Weight loss can help head off lasting damage caused by fatty liver

Non-alcoholic fatty liver disease is the most common cause of liver disease in the United States, and is estimated to affect up to a quarter of adults in the world. It is defined by excess fat accumulating in the liver and usually occurs in people with obesity, high blood sugars (diabetes), abnormal cholesterol or triglyceride levels, or high blood pressure. These disorders often run together and as a group are called metabolic syndrome. The “non-alcoholic” part of “non-alcoholic fatty liver disease” is important to distinguish it from alcohol-related liver disease, which can also cause excess liver fat.

How fat can damage the liver

In some people, the excess fat sits in the liver but may not cause any liver damage. However, in about one in 20 people, excess liver fat triggers chronic liver inflammation. This condition is called non-alcoholic steatohepatitis or NASH (“steato-“ means relating to fat and “hepatitis” means liver inflammation).

As with other liver disease, such as viral hepatitis or alcohol-related liver disease, chronic inflammation can cause ongoing damage, which leads to liver scarring known as fibrosis. Severe fibrosis is called cirrhosis regardless of the cause. People with cirrhosis are at risk for liver failure and liver cancer, and may need liver transplantation.

Diagnosing fatty liver

The key to preventing complications of NASH is to catch it early and treat it before the liver has sustained significant damage. Early diagnosis is tricky; usually people have no symptoms from their liver disease. If you have been diagnosed with any of the components of metabolic syndrome, you should talk to your doctor about your risk of having NASH.

The most accurate way to diagnose NASH is by liver biopsy. But blood tests and imaging tests can be used to determine who might be at low risk for NASH to avoid unnecessary liver biopsies. A useful, noninvasive test for some people is liver elastography, a special kind of ultrasound that estimates how much scarring there is in the liver. Elastography can help sort out who might benefit from further testing by liver biopsy. Regardless of whether NASH is present, exercising and eating a healthy diet can go a long way in treating metabolic syndrome and preventing complications down the road.

Weight loss is key to preventing complications of fatty liver

For people who are overweight or have obesity, the best treatment for NASH is weight loss. A landmark study showed that losing 10% of one’s body weight can reduce liver fat, resolve inflammation, and potentially improve scarring. More recently, in a meta-analysis published in JAMA Internal Medicine, researchers combined data from 22 studies that randomized patients to a weight loss intervention or a control arm (no or lower-intensity weight-loss intervention), to take a more thorough look at the effect of weight loss on non-alcoholic fatty liver disease.

That meta-analysis and other studies confirmed that weight loss by behavioral programs, medications, or weight-loss surgery can successfully treat NASH. Diet and exercise are the first line of treatment. At least 150 minutes of heart-pumping activity is recommended. While it’s not clear which diet is best, those that emphasize vegetables and whole foods, such as the Mediterranean diet, are good options. Regardless of the exact plan, lifestyle changes should be sustainable, and it’s usually best to lose weight slowly over time.

If sufficient weight loss is not attainable with these steps, weight loss surgery, such as gastric sleeve or gastric bypass, can be considered. There are currently no FDA-approved medications specifically for NASH, but medications that promote weight loss may be helpful. For certain people without diabetes, vitamin E can help treat NASH. For those with diabetes, certain medications that improve blood sugar, such as the thiazolidinedione drug pioglitazone (Actos) and the incretin mimetic drug liraglutide (Saxenda), may also have beneficial effects on the liver. Any decisions regarding medications for NASH, including the use of vitamin E, should be made in consultation with your doctor.

Individuals with NASH must also protect the liver from any other causes of liver inflammation. This means abstaining from alcohol and making sure you are vaccinated against the hepatitis A and hepatitis B viruses. Finally, anyone with NASH should also identify and treat individual components of metabolic syndrome they may have, in order to reduce the risk of heart disease and strokes.

