would be consuming 36 grams or 9 teaspoons of sugar just from the sauce in your meal!

While your body needs a healthy balance of sugar, carbohydrates, fats, and proteins to function, it is also that very balance that helps keep us healthy. Consuming sugar through natural sources such as a piece of fruit, and not fruit juice or dried fruit, affects your body differently than candy or hidden sugars in your foods.

The FDA has a new nutrition label law coming into effect which will list the added sugars on the nutrition label for consumers and provide some other helpful data.

Do anxiety symptoms improve when you cut back on sugar and feed your body the right foods?

It’s a good idea to talk with your doctor before making dramatic changes in what you eat. Involve a nutritionist (your doctor can refer you to one) if you need some extra guidance.

As with any dietary change, your body will need some time to adjust. If you are otherwise healthy and cut back on processed sugar, you may feel your anxiety slowly improve thanks to fewer ups and downs caused by the excess sugar. If you are only using diet to combat anxiety, this change may not be obvious or immediate. You may also need to speak to a doctor about a medication. An integrated treatment approach including talk therapy, mindfulness techniques, stress relief, good sleep hygiene, and a balanced diet are all equally important parts of your care.

What else should I know about diet and anxiety?

Anxiety is linked with many physical illnesses. In addition to taking guidance from your doctor about options for treating anxiety, you should augment that treatment by paying attention to how and what you eat. A review of the literature examining the effects of diet on anxiety-related behavior highlighted that foods high in fat and/or sugar, or that are highly palatable, can affect behavior in animal models, and may do the same in humans. More human studies are needed.

Some of the following tips may be useful for you:

• eat a healthy and balanced diet along the lines of a Mediterranean diet
• cut back on sugar and processed foods
• cut back on caffeine, alcohol, and smoking cigarettes
• eat foods rich in zinc, like whole grains, oysters, kale, broccoli, legumes, and nuts
• eat foods rich in magnesium: fish, avocado, dark leafy greens
• eat foods rich in vitamin B, such as asparagus, leafy greens, meat, and avocado
• eat foods rich in omega-3 fatty acids, for example, wild caught salmon
• eat probiotic-rich foods like kefir, yogurt, and other fermented foods.

Of course, first and foremost, follow the medical advice of your doctor. Discuss diet, lifestyle, and medication changes, and keep track of your symptoms to see whether they improve.

The post Eating well to help manage anxiety: Your questions answered appeared first on Harvard Health Blog.

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My Health - Beware! 10 Surprising Causes Of Urinary Tract Infection (UTI)

Beware! 10 Surprising Causes Of Urinary Tract Infection (UTI)

Health and Fitness Tips
Health is the level of functional and metabolic efficiency of a living organism. In humans it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological and social changes with environment.

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My Health - In children and teens, depression doesn’t always look like sadness

Follow me on Twitter @drClaire

When we think of a depressed person, we tend to think of someone who, well, acts sad. The picture we have in our head is of someone who doesn’t want to get off the couch or out of bed, who is eating much less or much more than usual, has trouble sleeping or wants to sleep all the time, who has trouble with usual daily activities, and doesn’t talk much.

Children and teens with depression can certainly look like that. But depression can play out in different ways, too. Numbers are hard to come by in younger children, but among 12-to-17-year-olds, almost 13% have had a major depressive episode. It’s important to be aware of the signs; depression is a treatable illness — and untreated depression can lead to long-term mental health and physical problems, and possibly even suicide.

Here are some possible signs of depression in youth:

• Dropping grades. Now, there are lots of reasons why grades can drop — including learning disabilities, ADHD, bullying, or substance use. But whenever a child’s grades are dropping, it’s important to think about depression as a possible cause.
• Irritability and anger. There are many reasons for this, including temperament, and teens are often irritable and angry. But if it’s new and persistent, or if a child or teen is getting in trouble much more than usual, think about depression.
• When a child who used to be interested in things is suddenly bored all the time, it can be a warning sign.
• Dropping out of activities. It’s certainly fine for interests to change. But if new ones don’t take their place, that too can be a warning sign.
• Difficulty with relationships. When children and teens are fighting with friends, or simply spending much less time than they used to with them, that’s a red flag.
• Dangerous behavior. A certain amount of risk-taking is normal, especially in teens, but if it’s new and persistent, it may not be normal. Any self-injurious behavior, like cutting, merits attention right away.
• Persistent physical complaints, such as stomachaches, headaches, or other pain. Obviously you need to get a thorough checkup for any persistent pain. But the mind-body connection can be very strong; sometimes people who are depressed have physical pain that feels very real.
• Fatigue. This is another symptom that needs to get checked out thoroughly, as there are many medical reasons why a person can have chronic fatigue. But depression is one of them.

