Getting sleep in the hospital

If you or any of your loved ones has ever been hospitalized, one of the complaints you may have heard about most is how hard it is to sleep in the hospital. There are lots of things about hospital routines that can make things difficult for patients to sleep, besides noise and illness. While some hospitals have taken steps to ensure that patients are not interrupted unnecessarily at night, this is not universal. Here are some things you can expect, and some steps you might be able to take to help the hospital give you a better night’s rest.

Some reasons you might be woken at night might be unavoidable

You might be on a particular medication, such as certain antibiotics, that must be given in the middle of the night, depending on when the first dose was given, and blood tests for levels of some antibiotics must be timed to their dosing, resulting in blood draws in the middle of the night, too. If you are admitted to check for a heart attack, you might also be ordered for timed blood tests that might involve having your blood drawn in the middle of the night. Vital signs, such as pulse and blood pressure, are required to be taken every four hours for some conditions, which would also awaken you.

One study shows the top thing keeping patients awake is pain, followed by vital signs and tests, noise, and medications. Studies have also shown that hospital routines can disrupt patient sleep, and having a designated quiet time, where nonessential tasks are minimized and lights and noise are lowered, may help. Here is a partial list of things that keep patients awake, and what you might be able to do about them.

Pain. Pain is easier to control before it gets bad. Don’t hesitate to ask for pain medicine at bedtime, even if your pain is not yet severe.

You are woken up to have your blood pressure taken. Vital signs are usually taken every eight hours. Often these are done between 11 pm and midnight, after the night shift starts, but it’s often just after you have fallen sleep. Alternatively, the night shift could be taking your vital signs at 6 am, when you’d be awoken for other hospital routines anyway. If you are given the opportunity to give feedback during or after your stay, it would be important to mention this — hospital administrators look closely at patient feedback.

The IV pump that keeps beeping. This is usually because the flow of IV fluid is blocked (occluded), most often because the IV was inserted in the crook of your elbow. Thus, every time you bend your arm, the pump will alarm and start beeping. If this is the case, ask to have the IV put in a different place, like your hand.

You are woken to be given medications. Sometimes a medication or breathing treatment might be ordered “every four hours” or “every six hours” which means the nurse or respiratory therapist is required to wake you to give it to you even if you are asleep. You can ask if the order can be changed to four times a day instead of every six hours, or “every four hours while awake” so you don’t have to be woken.

Noise. Lots of things can be noisy in the hospital at night — staff voices, cleaning machines, your roommate if you have one. You can always ask to have your door closed, and you can ask someone to bring in ear plugs.

You are up all night urinating. If this is not the case when you are at home, it might be because you were ordered for a diuretic to be given late in the day, after 6 pm or so, or you are ordered for IV fluids at a rate that is higher than you actually require. Your nurse can ask the doctor to change these orders.

Blood transfusions at night. If you need a blood transfusion, it is best not to do it during sleeping hours, because it requires the nurse to monitor your vital signs frequently and would keep you awake for hours. If you need a transfusion at that hour, ask if it can possibly wait until daytime.

Frequent nighttime disruptions can often cause patients to want to nap during the day, and throw off their sleep schedules. Patients might already be weak and tired from their underlying illness. If you’re hospitalized, it’s important to keep your normal sleep schedule and circadian rhythm. During the day, keep the window shades open for natural light and keep the room dark during sleeping hours. An eye mask might be helpful if exposure to light at night is unavoidable. A favorite blanket, pillow, photos, and your favorite music can help you relax and be more comfortable.

My colleagues and I at Somerville Hospital (since closed to inpatients) found that when we instituted a program to decrease disruptions during the night, such as purposely avoiding all the things described above, patients used as-needed sedatives about half as often in the hospital. Most hospitals can do better to make nighttime routines friendlier for patients, but institutional change can be challenging. Knowing what to ask for is useful and will help move healthcare forward.

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An omnivore’s dilemma: How much red meat is too much?

In October 2019, the Annals of Internal Medicine published controversial guidelines advising Americans to carry on consuming red and processed meat at current amounts. The guideline authors characterized meat-eaters as somewhat incapable of dietary change, and portrayed the benefits for reducing red and processed meat intake as insignificant. These guidelines contradict previous studies that link processed meat and red meat with early death and an increased risk of disease, including cardiovascular disease (CVD) and cancer.

If omnivores are confused, it’s hard to blame them.

Americans are eating less meat, but not less processed meat

To frame their argument, the article authors referenced an average meat intake from North America and Western Europe of two to four servings per week. But we are not France, and about a third of Americans eat more than this. In fact, on average we eat about five servings (17 ounces) of red and processed meat per week.

We have made progress decreasing our consumption of unprocessed beef, pork, and lamb over the past two decades. But our intake of processed meat remains unchanged: sausage, hot dogs, and ham reign among the nation’s most beloved processed meats.

Red meat and processed meat increase disease risk

The message from the Annals guidelines was perplexing and, at times, poorly translated by the media, with some headlines goading Americans to go full speed ahead on their intake.

This is particularly alarming, because recent research indicates eating 3 1/2 more servings of meat per week is associated with a higher risk of death. Consuming more than three additional servings may sound like a significant escalation. But consider that a standard serving equals about 3 ounces, a portion the size of a deck of cards. Eating a steakhouse filet, which typically weighs up to 12 ounces, you could consume roughly 3 1/2 servings in a single meal.

The connection is stronger for processed meats, which have a smaller standard serving size. For bacon lovers, eating a mere four slices more of thick-cut bacon a week is enough to increase risk of death.

Red and processed meat have also been associated with an increased risk of cancer. According to the World Health Organization’s International Agency for Research on Cancer, there is sufficient evidence to label processed meat as a carcinogen (a cancer-causing substance). Consuming a daily portion of less than two ounces per day — the equivalent of two slices of ham or bologna — is associated with increased cancer risk.

Eating less red meat makes room for healthier foods

Unfortunately, outlining the health hazards of red and processed meat sends a negative message and misses the bigger picture: many of us simply do not eat enough protective foods, and eating less meat would allow space for the foods we are neglecting.

According to the USDA, close to 90% of Americans do not eat the recommended amount of vegetables per day. (Most people should aim for two to four cups daily depending on their age and sex.) . Adults are not eating enough legumes, like beans and lentils, nor are we consuming enough seafood. The good news is that replacing some red and processed meat with whole grains, vegetables, and marine and plant-based proteins may help you live longer.

This is helpful for our collective health too, as livestock are responsible for 14% of greenhouse gas emissions that contribute to climate change and threaten our planet. (Seafood practices also contribute to global warming, but only lobster and crab come close to cattle, our country’s most popular red meat and the animal responsible for the greatest greenhouse gas emissions.)

Shift focus to the foods you should eat more of

Ultimately, we do Americans a disservice if we cast them as incapable of making change. We can’t assume that it would be a burden to switch from beef jerky to nuts or from ham to tuna.

But asking how much meat is too much is, perhaps, the wrong question. Rather, we should really be asking: what do we need to eat more of instead?

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Should you use probiotics for your vagina?

You know probiotics can be good for your gut, but does your vagina need one too? You might think so, based on probiotic marketing these days. Probiotics are in everything from drinks to pills and powders, and in many cases, are being promoted as a means of improving your vaginal health.

Women seem to be listening, says Dr. Caroline Mitchell, assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School. Vaginal probiotic supplements are hugely popular. This includes both probiotic pills and suppository capsules that are inserted into the vagina using an applicator.

But evidence of effectiveness is scant. “There is almost no evidence that these have benefit for vaginal health. The studies are mostly poorly done and don’t adhere to rigorous reporting standards, even if they are randomized trials,” says Dr. Mitchell. But that hasn’t stopped companies from promoting products for that purpose.

However, while today’s vaginal probiotic products should be viewed with a healthy dose of skepticism, that may change as scientific knowledge builds. Meanwhile, here’s what’s known — and unknown — about probiotics and your vaginal health.

Sorting facts about probiotics from fiction

Vaginal probiotics are touted as a way to introduce live microorganisms into your vagina to improve health. It’s true that your vagina, like your digestive tract, is teeming with beneficial bacteria and other microorganisms. When it comes to vaginal health, some common gynecological conditions are thought to be caused by an imbalance of bacteria inside the vagina. More often than not, when women seek out probiotics, they’re doing it in an attempt to ease discomfort caused by two of them: bacterial vaginosis and yeast infection, says Dr. Mitchell.