Awareness of fatty liver may help head off problems down the road

Non-alcoholic liver disease is becoming more prevalent as obesity becomes more common. It is also underdiagnosed, since it usually causes no symptoms. But increased awareness can lead to early diagnosis and prevention of serious problems down the road. Fortunately, active research is ongoing to define how to best identify people who are at risk and to develop new medications to treat NASH.

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Harvard Health AdWatch: An arthritis ad in 4 parts

Perhaps you’ve grown as weary as I have of repeated arthritis ads. They appear in frequent rotation on television, online, and in magazines, promoting Enbrel, Humira, Otezla, Xeljanz, and others.

If you’ve actually read or listened to these ads, you might have felt perplexed at certain points. Here’s a quick rundown on what they’re saying — and not saying — in one of those ads.

“The clock is ticking”

Part 1: A teakettle whistles on the stove and a disembodied voice speaks as this ad for Humira opens. “This is your wakeup call. If you have moderate to severe rheumatoid arthritis, month after month the clock is ticking on irreversible joint damage. Ongoing pain and stiffness are signs of joint erosion.” Three people are shown starting their day in pain: one rubs his knee and grimaces, another has a sore shoulder, and the third, sore hands. Their suffering is clear, and you hear ticking in the background as a digital clock clicks forward one minute.

Part 2: “Humira can help stop the clock.” A garage door opens and out comes the man with the achy knee, now smiling and comfortably walking out into the sunshine as the music swells. “Prescribed for 15 years, Humira targets and blocks a source of inflammation that contributes to joint pain and irreversible damage.”

Part 3: The long list of side effects is voiced while happy scenes and beautiful music distract you: an adorable dog hikes with its once-achy-kneed owner; a young mother drops off her kids with a beaming grandma who previously was wringing her sore hands. “Humira can lower your ability to fight infection. Serious and fatal infections including tuberculosis and cancers, including lymphoma, have happened, as have blood, liver, and nervous system problems, serious allergic reactions, and new or worsening heart failure. Tell your doctor if you’ve been to areas where certain fungal infections are common, and if you’ve had tuberculosis, hepatitis B, are prone to infections, or have flulike symptoms or sores. Don’t start Humira if you have an infection.”

Part 4: The big finish is short and to the point: “Help stop the clock on irreversible joint damage. Talk to your rheumatologist.”

What did the ad get right?

Let’s start with several accurate points:

• The prolonged morning stiffness depicted at the start is a typical symptom of rheumatoid arthritis (RA). It’s so characteristic that it helps doctors make the diagnosis.
• Humira is a brand name of adalimumab, a treatment for rheumatoid arthritis and related conditions. It’s often highly effective and has a good safety profile, despite the long disclaimer about side effects.
• The drug targets inflammation. It does this by blocking tumor necrosis factor (TNF), a substance directly involved in rheumatoid arthritis inflammation. Anti-TNF drugs were first approved by the FDA for rheumatoid arthritis more than 20 years ago. They have revolutionized treatment for this disease.
• An active lifestyle is a reality for many people with rheumatoid arthritis who begin effective treatment soon after symptoms begin. The potential for improvement is often underestimated, perhaps because it wasn’t long ago that doctors had few effective options to treat rheumatoid arthritis. Fortunately, that has changed.

Now, about the rest of the ad

• Ongoing pain and stiffness are not specific signs of joint erosion. They are symptoms of joint inflammation, which may, over time, lead to erosions. However, not everyone with RA experiences joint erosions, and it generally takes many weeks or months for erosions to develop. Showing a clock with minutes ticking by implies more urgency than is accurate.
• The word “irreversible” is stated three times in this 60-second ad. While it’s true that joint damage related to RA generally does not heal, some people have minimal or no damage, especially when taking effective treatment. The implication that permanent joint damage is inevitable seems overly dramatic to me, and perhaps alarmist.
• The FDA requires that long disclaimer. While it lists the most important risks and side effects of the drug, some of its equivocal language is chosen carefully: “Serious and fatal infections… and cancers… have happened.” Were these problems caused by adalimumab? Or were they unrelated? Or do they just not know? Generally, the safety profile of anti-TNF drugs is considered good. The most recent studies suggest that there is no significant increased risk of cancer, except for skin cancers.
• I would bet that the average person seeing this ad has no idea if they’ve been in places where “certain fungal infections are common” — or what that even means! In fact, it refers to certain infections that can become silent in the body, but re-activate in people taking adalimumab. This includes histoplasmosis (Midwest of the US), Coccidioides (southwestern US), and blastomycosis (Ohio and Mississippi River Valleys and the Great Lakes).