If you are seeing any of these in your child — or any other changes in behavior that you can’t explain and don’t seem right to you, talk to your doctor or seek out a mental health professional in your area. Don’t ignore the behaviors or try to explain them away. Better safe than sorry, and as with so many conditions, the sooner you catch depression, the easier it is to treat.

The post In children and teens, depression doesn’t always look like sadness appeared first on Harvard Health Blog.

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My Health - How To Garlic Treatment For Urinary Tract Infection (UTI)

How To Garlic Treatment For Urinary Tract Infection (UTI)

Health and Fitness Tips
Health is the level of functional and metabolic efficiency of a living organism. In humans it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological and social changes with environment.

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My Health - Why it’s so hard to lose excess weight and keep it off: The Biggest Losers’ experience

Follow me on Twitter @RobShmerling

For most people trying to lose weight, it’s a struggle. It takes more than good intentions and a lot of will power. One reason is that in order to lose weight, we are, in a way, fighting our own biology.

As we lose weight, the body adapts to resist it by lowering the resting metabolic rate — that’s the amount of energy spent while at rest, when the “engine” of the body is idling. Lowering the resting metabolic rate is a good thing if food is scarce and weight loss is occurring due to starvation. In that situation, it’s good that the body slows down to conserve energy and limit further weight loss.

But this evolutionary adaptation works against you if you are overweight or obese, and excess weight is a bigger threat to your health than starvation.

The experience of The Biggest Loser

Researchers have studied weight loss for decades to determine how the body responds to it. Among them are studies that enrolled participants in the television series The Biggest Loser. If you aren’t familiar with it, The Biggest Loser is a reality television series in which obese individuals compete to lose the most weight through an intensive program of exercise and dietary changes. A prior study found that after losing lots of weight, participants in The Biggest Loser had markedly reduced metabolic rates. But it was unclear how long those changes would last or whether they predicted regain of weight once the competition ended.

A new study of The Biggest Loser

A recent study looked at how participants in The Biggest Loser fared six years after their 30-week competition. Researchers publishing in the medical journal Obesity found that:

• At the end of the competition, average weight loss was nearly 128 pounds. Since the average starting weight was about 327 pounds, that’s a drop of nearly 40% of body weight.
• On average, participants experienced a 23% drop in their resting metabolic rate.
• Six years later, competitors regained an average of 90 pounds, but the significant slowing in metabolic rate persisted.
• There was not a direct correlation between the amount of metabolic slowing and the amount of weight lost during the show. However, after six years those who kept the most weight off had the most slowing.

These findings confirm that weight loss may lead to significant changes in metabolism that, in turn, resist further weight loss. In addition, keeping weight off may be especially difficult because those changes persist over time. The metabolic slowing that accompanies weight loss varies, however, so it may create less resistance to weight loss for some than others.

Now what?

The findings of this research may seem discouraging if you’re trying to lose weight.

On the other hand, maybe it should provide a measure of relief to know that the reason losing weight seems like an uphill battle is that it is! It’s not just that you aren’t trying hard enough —your efforts to lose weight are being actively undermined by biological adaptations of your body that developed centuries ago during evolution and are now hardwired into your DNA.

You might wonder: is there a diet, an exercise program, or a medication that can “reset” your metabolic rate or avoid its slowing during weight loss? In fact, you may have seen books or advertisements for certain diets or supplements claiming to do just this. Unfortunately, most have little convincing long-term evidence to back them up, or the changes are too small to matter much.

The bottom line

Knowing about the adaptations your body makes during weight loss and how that can frustrate your efforts to lose weight may make the effort seem futile. But it’s not. Determination, perseverance, and a sustainable plan are good first steps. It also helps to know what you’re up against. Contestants on The Biggest Loser know that well.

The post Why it’s so hard to lose excess weight and keep it off: The Biggest Losers’ experience appeared first on Harvard Health Blog.