Bacterial vaginosis is the most common vaginal infection in women of childbearing age. There’s still a lot that experts don’t understand about the condition, but it is associated with an overgrowth of harmful microorganisms (such as Gardnerella vaginalis or Prevotella), which outnumber healthier types of vaginal bacteria, including a common organism called Lactobacillus.

Vaginal yeast infection also stems from an imbalance in the vagina. But in this condition, the problem is a fungus called Candida, which overcomes healthy bacteria. Candida can exist normally in the vagina without any problem, but may cause trouble if it outnumbers other microorganisms.

“There are some women who could benefit from probiotics — at least in theory,” says Dr. Mitchell. Among them are women with bacterial vaginosis or yeast infection. For example, when it comes to recurrent bacterial vaginosis, the thinking is that introducing more of the helpful lactobacilli might protect against that overgrowth of harmful organisms, and consequently reduce recurrent infections. However, proof is lacking, says Dr. Mitchell. If that theory is shown to be true, a probiotic could be beneficial, but no one is sure. And it’s not at all clear that taking a probiotic orally will help the vagina.

There are also unknowns related to vaginal yeast infection. “In the vagina, yeast and lactobacilli coexist quite happily, while in the laboratory, lactobacilli can kill yeast,” says Dr. Mitchell. So, taking probiotics isn’t a scientifically based strategy, because real-life circumstances don’t match what happens in the laboratory.

For now, the only proven treatments for bacterial vaginosis and yeast infection are antibiotic or antifungal treatments, says Dr. Mitchell.

A solution springs from frustration

But sometimes women don’t respond to the standard treatments and experience recurrent problems that leave them searching for solutions. Dr. Mitchell says that some women she’s encountered are trying not only probiotic supplements, but also alternative treatments they’ve found on the Internet. These include putting yogurt-soaked tampons, tea tree oil, and even garlic cloves into their vaginas in an effort to introduce beneficial bacteria. These solutions, she says, are not only ineffective but highly inadvisable.

“It’s true that a compound in garlic, allicin, has been shown to kill yeast in a laboratory. But you cannot put enough cloves of garlic in your vagina — or take enough oral garlic capsules — to achieve the same effect,” says Dr. Mitchell. Tea tree oil also has no demonstrated benefit and can cause irritation. Yogurt-infused tampons don’t work either. Many probiotic supplements and most yogurts do contain Lactobacillus bacteria, but it’s generally not the same type of Lactobacillus found in your vagina. L. crispatus and L. iners are the most common species found in the vagina. Most probiotics and yogurt contain other species, such as L. rhamnosusor L. acidophilus, which are more common in the gut.

Benefit or harm?

There also isn’t enough information to determine if introducing new bacteria using probiotics might do more harm than good. One study published in September 2018 in the journal Cell found that when people were given a probiotic after antibiotic treatment, their natural gut bacteria actually took longer to recover than did the gut bacteria of people who didn’t take the probiotic.

What I tell people is that over all, vaginal probiotics are probably a waste of money,” says Dr. Mitchell. “But if you are going to pick one and you really want to try one, the probiotics that seem to show some benefit in studies are ones containing Lactobacillus rhamnosus GR-1.”

Keep in mind that supplements, unlike medications, are not FDA-regulated. “Studies have shown that when these products are cultured, they often don’t have as much of what is on the label as promised, or don’t even contain what is on the label,” says Dr. Mitchell. The FDA has also found that some supplements contain potentially dangerous contaminants.

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Eosinophilic esophagitis: A new food-related allergic condition on the rise?

In the early 1990s, doctors began describing a new condition affecting the esophagus of patients who were predisposed to allergies including food allergy, asthma, and eczema, and who were having trouble swallowing. Today, we call this condition eosinophilic esophagitis (EoE).

What is EoE?

EoE is an allergic inflammation of the esophagus that causes a range of symptoms. Adolescents and adults most often experience it as difficulty swallowing, sometimes feeling like food moves too slowly through the esophagus and into the stomach. In some cases, food actually gets stuck (and may require urgent removal). Children and some adults primarily experience reflux symptoms and abdominal pain rather than difficulty swallowing.

In most cases, EoE develops as an allergic response to certain foods including wheat, milk, egg, soy, nuts, and seafood. If it is not properly diagnosed and treated, EoE may lead to permanent scarring or strictures (narrowing of the esophagus).

How is EoE diagnosed?

When EoE is suspected, generally the first test is an upper endoscopy, in which a flexible tube with a small camera and a light on one end is used examine the esophagus. The endoscopy usually reveals characteristic features of EoE, such as concentric rings and linear furrows or vertical lines, as well as small white spots or plaques.

The diagnosis is confirmed if biopsies from the esophagus reveal the hallmark increase in eosinophils. Eosinophils are a relatively rare type of immune cell that play a prominent role in allergic disorders including EoE and asthma.

How common is EoE?

EoE can affect both men and woman of any age, but it appears to be most common in men in their 30s and 40s. It is currently estimated that EoE may affect up to one in 2,000 adults in the US, and evidence suggests that the numbers have been growing. A recent review of nearly 30 studies in Europe and North America found that there has been a progressive increase in the number of new EoE cases, especially since the early 2000s.

The rise in EoE cases may be partly due to greater awareness of the condition and more widespread use of endoscopy. But a number of studies have confirmed a true rise in the incidence of the disease.

Why might EoE be on the rise?

The exact reasons for the rise of EoE are unknown, and it is especially puzzling that in many cases EoE results from an allergic sensitivity to a food that has been well tolerated up to that point.

There are several hypotheses about why EoE is increasing. Many of them relate back to the idea that EoE, and other allergic and autoimmune diseases, seem to correlate with decreased exposure to microbes and infections. Possible explanations that have been explored include:

• The hygiene hypothesis: do fewer childhood infections equal more allergic diseases?
• Microbial dysbiosis: has the modern/Western diet and lifestyle changed our microbiome?
• Environmental factors: might changes in food production, genetic modification of crops, chemical additives, food processing, and pollutants play a role?
• Declining frequency of H. pylori infection: might this common stomach bacteria (a common cause of peptic ulcers) be protective against some allergic diseases?
• Increasing frequency of gastroesophageal reflux disease (GERD): could acid reflux break the barrier of the esophagus and allow food allergens to stimulate the immune system?
• Increasing use of acid-suppressing medications: does the use of antacids, especially early in life, change the microbes in the esophagus or somehow otherwise alter the risk of later food allergy?

How is EoE treated?

There are currently no FDA-approved treatments for EoE. Most people are initially treated with a proton-pump inhibitor (PPI) antacid, which resolves EoE in up to half of cases. If this does not work, either a mild topical steroid or identification and elimination of specific dietary triggers is attempted.

When steroids are used to treat EoE, these are generally in a liquid formulation that is swallowed, rather than inhaled as they would be for asthma. Swallowed steroids act locally on the esophagus and are minimally absorbed through the gastrointestinal tract. Although steroids for EoE are generally safe and effective, they do not lead to a long-term cure because the disease tends to come back as long as patients continue to eat foods that trigger the underlying allergic response.

Patients may also opt to identify their food trigger and eliminate it from the diet, and this represents a more definitive treatment approach. Unfortunately, currently available allergy testing does not accurately predict the foods that cause EoE. Trigger foods generally need to be identified using a process of food elimination and reintroduction. Wheat and dairy are the two most common triggers for EoE, and patients will often start by eliminating these two foods for about eight weeks. At that point, their symptoms are reassessed, and they also undergo a repeat endoscopy with biopsies to determine if the eosinophils have disappeared in response to the dietary changes.

Several medication therapies are on the horizon. These include better formulations of steroids and biologic medications that reduce the activity of eosinophils.

Summary

If you are having trouble swallowing or have experienced episodes of food getting stuck in the esophagus, particularly if you have other allergic conditions, discuss your symptoms with your doctor. Unrecognized or untreated EoE can lead to permanent damage to your esophagus.

For more information or to learn about strategies for living with EoE, visit the American Partnership for Eosinophilic Disorders.

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How to help your baby through shots and blood tests

As much as we try to avoid having our babies go through pain, sometimes it is inevitable — and sometimes, as is the case with vaccinations and blood tests, pain is part of something that is ultimately important for the baby’s health and well-being.

Luckily, shots and blood tests are both quick. But there are things you can do to help your baby feel less pain, be less afraid, and get through the procedure more easily.