What’s left unsaid?

The ad never mentions some important information about adalimumab:

• It’s expensive. While insurance may cover most or all of the cost, the price of adalimumab can run about $40,000/year.
• It’s given by injection under the skin (a bit like insulin injections for people with diabetes), usually every two weeks.
• Humira is only approved — and likely to work — for a few arthritic conditions, including RA. It’s not for osteoarthritis, the most common type of arthritis, an age-related, degenerative joint disease.
• Four other medications work in a similar way, with similar effectiveness and similar cost, side effects, and risks. Additionally, a host of other medications unrelated to TNF inhibition are also just as effective.

The bottom line

As drug ads go, those for arthritis in general and adalimumab in particular are not the worst I’ve seen. But they can be misleading, perplexing, and incomplete. Of course, the main purpose of these ads is to sell drugs, not to provide a complete and balanced review of treatment options for RA. You’ll need to ask your doctor for that.

Follow me on Twitter @RobShmerling

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Looking past the pandemic: Could building on our willingness to change translate to healthier lives?

If the COVID-19 pandemic has taught us anything, it’s that people have the capacity to change entrenched behaviors when the stakes are high enough. Who among us declared that 2020 would be the year for us to perfect the practice of physical distancing? Although we were clueless about pandemic practices a mere three months ago, we’ve adopted this new habit to avoid getting or spreading the virus. But what about other unhealthy behaviors that have the potential to shorten life spans across the US? On January 1, 2020, some of us made New Year’s resolutions aimed at improving our health: to eat less, lose weight, exercise more, drink less alcohol, stop using tobacco, get more sleep, start meditating regularly, schedule that colonoscopy, and so on. Might there be hope for gaining traction with one or more of these healthy behaviors, too?

Moving from clueless to changing behavior

Health psychologists and addiction medicine professionals like me use a standard model of behavioral change to understand how people move from a mindset of cluelessness to one of action. Predictably, we pass through the following six stages of change:

• Precontemplation (“Life is short — there’s nothing I need to change.”)
• Contemplation (“I suppose I should consider making a change.”)
• Preparation (“The time to make this change is very close. Here’s my plan.”)
• Action (“I’ve done it. I hope I can keep it up.”)
• Maintenance (“I can make this work for as long as I need to; I’ll keep on keeping on.”)
• Moderation or Termination (“I’ll rely upon my common sense and sound medical advice to decide whether to maintain or let up when the time is right.”)

The empty streets of New York and many other major US cities bear witness to the fact that with regard to social distancing, large numbers of Americans have moved rapidly from precontemplation to maintenance. Because we have embraced this dramatic change and the mortality curve is being flattened in some parts of the US, the actual death toll from COVID-19 is likely to be a fraction of what it would have been if we had stayed put, mired in precontemplation or contemplation.

The pandemic is not the only danger to our health and lives

But wait a second. Don’t lifestyle blights like obesity, hypertension, addiction, and violence exact a far greater human toll from us than COVID-19? And aren’t these biopsychosocial maladies correlated with low socioeconomic status? And aren’t COVID-19 fatalities particularly high in disadvantaged people who suffer from one or more chronic illnesses?

A quick look at US death rates and life expectancy on a state-by-state basis suggests, sadly, that the answer to all three questions is yes. The impact of “lifestyle health” and socioeconomic status on life expectancy is very high: residents of Marin County, California can expect to live a dozen or more years longer than residents of Harlan County, Kentucky!