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My Health - Can you rewire brain to get out of a rut? (Yes you can…)

Regardless of the context, routines — once comforting and safe — can gradually become ruts. Stable relationships, familiar patterns, and secure jobs can quickly lead to boredom, depression, unconscious anxiety, or a debilitating addiction. As Brooklyn clergyman Samuel Parkes Cadman once said, “the only difference between a rut and a grave is a matter of depth.”

Ruts are indeed threatening and stultifying. But are we doomed to be in them once we fall into them, or can our brains be changed? To answer this question, psychologist and brain researcher Caroline Di Bernardi Luft and her colleagues conducted a study, drawing on what we already know about how we fall into ruts in the first place.

Why do we get stuck in ruts?

We become stuck in ruts due to our brains’ habitual electrical patterns. Past experience shapes present and future behavior. Faced with new situations, our brains will apply rules based on prior events to match the current context. And there’s a part of the brain that is especially wired to do this. Called the dorsolateral prefrontal cortex (DLPFC) — think of it as the brain’s “pattern seeker” — this brain region works hard to find old rules that can be applied to the here and now to circumvent the chore of new learning. Dr. Di Bernardi Luft and colleagues wanted to see if people could get out of ruts when the brain’s pattern seeker was blocked.

How to create a rut in an experiment

In order to explore this, they had to first get people into a rut. So they gave them four types of matchstick arithmetic problems, each with a different rule set. Once they got used to a rule, they were given a problem with another set of rules. So, to solve each new category of problem, they had to get out of the rut of the old way of thinking.

In a typical problem, matchsticks are used to form an incorrect equation consisting of roman numerals (I, II, etc.) and arithmetic operators (e.g., +, –). Participants would then have to correct the equations by moving only one matchstick. The problem is not just math, it’s creative too.

For each of the four types of matchstick problems (A, B, C, and D), there is a different rule. For example, for problem type A, you could move a matchstick within a numeral, so that IV = III + III becomes VI = III + III when you move the “I” in “IV” to form a “VI.” For B, you move a matchstick from a plus sign (e.g., I = II + II becomes I = III – II when the vertical part of the plus is moved to join the first “II.”). For C, you rotate a matchstick within a plus sign to create an equals sign (e.g., change “+” to “=”). And for D, you change an “X” into a “V” by sliding the matchstick of the right arm of the “X” to the right.

To solve the problems effectively, you have to forget prior rule sets, but this is difficult to do. As a result, you sometimes get stuck in a rut.

How to inhibit ruts with electricity

With this challenge at hand, the researchers then passed a specific kind of electrical current from positive (anodal) to negative (cathodal) electrodes through the scalp overlying the DLPFC. Called transcranial direct current stimulation (tDCS), this type of low level electricity can excite or inhibit the brain tissue beneath the scalp. Beneath the positive electrode, it stimulates the underlying brain tissue, and beneath the negative electrode, it inhibits the brain tissue. As a comparison, they also used a sham current. After each of these types of current was applied, participants were given the matchstick problems. Of the different problems, the “C” type problems were the most difficult, and required forgetting prior rules.

So what did they find? The main finding of the study was encouraging: when a negative current was applied over the DLPFC, it was easier to break former habit patterns for “C” type problems. The implications of this were quite exciting. Breaking former habits makes you more creative. You behave less like an automaton, and look at things in a unique way. In effect, you become unstuck and get out of your mental rut. It is possible to get out of a mental rut after all!

What does this mean for you?

In my book, Tinker Dabble Doodle Try: Unlock the Power of the Unfocused Mind, I explain how very important it is to become unfocused if we are to break away from mental patterns. This does not imply that you must be distracted, but that you should build “unfocus time” into your day. This turns off regions like the DLPFC, and turns on other circuits instead. Going for a meandering walk, daydreaming, doodling, and 90 minutes of napping are all ways of turning off the DLPFC to enhance creativity. They relax the usual mental constraints and help you break through your habits too.

So, while you are waiting for a product that delivers this electrical zap to help relieve boredom and get you out of a rut, why not try out one of the simple methods above for 15 minutes a few times a day? When you do, you will likely prepare your brain inevitably for a much more exciting and creative life. And ruts will become far less detrimental to you too. In essence, you will have taken advantage of your brain’s ability to rewire itself, which Dr. Di Bernardi Luft and her colleagues demonstrated so elegantly.

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