Helping your baby through the pain of shots and blood tests

Here are some suggestions that will help:

• Hold your baby. Having you be close by, and feeling your skin against theirs, can be very comforting.
• Swaddle your baby. When babies are wrapped up tightly, it helps them contain their bodies and their emotions. Obviously, shots and blood tests involve at least one leg or arm, so you can’t completely swaddle them, but you can swaddle whatever isn’t in use.
• Breastfeed, if possible. It’s not always possible for the nurse or the person drawing blood to do their job while the mother nurses because it can be hard to hold the child still, and sometimes people worry about the baby choking on milk when he or she cries. But if it is possible, it can be helpful.
• Use a pacifier. Sucking often soothes babies.
• Talk to your baby. Hearing your voice is both calming and distracting to babies.
• Talk to your doctor about using sugar water. Studies have shown that dipping a pacifier in sugar water or putting some into the baby’s mouth with a syringe can make a procedure less painful. It’s not fully clear how it works; it may activate the body’s natural systems for fighting pain.

As soon as the shot or blood test is done, pick your baby up and hold him or her close. That way the baby knows that it’s all over — and that you are there to take care of them.

Most of the time, babies are fine once the worst of it is over. But sometimes babies can have soreness where the needle went in, and it’s not uncommon for babies to feel uncomfortable or a bit sick for a day or so after vaccines. All the suggestions above can help with lingering discomfort. Usually medication isn’t needed, and after immunizations, using medications like acetaminophen can sometimes decrease the effectiveness of the vaccine itself.

Your doctor can help you decide what makes sense for your baby and your situation.

Follow me on Twitter @DrClaire

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A new look at steroid injections for knee and hip osteoarthritis

Osteoarthritis is a common and potentially debilitating condition. It’s a degenerative joint disease (often called the “wear-and-tear” type) in which the smooth lining of cartilage becomes thinned and uneven, exposing the bone beneath.

Although osteoarthritis is tightly linked with aging, we now know there is more to it than age alone: genetics, weight, physical activity, and a number of other factors can conspire to make it more likely that someone will develop osteoarthritis while someone else won’t. Osteoarthritis is the primary reason that more than a million joints (mostly hips and knees) are replaced each year in the US.

Treatments short of surgery can help but they don’t always work well, don’t cure the condition, and may be accompanied by side effects. Surgery is usually the last resort, reserved for people who have declining function, unrelenting pain, or both despite trying other treatments such as pain relieving, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, others) or naproxen (Aleve, others), or injections of steroids or hyaluronic acid (a type of lubricant). Nonmedication approaches can also help, such as loss of excess weight, physical therapy, or use of a cane or brace.

Calling steroid injections into question

Steroid injections can quickly relieve inflammation in the joints, and the effects may last from several weeks to several months. I’ve seen a number of patients who got significant relief from steroid injections every three or four months. But, a new report of one medical center’s experience and a review of past research came to some concerning conclusions about joint injections for osteoarthritis of the hip or knee. These included:

• a lack of compelling evidence that they work
• about 7% to 8% of people getting steroid injections seem to worsen, with their arthritis accelerating “beyond the expected rate”
• unusual fractures may occur (in about 1% of people)
• bone damage (called osteonecrosis) (in about 1% of people).

Other side effects include a temporary increase in blood sugar, bleeding into the joint, and, quite rarely, infection. And, of course, the injection itself can be painful, although numbing medication is usually provided.

The authors suggest that doctors order x-rays before each injection and not perform injections if there is evidence of any of these complications or unexplained pain. However, it’s not clear how effective this approach would be.

Now what?

The findings of this report regarding injections of steroids for knee and hip osteoarthritis are disappointing, especially for those who have not improved with other treatments.

Regarding the benefit of the injections, it’s important to keep in mind that even if the average benefit of a treatment is small, it does not mean that treatment is useless. Though temporary, some people do report significant improvement with steroid injections.

It’s also not entirely clear that the problems described in this study are actually caused by the steroid injections. And, from my own experience, the rates of complications seem high to me. That said, a 2017 study did find that people getting steroid injections had more thinning of joint cartilage than those getting placebo injections.

In my own practice, I’ll still offer a steroid injection for osteoarthritis, but only after carefully reviewing the potential risks and benefits. If it is not terribly helpful, I would not encourage repeated injections. On the other hand, if it works well, a limited number of injections (up to three or four per year is a common limit) may reduce pain and improve function and quality of life.

Restricting the injections to those who improve the most and limiting the number of injections each year may be a better strategy than eliminating steroid injections altogether, especially since the most serious side effects are quite rare.

We’ll need additional studies that examine the type, dosage, and frequency of steroid injections that might provide more benefit than risk. And we’ll need better ways to predict who will improve the most. Until then, I think it’s important to keep an open mind about just how helpful — and how safe — steroid injections for osteoarthritis truly are.

Follow me on Twitter @RobShmerling

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Researchers urge prostate cancer screening for men with BRCA gene defects

Prostate cancer screening with the prostate-specific antigen (PSA) test has been criticized for flagging too many slow-growing tumors that might never be life-threatening.

But some men have inherited gene defects that boost their risk of developing prostate cancers that can be quite aggressive. Is PSA screening particularly well-suited for these genetically defined groups? New research suggests the answer is yes.

In November, a team of British scientists released highly anticipated findings from a study of PSA screening in men with defects in a pair of important genes called BRCA1 and BRCA2. Better known for increasing the odds of breast and ovarian cancer in women, BRCA gene defects are also risk factors for aggressive prostate cancer in men. Cells with defective BRCA genes have a compromised ability to repair the DNA damage they sustain routinely every day. As that damage accumulates, those cells become prone to forming tumors.

What the investigators wanted to know was if PSA screens detect more prostate cancers in men who test positive for BRCA mutations than those who do not. To find out, they screened just over 2,900 men ages 45 to 69 who were split into four groups: a BRCA1 mutation-positive group, a BRCA2 mutation-positive group, and two groups that tested negative for mutations in either gene. The men were screened annually for four years, and had a prostate biopsy if their PSA levels ran higher than 3.0 nanograms per deciliter.

What the results show

In all 357 men were biopsied, and 112 of them were diagnosed prostate with cancer. The BRCA2 mutation carriers had the greatest cancer risk: 5.2% of them were diagnosed with the disease, and most of their tumors had intermediate- or high-risk features. BRCA1 mutation carriers had a lower risk: 3.4% of them were diagnosed with prostate cancer. And the men who tested negative for BRCA1 and BRCA2 mutations had the lowest risk overall, with diagnosis rates of 3.0% and 2.7% respectively.

Based on the results, Ros Eeles from the Institute of Cancer Research in London, who led the research, issued a statement calling on regulatory bodies to update guidance so that men with BRCA2 defects can get regular PSA screening after age 40.

Most expert groups in the United States recommend that doctors start talking about the pros and cons of PSA testing with patients who are 55 or older. However, guidelines are being rewritten to focus screening on high-risk groups at younger ages, and BRCA2 mutation carriers are widely considered to be in the highest-risk category.

Men should consider being tested for BRCA mutations under the following conditions:

• If there’s a history of prostate, breast, or ovarian cancer in the immediate family, particularly among younger members
• if other family members test positive for BRCA1 or BRCA2 mutations
• if they are of Ashkenazi Jewish descent, since BRCA mutations occur frequently in this ethnic population.

Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, says new guidelines that should be available soon will provide more information for families at risk of these cancers. If possible, he says, men should consider getting a PSA test when they’re 10 years younger than the age at which the youngest family member was diagnosed. Fortunately, he adds, new tailored treatments are becoming available for BRCA mutation carriers, and studies so far show promising responses.

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Wearables and sleep: What can they really tell us?

Smart devices are everywhere, including wrist-based monitors. These wearables promise to count our steps, remind us to move, and provide insight on our sleep. But can we trust them to measure our sleep accurately?

Most wrist-based devices are based on an accelerometer, which measures wrist movement. The data gathered from the accelerometer — how often the wrist moves and how forceful that movement is — are coded as sleep or wake. In some cases, programs will also label sleep as light or deep, seeming to imply that the sleep is good or bad. Some devices also monitor heart rate. Small variations in the timing of heart rate — which occur naturally under certain situations with a regular heart rhythm — may provide some clues about sleep stage as well. During stable deep sleep, breathing is typically very regular, and so is heart rate.

After these wrist devices collect data on our movements and/or heart rate during sleep, it is wirelessly transmitted to our phone or computer, and software programs analyze it to create charts and graphs that allow us to “see” our sleep.

Sleeping is believing, right?