What enables us to change our social behaviors so rapidly to combat a viral adversary, while, relatively speaking, we are losing the war against lifestyle and socioeconomic enemies like obesity, addiction, and violence? Perhaps this has to do with the fact that when it comes to the latter, the famous words of Walt Kelly’s Pogo apply: “We have met the enemy, and he is us.”

Human nature is complex. Compared with seemingly intractable lifestyle afflictions, which may be determined or amplified by socioeconomic factors, a coronavirus represents a more tractable adversary. It’s possible that the scientific, medical, and technological expertise of our hyperconnected global brain trust might ably defeat it. But individually as well as collectively, we seem to be less proficient when it comes to taking on and defeating the lifestyle enemies that “are us.” We stay mired in precontemplation and contemplation until it is too late. Why do so many smokers opt to quit only after a diagnosis of lung cancer? Why is it that some alcoholics do not stop drinking until the onset of jaundice caused by end-stage alcoholic liver disease? How many more shrines shall we erect to the victims of senseless violence directed to the self or others, pledging now to wake up and make a difference?

Just as our society has rallied to take on a wily viral adversary like COVID-19, starting right now it is just as important for us to focus attention on addressing, curing, and — better yet — preventing lifestyle afflictions like obesity, addiction, and violence. We can start small during this time of sheltering in place, by combating couch-potato tendencies with daily exercise, avoiding the temptation to get buzzed, and keeping the Healthy Eating Plate in mind as we wrestle with the temptation to manage stress by consuming unhealthy comfort food.

Together — as individuals, families, communities, and a society — we should resolve to take action to promote health. Our successes battling this viral pandemic should inspire us to combat every serious adversary that threatens our well-being, not merely those that pose a sudden, immediate, and frightening threat.

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More sexual partners, more cancer?

Two headlines caught my eye recently:

The relationship between chronic diseases and number of sexual partners: an exploratory analysis

and

Study warns more sex might mean higher likelihood for cancer

It may be hard to believe, but both of these refer to same medical research. I’m not sure which one I like better. The first one is the actual title of the research, which provides no information about its findings. The second one is a newspaper headline. It cuts right to the chase about the study’s main findings. While it’s much more specific — and alarming — it is also misleading.

Is there a link between the number of sexual partners and cancer?

The study investigating this possibility was published BMJ Sexual & Reproductive Health. It enrolled about 2,500 men and 3,200 women who were 50 or older (average age 64). Each person was surveyed about the total number of sexual partners they’d had over the course of their lives. This information was compared with a number of medical conditions they’d developed, including cancer, heart disease, and stroke.

The study demonstrated that

• Men who reported 10 or more sexual partners in their life were nearly 70% more likely to have developed cancer when compared with those reporting 0 or 1 lifetime sexual partners.
• For women, the findings were even more dramatic: women who reported 10 or more sexual partners in their life were nearly 91% more likely to have developed cancer when compared with those reporting 0 or 1 lifetime sexual partners.

Men were more likely than women to report having at least 10 partners (22% of men vs. 8% of women) while women were more likely to have fewer partners (41% of women and 28.5% of men reporting having had 0 to 1 partners).

It’s worth noting this study was performed in England with health information initially collected in the late 1990s. The results could have been different if researchers had assessed risk of a different population or at a different point in time. In addition, self-reporting was relied upon to assess sexual behavior, and it’s possible the reported number of sexual partners and other health behaviors were not accurate.

Does this mean having sex leads to cancer?

The answer is almost surely no.

That’s because this type of study cannot assess whether sex causes cancer. It can only determine whether there is a correlation between the two. Also, we already know of ways that sexual behavior can indirectly affect cancer risk without actually causing cancer, especially through sexually transmitted infections. Some of the strongest connections are for:

• human papilloma virus (HPV), which increases the risk of cancers of the cervix, mouth, penis, and anus
• human immunodeficiency virus (HIV) infection, which increases the risk of cancers such as Kaposi’s sarcoma and lymphoma
• hepatitis B and hepatitis C infection, which have been linked to liver cancer
• gonorrhea, which increases the risk of prostate cancer (particularly among African American men).