It can be nearly magical to go to bed, sleep, and then instantly get a graph that shows what we did while we were sleeping. Was it a good night? How much deep sleep did we get? A few taps on the phone will show the truth. A graph will tell us how we spent the last several hours, with a breakdown of time awake, time in deep sleep, and light sleep. We may even get an overall “score” for the night. This is data-based, so it must be accurate, right? Turns out, the answer is much more uncertain.

How well do these devices measure sleep?

First, it is worth noting that the software algorithms that decide what is sleep and what is wake are a bit of a “black box.” These are proprietary, owned by the various companies that make the devices, meaning sleep doctors and researchers don’t know exactly how the programmers decided to make these determinations. Between different brands, or even different devices within a brand, the software code, and therefore sleep interpretation, could vary.

Consider that perhaps one wrist device determines that you’re awake after a bunch of forceful movements — think brushing your teeth — while for another device, a single small twitch of the arm may be considered being awake. How many movements mean we’ve woken up? One? Ten? Over what time period, one movement per minute? Ten movements over two minutes? How forceful do those movements have to be? How does the software decide we’re up for good or if we fall back asleep after movement? How good is the device at even catching movement — does it know if the wrist device is too loose? With all of these factors, the possibilities to code the data and interpret the data are infinite.

Second, there’s little to no data that compares wearable devices to research or clinical measurements. Actigraphs are small wrist-based devices that sleep providers and researchers utilize to measure sleep over longer periods. Similar to the consumer-available devices, they use accelerometers to sort sleep versus wake. Actigraphs, however, have been extensively studied and compared against sleep logs, sleep studies, and other data. Sleep providers have a fairly good sense of their strengths and limitations, and therefore how to use the data. The consumer devices are rapidly changing — newer monitors, frequent software upgrades. In general, the studies suggest that these wrist devices overestimate sleep duration (how long we’re asleep), and how much of the night is spent asleep (sleep efficiency).

Finally, there’s even less data on how these devices are impacted when there is a coexisting sleep or medical condition, or by medications. Consider a patient with insomnia who meditates when he can’t sleep and lies still in bed. This absence of movement and steady breathing could easily be misinterpreted as sleep by a wrist-based device.

What’s the gold standard for measuring sleep?

 A sleep study, also called a polysomnography, measures brain waves, muscle tone, breathing, and heart rate, while a technician supervises, often in a hospital setting. The information from the brain waves determines wake versus sleep, and the stage of sleep. This is considered the gold standard for determining sleep characteristics in most circumstances. However, it is time- and labor-intensive, and expensive (and not always covered by health insurance).

Should we pay any attention to these devices?

Wrist-based devices seem to be here to stay, and people are going to be curious about their sleep. In general, I counsel my patients to review their sleep data with a grain of salt. It’s just one piece of the picture to incorporate, and doesn’t substitute for a quality sleep log or other forms of sleep assessments. The benefit is that the collection of this data is fairly passive, and can be done for longer stretches of time to gain insight into patterns.

Keeping in mind how these wearables measure sleep helps us know what they can and can’t do. In general, the devices probably do give us a rough sense of the time we’re spending in bed (which may or may not equal sleep time), and the regularity of sleep zone (the time we slept or tried to sleep between going to bed and getting up). Gaining insight on these two factors can be very helpful, and hard to pin down for some patients in other ways. Though the wrist devices don’t substitute for a medical opinion or sleep study in a hospital, if they help us reflect on our sleep and how much (or little) we’re getting, they may have a role if used carefully.

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A low-tech school vacation: Keeping kids busy and happy without screens

As we near the holiday season, along with trying to keep track of holiday events, parties, and gifts, parents have to think about what to do with their children during school vacation. Given how exhausting the holiday season can be, it’s understandable why parents often let their children spend hours with the TV, tablet, or video games. After all, happy, quiet kids make for happy parents who can finally get stuff done — or relax.

Except kids are spending way too much time in front of screens. According to Common Sense Media, kids ages 8 to 12 are spending nearly five hours a day on entertainment media — and tweens and teens are spending seven hours. This is just entertainment media; it does not include time spent using screens for school or homework.

Given how enticing entertainment media can be, those numbers can easily go higher during unscheduled times like weekends and school vacation. That’s why it’s good to be proactive and come up with other activities. Below are some ideas for parents and caregivers to try. These are mostly good for kids through elementary school, but tweens and teens may enjoy some of them too.

Spending time off the screen

Go outside. This sounds obvious, but spending time outdoors is something kids do less than they used to — and it can be really fun. If you have a yard, go out into it and play hide-and-seek or build a fort from snow or anything else that’s around. If you don’t have a yard, go to a local park or just go for a walk.

Go to the library. Do this early on in vacation, so that your child has lots of books to pass the time. Check out as many as they allow and you can carry.

Build a fort in the living room. Use blankets or sheets over chairs; if you have a small tent, set it up. Bring in pillows, sleeping bags, and flashlights; let the kids sleep in it at night. Let it stay up all vacation.

Build a city in the living room. Use blocks, Legos, boxes (or anything else), and add roads, cars, people, animals, trains, and other toys. Let it stay up all vacation, and make it bigger every day.

Getting creative off the screen

Get creative. Go to the craft store and stock up on inexpensive supplies. Buy things like poster board, huge pieces of paper (you could use those for your city, too, to make parks, roads, and parking lots), paints, and markers. You can make a paper mural, a comic book, a story, posters, or whatever catches your child’s imagination. If you know how to knit or sew, think about teaching your child or making a simple project together.  Play music while you create.

Read out loud. There are so many books that are fun to read aloud. When my children were younger, we read the Harry Potter series out loud, as well as the Chronicles of Narnia and books by E.B. White and Roald Dahl. Act out the voices. Have some fun.

Have a puppet show. If you don’t have puppets, you can make some with socks — or you can hold up dolls or action figures and do the talking for them. You can make a makeshift stage by cutting out the back of a box and taping cloth (like a pillowcase) to fall over the front.

Get out the games. There are so many that work across the ages, like checkers, chess, Uno, Connect 4, Sorry, Twister, Clue, Scrabble, or Monopoly. We forget how much fun these can be.

Bake. You don’t have to get fancy — it’s fine to use mixes or pre-made cookie dough. There’s nothing better than baked goods straight from the oven, and adding frosting and decorations makes it even more fun. Turn on music and dance while things bake.

While parents or caregivers need to be involved with some of these activities (like the ones involving the oven, or reading out loud), kids can do many of them independently once you have it started. Which, really, is what children need: time to use their imagination and just play.

But you just may find that once you have things started, you want to play, too.

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Infertility: Grandparents in waiting

“Do you have grandchildren?” This seems like a simple question and one appropriate to ask women and men of a certain age. However, for those who are grandparents-in-waiting this question can bring layers of pain, fear, and challenge. These feelings are all the more powerful for grandparents-in-waiting who themselves experienced infertility years earlier, but they can wallop anyone whose child is struggling to have a child.

I’ll begin by defining “grandparents-in-waiting.” I use this to refer to people — usually in their 60s and 70s — who have adult children dealing with infertility or repeated pregnancy loss. Grandparents-in-waiting include those who already have grandchildren from their other adult children, and grandparents-in-waiting who have no grandchildren. There are also grandparents-in-waiting who face the dual challenge, or mixed blessing, of having a grandchild on the way through one daughter or son while another adult child grapples with infertility.

Feelings that may arise for grandparents-in-waiting

If you are a grandparent-in-waiting, here are a few of the feelings you might be experiencing or can anticipate.

Helplessness. There is a saying common among parents, “You are only as happy as your least happy child.” Whether one has zero grandchildren or 10, it is painful to see one’s child struggling to have a baby. You may be surprised to find yourself coping with your helplessness and lack of control by avoiding your friends. After all, many of them are grandparents, and being with them risks opening yourself up to news of new pregnancies or chatter about grandchildren.

Anger. By the time you reach your 60s or 70s, you’ve learned all too well that life is unfair. That said, it is hard to get away from the feeling that it is all so unfair. Pregnant women seem ubiquitous when your child is longing to be pregnant. If you are a veteran of your own infertility, you will recognize the nasty and harsh feelings that can arise toward pregnant women. If you had your own child or children with ease, these feelings can be unsettling. Grandparents-in-waiting need to know that angry, resentful feelings toward pregnancies — and even toward their friends’ grandchildren — don’t mean that they are turning into bad people.

Sadness. Having a child go through infertility, or suffer pregnancy loss, is a double sadness. You are sad for your child and you are sad for yourself, all the more so if you have no grandchildren. It is hard not to look around and feel that grandparenthood is a lottery. Some people have one child and wind up with four grandchildren. Others have four children and just one grandchild who lives thousands of miles away.

Rising to the challenge as a grandparent-in-waiting

Perhaps the biggest challenge for a grandparent-in-waiting is to deal with your own feelings without making things any more difficult for your child. Here are some guidelines for dealing with your daughter, daughter-in-law, or son during infertility.

• Let them control communication. Some adult children want to share their infertility struggles with their parents; some do not. If your child seeks privacy, respect that. Let them know that you are there if something changes and they want to talk.
  If your child is open with you, talk with them about what helps and what does not. For example, they may want to fill you in on what is happening, but be upset if you offer advice or try to “help” more actively. An open discussion can help you avoid feeling like you are walking on eggshells.
• Avoid any hint of blame. Regret is often the most painful part of infertility. Be aware that your child may blame herself or himself for “waiting too long,” “having other priorities,” or perhaps choosing the “wrong” doctor. Be there to listen but do all you can to avoid contributing to self-blame.
• Communicate acceptance. While grappling with infertility, people begin to think about other options such as adoption, egg donation, and surrogacy. If your child is beginning to consider “option B,” she or he will be sensitive to your reaction. It will mean a lot to your child to know that you will welcome and adore a grandchild regardless of how that child joins the family. That said, you need to be careful not to inadvertently communicate pessimism regarding current treatment. Your daughter or son could perceive your embrace of adoption or egg donation as evidence that you don’t think that their efforts on their own, or with IVF, will work.
• Be the parent. Your daughter may be super successful in her career, but right now she is your child and she needs you. Whether she communicates it or not, it means the world to her to know she can lean on you. By being the parent and doing your best parenting thing, you will let her know that you are there for her and that you are okay with your wait to be her child’s grandparent. She needs to feel that you are not suffering. Or perhaps more accurately, she needs to know that you can push your own pain firmly aside because your priority is to help diminish hers.

It is not easy to be a grandparent-in-waiting. Aging teaches all of us that life is short. Your wait for a grandchild is all the more difficult when you feel that you are losing precious time. There is no way to explain away or sugar-coat the loss of time. Still, I hope you are comforted to know that being able to be there for your child at this difficult time is a gift and a blessing.

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DOACs now recommended over warfarin to prevent blood clots in people with atrial fibrillation

For decades, warfarin (Coumadin) was the standard anticoagulant medication used to prevent blood clots, which can lead to stroke, in people with atrial fibrillation (afib). Direct oral anticoagulants (DOACs), sometimes called novel oral anticoagulants (NOACs), are a new type of anticoagulant medication that came on the market in 2010.

In 2019, the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) updated their afib guidelines to strongly recommend using DOACs over warfarin in people with afib.

Warfarin is effective, but has downsides

Afib is a condition in which the upper chambers of the heart (the atria) quiver, and blood doesn’t flow well. This may lead to the formation of blood clots, which can travel to the brain and cause a stroke. Anticoagulants, which are also referred to as blood thinners even though they don’t actually thin the blood, make it harder for blood to clot and help keep existing clots from growing.

Warfarin was introduced into clinical practice for the prevention of clots associated with afib in the 1950s, and has proven to be a very effective therapy. Unfortunately, it requires close monitoring with blood tests to make certain that the blood does not clot too quickly or too slowly.

The ability to keep the blood thinned in the correct range can be very difficult because warfarin interacts with many foods and medications. In addition, up to 25% of the population is born with a genetic characteristic that makes it extraordinarily difficult to keep the blood thinned in the therapeutic range on warfarin.

DOACs more effective, less finicky than warfarin

Intensive efforts were underway for decades to develop alternatives to warfarin. This resulted in the FDA approval of four DOACs for clot prevention in atrial fibrillation, beginning in 2010: apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa), and rivaroxaban (Xarelto).

The use of DOACs compared with warfarin has been studied extensively, and we now have years of experience using these drugs. DOACs are remarkably free of side effects and do not require blood test monitoring. They have proven to be as effective as warfarin to prevent clot formation, and in some cases have proven to be slightly better than warfarin.

DOACs less likely to cause life-threatening bleeding

The major complication of taking any anticoagulation medication is bleeding. This risk is present with both warfarin and the DOACs. However, the risk of the most life-threatening form of bleeding — bleeding into the brain — has been shown to be roughly 50% less likely on the DOACs compared with warfarin.

One major concern I often hear from patients and physicians is that the blood-thinning effect of DOACs is irreversible. Fortunately, we now have antidotes for all of the DOACs. (The anticoagulant effects of warfarin are easily reversed with vitamin K.)

In addition, DOACs have a more rapid and predictable effect than we see with warfarin. DOACs thin the blood within a day; once stopped, the anticoagulation effect wears off quite rapidly, within 24 to 48 hours. It can take days to weeks for warfarin to thin the blood in the correct range, and at least three to five days before the blood is no longer thinned after stopping warfarin.

DOACs now seen as the better option for most people with afib

We are increasingly using DOACs as a first choice for anticoagulation in afib. We are also giving many patients the option to switch from warfarin to DOACs if they are already on warfarin. In general, this change can be made easily. The only patients with afib who should stay on warfarin rather than using a DOAC are those with a mechanical artificial heart valve.

There are some small differences between the different DOACs, but they are not major and can be discussed with your physician. For example, some DOACs may be better or worse for a patient depending on his or her kidney function.

The cost of these drugs is dropping, but is certainly more than warfarin. Increasingly, insurance companies cover their preferred DOAC, which makes using a non-preferred DOAC much more expensive. For most people, using the DOAC that is least expensive based on their insurance coverage is absolutely fine.

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Weight loss surgery for children and teens struggling with obesity

Right now, one in 12 children and adolescents in the US are severely obese. If that isn’t startling enough, consider this: among 12-to-15-year-olds, that number jumps to one in 10 — and among 16-to-19-year-olds, it is one in seven. According to the American Academy of Pediatrics (AAP), the best hope for many of these youths may be bariatric surgery. Bariatric surgery is surgery that helps with weight loss by making the stomach smaller and making other changes in the digestive system.

It’s jarring to think about doing irreversible surgery on an adolescent — or a child, as the AAP discourages age limits for bariatric surgery. But the reality is that obesity, with all of its risks, can be equally irreversible.

In children and teenagers, obesity is defined as a body mass index (BMI) greater than or equal to the 95th percentile for age and sex. If you are obese by the time you are 12, research suggests you have a 98% chance of being obese as an adult. Those are not good odds — and they are made more alarming by the complications of obesity. Diabetes, high blood pressure, fatty liver disease, and obstructive sleep apnea (which can lead to further problems, including heart disease) are the most common complications among younger people. In adults, the list expands to include even more problems, such as stroke, arthritis, and cancer.

Clearly, this is not a problem we can ignore.

When obesity isn’t severe, lifestyle changes such as eating a healthy diet and getting more exercise are absolutely the go-to methods of care. But once you get into severe obesity — usually a BMI of 35 or higher — lifestyle changes just don’t do the trick. (Severe obesity is a BMI greater than or equal to 120% of the 95th percentile for age and sex.) If lifestyle changes are all we suggest for children with severe obesity, we are condemning them to obesity and all of its complications. It’s that simple.

What does research on bariatric surgery tell us?

In the longest study of the effectiveness of bariatric surgery in youths, which followed patients for eight years on average, those that had surgery lowered their BMI by 29%. Those that didn’t have surgery? Their BMI went up by an average of 3.3 points.

Of course, the idea of surgery raises concerns. Yet bariatric surgery is actually safe and effective if done by experienced surgeons working in a high-quality center, with a strong multidisciplinary team that can give patients and families the ongoing education and support they will need, including psychological support. Surgical complications are infrequent and usually minor. The most common complication is micronutrient deficiencies, such as iron deficiency. While these can be prevented by taking supplements regularly, the reality is that adolescents are not always great about taking anything regularly. That’s why it’s important that the surgery be done at a center that offers a team approach and follow-up care in years to come.

Which children might benefit from weight loss surgery?

According to the AAP, parents and pediatricians can consider bariatric surgery if a child or teen

• has a BMI greater than or equal to 35 and one or more complications of obesity
• has a BMI greater than or equal to 40 whether or not they have complications.

Not everyone who falls into those groups should have surgery, though. It is not recommended for youths who

• have untreated or poorly controlled substance abuse problems
• have eating disorders
• are pregnant or planning pregnancy.