In addition, people with more sexual partners tended to smoke more and drink more alcohol. These factors could, themselves, increase the risk of cancer. So, certain factors — in these cases, infections, smoking, and drinking — could have an impact on cancer risk, rather than having sex or the number of sexual partners.

While future research could find previously unidentified risks in having a higher number of sexual partners, we already know enough to explain the connection.

The bottom line

While it may be tempting to conclude from this new research that limiting the number of sexual partners you have will lower your risk of cancer, I think that would be a misinterpretation of the data. The better take-home message would be to take precautions to avoid sexually transmitted diseases and pursue other proven strategies to lower your cancer risk, including stopping smoking and limiting alcohol.

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New radiation therapies keep advanced prostate cancer in check

Treatments for prostate cancer are always evolving, and now research is pointing to new ways of treating a cancer that has just begun to spread, or metastasize, after initial surgery or radiation. Doctors usually give hormonal therapies in these cases to block testosterone, which is a hormone that makes the cancer grow faster. But newer evidence shows that treating the metastatic tumors directly with radiation can produce better results.

In March, researchers published the latest study that supports this approach. Based at Johns Hopkins University School of Medicine in Baltimore, the team used a method for delivering powerful beams of high-dose radiation to very small cancers in the body. This approach is called stereotactic ablative radiotherapy (SABR), and it can spare healthy tissues with remarkable precision. Doctors map out where to pinpoint the radiation in advance by putting patients into a computed tomography (CT) scanner that takes x-rays of the body from many different angles.

During their study, the Johns Hopkins team recruited 54 men with three or fewer metastatic tumors. All the men had already undergone initial treatment for cancer while it was still in the prostate, and some had also been treated with hormonal therapy, though not within six months of being enrolled for the research. The men were 68 years old on average, and they were each randomly assigned to one of two groups: A third of the men were placed in an observation (control) group, meaning they received no additional treatment until the study was over. The rest were given SABR at a rate of one to five treatments per tumor over a period of about a week.

Then the men were followed for six months and monitored for changes such as PSA increases, tumor growth, worsening symptoms, or how many men wound up on hormonal therapy.

What the results showed

Results showed that the SABR-treated men fared better in all respects. Overall, 19% of those who got the targeted radiation had their cancers progress, compared to 61% of men in the control group. Taken together, the findings support a view that all detectable lesions should be removed, if feasible, to maximize the odds “of a cancer cure,” according to the authors of an editorial accompanying the published paper.

What makes SABR effective for treating early-stage metastases? Scientists are trying to find out. The investigators behind this study speculated that irradiating visible traces of cancer might block signals that feed the growth of even smaller tumors that are still too small to see. It’s also possible that radiation induces a sort of vaccinating effect, which prompts the immune system to attack other tumor cells.

Meanwhile, SABR could soon benefit from an ability to flag even smaller tumors for treatment. A new type of imaging scan called PMSA-targeted positron emissions tomography (PET) was tested in the study, and it found very small tumors that CT scanning had missed.

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 the whole concept of treating metastatic prostate cancer “is undergoing re-evaluation.” He added, “The findings in this case need to be supported with a larger study. However, this research provides more evidence that for patients with less extensive metastasis, SABR treatments can significantly delay systemic therapies such as chemotherapy or hormonal treatment.”

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7 tips for going outside safely with your children during the COVID-19 pandemic

During the COVID-19 pandemic, getting outside can be a great idea for both the physical and mental health of you and your family. But as with everything else these days, going outside needs to be done safely. Here are my top seven tips for what you need to think about as you put on your shoes and head outdoors.

1. Be careful about what you touch as you go outside or return home. For those who live in single-family homes this isn’t a big deal, but if you live in a shared building, you need to be careful about things like elevator buttons and doorknobs that others touch. Make a game of it so your kids don’t touch — pretend that surfaces (including walls) are hot — and wear gloves, or bring a paper towel or tissue so you can hit those buttons and touch doorknobs.
2. Bring hand sanitizer so that you can wash hands while you are out, if needed.
3. Choose the best outdoor space. Your own yard is best, but that isn’t an option for everyone. Ideally, you should go somewhere where you won’t encounter lots of other people. This has become a problem as lots of people head outdoors!
4. Keep up the physical distancing while you are outdoors. The chances of you catching something from someone as they pass you is quite small, but it’s best to give the widest berth you can.
5. Only go outdoors with the people you live with. It’s tempting to join another family for a walk, but it’s hard to keep six feet between you — and children may have a particularly hard time with this. Speaking of things that children have a hard time with…
6. Don’t touch stuff. So, no playing on playground equipment, sitting on benches, sharing balls, or touching signposts or mailboxes or anything else. You just don’t know who has touched it or when. Having the hand sanitizer helps when children and others forget.
7. Bring masks along. Hopefully they will stay in your backpack with your water bottles and snacks, but if keeping physical distance between you and others becomes difficult at any point, you can whip them out and put them on. According to the American Academy of Pediatrics, children under 2 shouldn’t wear masks for safety reasons, but everyone else should have a mask — or some other face covering — on hand just in case.

It sounds like a lot, but it’s not — and it’s completely worth doing so that you can all get out of the house, get some exercise, have some fun, and feel a bit more normal.

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Is angioplasty plus stenting or coronary artery bypass surgery better for treating left main coronary artery disease?

One of the most dangerous places to have a coronary blockage is in the left main coronary artery. Why is a blockage there so precarious?

To answer that, let’s start with some basic cardiac anatomy. The two major coronary arteries — the blood vessels that supply blood to the heart — are the left and right coronary arteries. The left main coronary artery (LMCA) is the very first portion of the left coronary artery. It provides oxygenated blood to most of the left ventricle, which is the main pumping chamber of the heart.

Any amount of blockage in the LMCA, such as from plaque buildup or a clot, is referred to as “LMCA disease.” However, treatment is only needed when there is a blockage of 50% or more. At that level, there is an increased risk of death, a major heart attack, or a life-threatening arrhythmia (irregular heartbeat). That’s why it needs to be treated quickly after a blockage is detected.

But what exactly is the best treatment of LMCA disease? This is the source of a lot of recent and ongoing controversy.

Treatment options for LMCA disease

Currently, there are three options for treating LMCA disease:

• Coronary artery bypass grafting, also known as bypass surgery or CABG, in which a blood vessel taken from a person’s leg, arm, or chest is moved and used to reroute blood around a clogged coronary artery.
• Percutaneous coronary intervention, also known as angioplasty and stenting. In this procedure, a catheter with a deflated balloon and stent (a wire mesh device) at the tip is threaded into the heart through a blood vessel in the leg or wrist. The balloon inflates along with the stent, clearing the blockage. The stent is left in place to prop open the blood vessel.
• Medical (drug) therapy.

Medical therapy is used in combination with both bypass surgery and stenting to help improve long-term outcomes. However, medical therapy alone has been shown to have worse outcomes in managing LMCA disease.

When comparing bypass surgery and stenting, there are some pros and cons to each. Stenting is much less invasive than bypass surgery, and has a significantly quicker recovery time. However, studies have shown that patients who have very complex LMCA disease (based on specific anatomic features) have better results with bypass surgery in the long term. But when there is less anatomic complexity, there is some uncertainty regarding which treatment is better.

Recent studies: More data, but no clear answers

Two recent clinical studies (NOBLE and EXCEL) compared bypass surgery and stenting in the low and intermediate anatomic complexity groups, and found two different results.