It is also not recommended for those who can’t follow all the post-operative recommendations, including all the lifestyle and eating changes that are mandatory after surgery. Anyone who has had bariatric surgery needs to be very careful and thoughtful about what they eat, not just in the weeks and months after surgery, but for the rest of their lives. They’ll also need to take supplements every day.

The bottom line

While bariatric surgery is clearly not a decision to be taken lightly, it’s not a decision we should be avoiding, either. If we want to give severely obese youth their best chance of a healthy life, we have to get over our fear of surgery — and the common bias that obesity is just a matter of personal responsibility (think willpower) and not the medical problem that it is. Our children deserve better.

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Lasmiditan: New first-in-class drug treatment approved for migraine

Migraine is a huge medical problem, accounting for half of the disability produced by all neurologic diseases worldwide. The medication sumatriptan (Imitrex) is well known for the treatment of a migraine attack. Sumatriptan is part of a group of medications known as the triptans.

Triptan medications have been in use for over 20 years and are very effective for the acute treatment of headache (relieving migraine headaches that are already in progress). But they also have limitations; triptans can cause temporary narrowing of blood vessels in the heart and elsewhere that can result in side effects, such as chest pain or tightness or shortness of breath, which may at times be serious.

A medication that worked as well as a triptan, but without the same restrictions on use (for patients with prior heart attack, angina, or those with other vascular conditions) as the triptans, would be a welcome addition. Enter lasmiditan (Reyvow), which works without causing blood vessels to narrow.

How does lasmiditan work?

Lasmiditan is the first of a new group of headache medicines that are being called the “ditans.” Just like the triptans, lasmiditan can block a number of the processes that lead to the development of a full-blown headache. Taken at the first sign that a migraine is starting, it has the potential to stop the development of the headache and return the patient to normal function.

Clinical trials have shown a significantly greater number of patients being headache-free at two hours with lasmiditan compared to placebo. The main side effects noted in these studies were dizziness and sleepiness. These effects are probably related to the fact that this medication gets into and works inside the brain (triptans do not).

How lasmiditan works requires a bit of explanation. At one point in time, migraine was thought to result from abnormal dilation, or widening, of the blood vessels inside the head. A search for medications that could block this process, by producing blood vessel constriction (narrowing), led to the development of sumatriptan.

Sumatriptan was thought to be a blood vessel-constricting drug that targeted serotonin receptors (which are part of the pathway that triggers migraine pain) in the blood vessels and elsewhere, and blocked the development of headache. But it turned out that the headache benefit did not depend on blood vessel constriction. Surprisingly, the benefit was likely due to the triptan’s action at other serotonin receptors.

This led researchers to search for a medication that worked only at these other serotonin receptor sites, which could possibly block headache without causing vessel constriction. This search led to the development of lasmiditan.

Lasmiditan works on a specific type of serotonin receptor found not on blood vessels, but on nerves that are responsible for transmitting the pain of headache. These nerves are located both inside the brain itself, and inside the skull but outside of the brain. In testing, lasmiditan seems to block headache without having any effect on blood vessels.

FDA approves lasmiditan to treat migraine

The FDA recently approved lasmiditan and it should be available shortly in several dosages in pill form for treatment of a migraine attack. Lasmiditan should be used no more than once a day and no more than four times a month. Because of the possible side effects — dizziness and sleepiness — patients should not drive or perform other activities requiring mental alertness for eight hours after use. Animal studies suggest lasmiditan may not be safe in pregnancy, and thus should be avoided by women who are or may become pregnant.

Given the restrictions, this drug might be a choice for nonpregnant patients who cannot take triptans and want to treat a headache at the end of the day when going to bed anyway, or when the usual treatment of headache involves a period of sleep.

New drug represents greater understanding of headache

The development of lasmiditan represents increased scientific understanding of the problem of headache. As our knowledge develops, we can develop more specific and more effective treatments.

It is difficult to know at this point just where lasmiditan fits into the overall management of migraine. Whether we are on the verge of developing a whole new group of “ditan” medications will in part be determined by how well this first group member is accepted, and how useful it turns out to be in the real world.

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Sexually transmitted infections are on the rise: Should you worry?

In 2018, the number of bacterial sexually transmitted infections (STIs) reported in the United States reached an all-time high. This is worrisome for many reasons. Having an STI can raise risks for HIV, infertility, pregnancy complications, and infant death. Fortunately, all of these outcomes can be avoided if people receive appropriate treatment.

What are STIs?

STIs are illnesses caused by microorganisms passed between people during sex. An STI can affect anyone who is exposed to it. Syphilis, gonorrhea, and chlamydia are the most common bacterial infections. Trichomoniasis, a protozoan infection, is also diagnosed frequently in women (men who are affected almost never have symptoms).

A number of viruses can be sexually transmitted, including herpes simplex virus (HSV), human papilloma virus (HPV), HIV, hepatitis A, hepatitis B, and hepatitis C.

What are the symptoms of an STI?

New rashes on or near the genitals or elsewhere on the body, swollen lymph nodes, fevers, or discharge from the penis, vagina, or anus could all be signs of an STI. While many people who have STIs notice such symptoms, some STIs are asymptomatic and can only be identified by screening tests. For example, estimates suggest chlamydia affects close to three million Americans each year, yet symptoms may only occur in 5% to 30% of people. Other STIs, like Mycoplasma genitalium, may not cause symptoms and can be hard to diagnose.

Why are sexually transmitted infections increasing?

There are many reasons, including:

• Not using barriers — such as condoms and dental dams — during sex. Although condoms can prevent transmission of most STIs, many people of all ages and genders do not use them.
• Changing attitudes and knowledge around HIV may give some people a false sense of safety about unprotected sex. A new World Health Organization campaign (undetectable equals untransmissible, or U = U) notes that HIV is unlikely to be transmitted by a person with undetectable levels of the virus due to treatment. Similarly, HIV prevention strategies like pre-exposure prophylaxis (PrEP) may make some people feel less concerned about having unprotected sex.
• Significant budget cuts to local and state STI programs in recent years. This has led to facility closures and fewer sites for screening. New federal restrictions on family planning organizations like Planned Parenthood, which provides sexual health care and STI screening and treatment for hundreds of thousands of Americans, make widespread access to care increasingly hard.

Who should be tested for STIs?

If you think you might have symptoms of an STI or are concerned about recent sexual contacts, it’s best to be tested. Additionally, the United States Preventive Services Task Force (USPSTF) recommends routine screening in sexually active young women, men who have sex with men, and others at high risk for STIs, including anyone who has unsafe sex or shares needles or equipment used to inject drugs, including cottons and cookers.

If you would like to be tested for STIs, this locator tool may help you find a testing site in your area. Some testing sites are free and confidential.

What else should I know about STIs and testing?

STIs can infect any mucosal tissue exposed to the infection, such as the throat, anus, rectum, and genitals. The CDC recommends checking men who have sex with men at all three sites because studies show this helps identify more infections. A recent study reviewed screening results from 2,627 women who came to a sexually transmitted diseases clinic in Rhode Island. Among women who chose to have a multisite screening test, researchers found that 19% of chlamydia and gonorrhea infections would have been missed with genital screening only.

If you have unprotected sexual contact, STI testing should include

• the throat (for unprotected oral sex)
• the rectum (for unprotected anal sex)
• the penis or vagina (for unprotected penile or vaginal intercourse).

Keep in mind that STIs can also be spread by fingers and sex toys. A detailed sexual history is important to determine what sites need to be tested.

What can I do to prevent infections?

The best ways to prevent sexually transmitted infections are:

• Talk openly about your sexual practices with your partners and health care providers.
• Regularly test for STIs.
• Use barrier protection — like condoms and dental dams — when engaging in oral, anal, or vaginal sex.
• Ask your doctor if you should consider pre-exposure prophylaxis (PrEP), a daily pill that protects against HIV infection.
• Get vaccinated against HPV. This helps protect against HPV-related cancers of the cervix, genitals, anus, mouth, and throat. Vaccines are also available to protect against Hepatitis A and B.

If you do have an STI, make sure you get appropriate treatment. Additionally, consider using expedited partner therapy, an approach where a person diagnosed with gonorrhea or chlamydia receives a prescription for antibiotics for their partner. This is allowed in most states and has been shown to prevent recurrent infections by decreasing the number of people who continue to have sex with an untreated partner.

Where does all of this leave you?

Sexually transmitted infections are preventable and treatable. Good sexual health requires talking to your partners and health care providers openly about your sexual practices, being tested at all relevant sites on the body and, if necessary, being treated promptly. For more information, see the CDC fact sheets on STIs or learn more from TheBody.com.

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Trouble with crossword puzzles? Improve your semantic memory

Can you distinguish the taste of a red wine versus a rosé? How about the look of a 1960s muscle car versus a foreign import? Do you prefer to grow lilies or tulips? Would you rather listen to Dark Side of the Moon or “Fly Me to the Moon”? To answer any of these questions, you need to use your semantic memory.

Your semantic memory is your store of factual knowledge of the world and the meaning of words. It’s how you know that a fork is for eating (not twirling your hair) and what color a lion is. It’s both the source of your vocabulary and how you know what something does even if you don’t know the name of it — like that little bit of plastic that covers the end of a shoelace (an aglet).

Use episodic memory to increase your semantic memory

To form new semantic memories, you need to use your episodic memory to learn new information. For a week, month, or year, you might remember where you were and what you were doing when you learned a new fact. Over time, however, you will forget the context and just remember the fact. Once only the fact remains, it is part of your semantic memory.

The left temporal lobe: Your brain’s dictionary

Several landmark papers have examined where semantic memory is stored in the brain. In 1996, two related studies were published in an article in Nature.

For the first, the researchers enrolled over 100 patients with strokes and other brain lesions in their left temporal lobe. (Put your finger on your left temple, just behind your eye — that’s where the left temporal lobe is located.) They asked these patients to name famous people, animals, and tools that were man-made objects. They found that the location of brain lesions affected recall. Patients with the most anterior lesions (close to their eyes) had the biggest difficulty naming persons. Patients with the most posterior lesions (toward the back of head) had the greatest difficulty naming tools. And those with lesions in between these areas had the most difficulty naming animals.

In the second study the researchers had healthy adults name famous people, animals, and tools while undergoing a positron emission tomography (PET) scan that showed brain activity. As expected, naming people yielded the most anterior activity, tools the most posterior activity, and for animals the activity was in between.

Dementia may erase words from the dictionary

More recent research links deterioration of the anterior temporal lobe to the difficulties understanding what a word means exhibited by people with some types of dementia. Although people with Alzheimer’s disease most commonly exhibit this abnormality, it is most prominent in a type of aphasia known as semantic dementia. When you speak with these individuals, they may start off sounding normal, but you will notice that they refer to all sorts of different items as the “thing” or a similar word. As you talk with them further, you will discover that they do not know what certain words mean, such as “medicine” or “shoe” — two examples from one of my patients.

Semantic memory in other brain regions

Just as our knowledge is not limited to words, neither is our semantic memory limited to the left temporal lobe. The right temporal lobe has been linked to knowledge of nonverbal information (such as the weight of a golf ball versus a ping-pong ball) and facial recognition. Other parts of the brain also participate in semantic memory. For example, what Frank Sinatra singing “Fly Me to the Moon” sounds like is stored in your auditory association cortex in your superior temporal lobe. Your image of a Chevrolet Camaro is stored in your visual association cortex in your occipital lobes. And the feeling of tulip petals resting on your cheek is stored in your sensory association cortex in your parietal lobe.

Semantic memory does not decline in aging

Can improving your semantic memory help you do a crossword puzzle? Yes. Not only does semantic memory store the meaning of words as well as nonverbal concepts, it also stores the relationships within and between words and concepts. For example, your semantic memory of the band Pink Floyd may be linked to the President of the United States in the following way: Pink Floyd’s album Dark Side of the Moon may be connected in your semantic memory to moon landings, which is then connected to astronauts, to John Glenn, to senators, to politicians, and to presidents.

Lastly, a bit of good news: research suggests semantic memory does not decline in normal aging. As you continue to learn new information throughout your life, your vocabulary and your ability to solve crossword puzzles may actually improve with age.

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Medications as effective as stents for most with coronary artery disease

How best to treat a patient with stable coronary artery disease (CAD)? The cardiology community has debated this question for decades, arguing whether it’s best to take a conservative or invasive approach.

The ISCHEMIA trial (ischemia means not enough oxygen is getting to the heart muscle), a new study reported at November’s American Heart Association meeting, provides some answers. This study suggests that for most, managing CAD with medications alone (the conservative approach) is as safe and effective as the more invasive strategy of cardiac catheterization and opening of the blocked artery.

Findings of the ISCHEMIA trial

ISCHEMIA followed over 5,000 patients with significant narrowing in one or more coronary arteries. Half of the patients were randomly selected to receive conservative treatment with optimal medical therapy (OMT) and lifestyle changes to treat risk factors such as high blood pressure and high cholesterol. The other half were given OMT and also sent for cardiac catheterization (threading of a flexible catheter into the heart arteries to look for narrowed or blocked coronary blood vessels). When blockages were found, these patients underwent placement of a small mesh tube, called a stent, to prop open the affected area. When blockages were too complex for stent placement, open-heart surgery was performed.

The findings were surprising. Many cardiologists would have predicted that the invasive strategy would be superior to the conservative strategy. The group that received stents did report greater relief of angina, or chest pain. But there was no significant difference between the two groups in terms of rates of heart attack, death, or hospitalization for worsening heart pain.

Proponents of the conservative approach argue that OMT makes more sense than stenting because it addresses all the arteries in the heart, not just the small section of narrowing addressed by a stent that may be causing angina but may not represent a risk to health.

Stents still a good choice for unstable angina

Since their introduction in the 1980s, stents have been widely used in the treatment of CAD. Stents are effective at relieving angina in patients who continue to experience symptoms despite being on appropriate medicines. Angina refers to the symptoms — typically pressure or tightness across the chest — that occur when the heart muscle does not get enough oxygen-rich blood.

Angina is a symptom of advanced atherosclerosis, a process of inflammation and plaque formation that leads to blood vessel narrowing. If an atherosclerotic plaque ruptures, this can trigger the formation of a blood clot, severely and suddenly obstructing blood flow. Depending on the degree of obstruction and which artery is involved, this may cause abrupt worsening of angina, called unstable angina, or death of the heart muscle, called a heart attack. Unstable angina occurs at rest, or with increasingly little exertion.

Patients experiencing unstable angina or heart attack almost always require urgent cardiac catheterization, and often stent placement.

Medications as effective as stents for stable angina

Unlike unstable angina, patients with stable angina have more predictable, chronic symptoms that can be managed with medications. Stable angina worsens with exertion or sometimes with emotional stress, and improves with rest. Reduction of stable angina involves improving the mismatch between oxygen supply and demand. This can be accomplished either by lowering demand or improving supply.

Demand can be reduced with OMT, which may include beta blockers, which slow down the heart rate, or nitroglycerin, which decreases the work of the heart by relaxing blood vessels. Statins and aspirin are another important component of OMT, because they help to stem the progression of heart disease, reducing the risk of unstable angina or heart attack. When medication fails, blood supply to the heart muscle can be increased by removing the blockage with a stent or bypassing the blockage with open-heart surgery.

Many cardiologists have assumed that stents are effective, not only at relieving symptoms but also at preventing future heart attacks, leading many to pursue early cardiac catheterizations for their patients with stable angina. However, the ISCHEMIA trial suggests that medications are just as good at preventing heart attacks and death in stable patients.

This is welcome news for patients who previously would have been urged to have a cardiac catheterization and stent placement for stable angina. It now seems clear that these patients can be safely managed with medications alone, avoiding the risk and discomfort of the procedure, not to mention reducing healthcare costs.

Optimal medical therapy safe and effective for most with coronary artery disease

ISCHEMIA is not the first study to demonstrate that OMT is a safe and effective alternative to stent placement. But it is the most influential because of its careful design, large number of patients, and comparison of the newest stents and most current medical treatments.

So, how best to manage patients with stable coronary artery disease? A safe and effective long-term strategy for most is to start with medications and healthy lifestyle. For those who continue to be limited by angina, an invasive procedure is appropriate for symptom control. Stents relieve angina, but they do not prevent heart attacks or death.

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Got children? How to get out the door on time

Despite valiant planning efforts and repeated requests, your children are half-dressed. They made the house look like a category F5 tornado came through, and are nowhere near ready to go when you need to get out the door. You can feel your temperature rising as the clock ticks toward late again. If this sounds familiar, below are some helpful tools. Consider building these strategies into your routine to help you get out the door on time with fully-dressed children in tow.

Practicing dry runs of the strategies below with younger children can help prepare you for when you need to leave the house on time in the future.

Make a checklist

If your child has difficulty remembering each step of a morning routine and tends to get distracted easily, a visual list may help. Have your child check off each task completed. Children often like checking off boxes on a whiteboard, for example.

Specific steps might include getting out of bed, making the bed, getting dressed, putting dirty clothes in the hamper, brushing teeth, eating breakfast, and so on.

Set time benchmarks

It can be helpful for children to have time benchmarks by when a task should be completed. Consider the time you need to leave and the time it usually takes to accomplish each task. For example, a child should get out of bed by 7:00 a.m., make the bed by 7:05 a.m., and manage all other morning tasks in time to get out the door by 7:45 a.m.

If your child does not know how to tell time yet, you could use sand timers. Your child will know that time is up when all the sand has settled to the bottom of the timer. Once a task has been completed, you can re-enter the room where the child is and start another sand timer.

Praise each completed step

Providing specific positive attention to your child after each completed step is one way to encourage that behavior to continue. If you say, “Great job,” your child will not know whether it was “great” to get out of bed, make the bed, get dressed, or another behavior. Instead, you could say, “Way to go getting dressed by 7:10 a.m.!”

Praise can be even more effective if one praises enthusiastically and with physical touch, such as a pat on the back or a high five. If a child has sensory processing difficulties, such as being uncomfortable with physical contact, then you can use a nonverbal gesture, such as a thumbs-up, instead. You may find it helpful to set alarm reminders on your phone to cue you to praise children at each step.

Try a reward chart

A reward chart can provide a reinforcement boost to routine behaviors. For example, your child could earn a sticker or a star for each step completed on time. The stars can be used for rewards that your child has identified as motivating. Rewards do not have to cost money. For example, one reward may be your child choosing the meal for dinner.

• If a child earns a star for the behavior, then your praise would include, “Way to go getting dressed by 7:10 a.m. (high five)! You get a star (add star to reward chart)!”
• If the child did not complete the behavior on time, you could say in a neutral tone, “You did not get dressed by 7:10 a.m., so you do not get a star. I know you can try again tomorrow.”
• If a behavior does not seem to be within reach after some practice, try breaking it into steps. For example, your child puts on a shirt by 7:10 a.m. (praised behavior), and you help the child put on the remaining clothing items.

Stay calm

It is important to remain calm even though you may be stressed about being late and frustrated with your child. Any attention, even frustrated tones, will strengthen a behavior. Your goal is to give attention to the completed versus the incomplete tasks. You also want to remind your child that there is another chance to complete a behavior in the future. Your attention is like gold: cheering on behaviors you want to see brings that desired jackpot of attention within reach for the child. Practice makes progress. You’ve got this!

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Psoriasis and cancer: What’s the link?

Psoriasis is a relatively common, chronic inflammatory skin condition. It is likely caused by genetic predisposition combined with triggers such as infections, trauma, stress, and medications. The classic presentation is itchy, scaly, pink plaques most commonly found on the elbows, knees, and scalp.

In a recent systematic review and meta-analysis of 58 studies published in JAMA Dermatology, researchers found an association between psoriasis and an increased risk of developing cancer.

The JAMA Dermatology study focused on data from previous studies analyzed between April 9, 2018, and February 22, 2019. The researchers found that people with psoriasis had an increased risk of developing cancers including colon, kidney, laryngeal, liver, lymphoma, non-Hodgkin lymphoma, esophageal, oral, and pancreatic cancers. They also found that people with severe psoriasis who developed cancer also had an increased overall risk of dying.

How might psoriasis increase cancer risk?

Although this study does not specifically examine the reasons why people with psoriasis may be more likely to develop cancer, we can offer a few possible explanations. Psoriasis is an inflammatory condition involving overactive immune cells in the body. We know that other chronic inflammatory diseases, such as Crohn’s disease, are also associated with increased risk of developing cancers.

Many patients with psoriasis also have metabolic syndrome, tobacco use disorder, and increased alcohol use. Some of these conditions have also been associated with increased risk of cancer. This study does not go into detail about the extent to which these comorbidities may influence the increased risk of cancer in psoriasis patients.

People with severe psoriasis often do not get enough relief with topical therapies (ones applied to the skin), such as topical corticosteroids and vitamin D analogues. They may then be started on medications that target specific immune cells and proteins. Some of these medications increase the risk of infections. Previous studies have found little to no increased risk of cancer in patients receiving these therapies. Other treatments, such as phototherapy (light therapy), are known to increase risk of developing skin cancers.

What can you do to reduce cancer risk if you have psoriasis?

Psoriasis remains one of the more common inflammatory skin conditions. This study does not suggest ways in which people with psoriasis may reduce their risk of developing cancer. But there are several lifestyle modifications that could help to decrease cancer risk while also benefiting your overall health.

For example, quitting smoking, drinking less alcohol, eating a healthier, well-balanced diet, and moderate physical activity may not only reduce your risk of developing cancer, but also may reduce your risk of cardiovascular disease. You should also work with your primary care physician to stay up to date with routine cancer screenings, such as colonoscopies, mammograms, and lung imaging.

Further studies are needed to determine the specific mechanisms underlying the potential link between psoriasis and increased cancer risk, as well as how specific lifestyle factors and medications may play a role.

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The complicated relationship between fish oil and heart health

For nearly two decades, the American Heart Association (AHA) has recommended that people with coronary heart disease (CHD) consume omega-3-fatty acids (the kinds of fatty acids found in fish and fish oil) to prevent another heart attack. This recommendation was based on early randomized, controlled trials, which found that fish oil supplementation was associated with lower rates of stroke, heart attack, and death in people who already had heart disease. On the other hand, the impact of fish oil supplements on preventing a first heart attack or stroke (primary prevention) was never clearly demonstrated.

Recently there have been large trials examining the complex relationship between fish oil and heart health. The results have been mixed and somewhat confusing, leaving both patients and physicians to wonder: will fish oil supplements reduce my risk of heart disease?

What’s the connection between fish oil and heart health?

How might omega-3-fatty acids found in fish oil provide heart health? Multiple possibilities have been proposed and are supported by animal research. These protective mechanisms include

• stabilizing blood flow in and around the heart
• reducing blood triglyceride levels
• lowering blood pressure
• preventing blood clots
• reducing inflammation.

Research examining each of these is ongoing.

Many studies, varied results

Despite these animal data, clinical studies in humans have not consistently supported the protective benefits of fish oil supplementation.

A meta‐analysis published in JAMA Cardiology found no clear benefit to fish oil supplements in preventing heart disease or major cardiovascular disease (CVD) events such as heart attack or stroke, in people who were at increased risk for CVD.

This was followed by the publication of the ASCEND and VITAL trials, both with mixed results. In ASCEND, which examined diabetic patients without known CHD, fish oil supplements did not reduce heart attacks or strokes, but did significantly lower risk of death from heart attack and stroke. VITAL examined the effects of fish oil on primary prevention in people with regular risk of heart disease, and also failed to find a significant reduction in all major CVD events. However, there were fewer heart attacks in study subjects who took fish oil supplements, particularly in those who did not eat fish.

The REDUCE‐IT trial was published next. This trial looked at the effect of high-dose fish oil supplements on people with high blood triglyceride levels who were at elevated CVD risk. In contrast to previous studies, REDUCE-IT found a significant reduction in cardiovascular events among study subjects who took the high-dose fish oil supplements. While most studies have tested 1 gram or less of fish oil with a combination of eicosapentaenoic acid (EPA) and docosahexaenoic (DHA), REDUCE-IT used a dose of 4 grams of EPA alone. (Vascepa, a prescription version of the EPA fish oil supplement used in REDUCE-IT, is FDA-approved to treat very high triglyceride levels of 500 mg/dl or higher. In November, the FDA expanded its approval of Vascepa; it can now be prescribed to reduce the risk of cardiovascular events like heart attack and stroke.)

In October 2019, a repeat of the JAMA Cardiology meta-analysis, but now including 13 trials instead of the original 10, was published in the Journal of the American Heart Association. The addition of these three trials increased the sample size by almost 65%, from 77,917 study participants to 127,477 participants. In reanalyzing the expanded data, researchers found that fish oil omega‐3 supplements lowered risk for heart attack and CHD death. There was no effect on stroke. Interestingly, risk reductions appeared to be linearly related to omega‐3 dose. In other words, the higher the dose, the greater the risk reduction.

What does this mean for you?

Omega-3 supplements from fish oil appear to be heart-healthy and have a protective effect on CHD. But before we all start reaching for supplements, it may be worth following a heart-healthy diet full of fresh fruits and vegetables, with lean protein such as fish, as recommended by the AHA. For those of us at highest risk, especially those with elevated triglyceride levels, it is worth speaking with your physician about high dose EPA fish oil supplements.

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