Let’s start off with the NOBLE study, which compared stenting to bypass surgery with regard to the combination of death, heart attack, need for repeat stenting or bypass surgery, and stroke after five years in patients with LMCA disease. It found that stenting was worse than bypass surgery for this combination of outcomes. However, the difference was mainly due to stenting patients having a higher rate of heart attacks and needing repeat stenting or bypass surgery. There was no difference in death or stroke between the two groups.

The EXCEL study also compared patients who underwent stenting with those who underwent bypass surgery for LMCA disease, but looked at the combination of death, stroke, and heart attack after five years; unlike NOBLE, the main endpoint of this study did not include the need for repeat stenting or bypass surgery. This study found no difference between the two treatments for the main endpoint. The stenting group had a slightly higher rate of death, but it wasn’t due to cardiac causes. (There were slightly more patients in the stenting group who died from infection and cancer, which was felt to be unrelated to the procedure.) Similar to NOBLE, EXCEL also found that patients undergoing stenting had higher rates of needing bypass surgery or repeat stenting. There was no difference in stroke rates.

A recent meta-analysis (a study that pools together and analyzes many studies) found that bypass surgery and stenting were equal in terms of death, heart attacks, and stroke for the low- and intermediate-complexity groups. However, patients undergoing stenting required slightly more repeat stenting or bypass surgery afterwards.

Final takeaway

Ultimately, what are patients with LMCA disease to do? Based on the data, patients who have anatomically complex LMCA disease should undergo bypass surgery, if possible. In patients with low or intermediate anatomic complexity, shared decision-making between patients, cardiologists, and heart surgeons is required to determine the best treatment option for each individual patient.

Some patients may be too frail or may have medical conditions that prevent them from undergoing bypass surgery. Other patients may not want the longer recovery process associated with bypass surgery, and those patients could be considered for stenting. Otherwise, bypass surgery would be a very good option.

Follow me on Twitter @DrDarshanDoshi

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Strategies to support teens and young adults with autism spectrum disorder during COVID-19

The COVID-19 pandemic has been described as “the war of our generation.” Millions of families are bravely waging war on COVID-19 by rising to the many challenges of social distancing, including upended school and work routines, financial insecurity, and inability to see loved ones, all compounded by the uncertainty of how long this will last. These challenges are likely magnified for those with autism spectrum disorder (ASD). Features of ASD, including impaired social and communication skills, repetitive behaviors, and insistence on sameness, can make it very difficult to understand social distancing, express distress, and adapt to new routines.

What has the impact of the COVID-19 pandemic been on teenagers with ASD and their families?

Social distancing has created many new challenges for families caring for teenagers with ASD in the home. Many teenagers with ASD receive support services including special education, behavioral therapy, occupational therapy, speech services, and individual aides through school. Delivering these services virtually is a major challenge, particularly since many teenagers with ASD already have social and communication difficulties, limiting the utility of video chat. Parents are therefore finding themselves simultaneously expected to play the role of parent, special education teacher, and individual aide, all the while providing care for other children and juggling work-from-home responsibilities. Aggressive and self-injurious behaviors may also increase during this time of fear and uncertainty.

What about young adults who live in group homes?

Group home residents have been impacted by social distancing in several unique ways. First, many group homes across the United States have restricted visitors to legal guardians. For many, this means that they are not permitted in-person visits with parents. Second, group home residents are now no longer permitted to engage in their normal routines at day programs and work sites. Because of these restrictions, group home residents are now generally confined to their group homes, and social interactions are limited to ad hoc activities with other residents and staff members, often within the group home. Third, the disappointment of missing highly anticipated events such as outings and family holidays can be amplified for a person with a limited understanding of the pandemic, particularly for those with intellectual disability. Many individuals with ASD may even view these restrictions as punitive, increasing the risk of anxiety, depression, or behavioral outbursts.

Strategies to support teenagers and young adults with ASD during COVID-19

Educate teenagers about COVID-19. Since confusion can fuel fear and anxiety, it is important to educate teenagers and young adults with ASD about COVID-19 and social distancing. Exposure to COVID-19 through the media can be overwhelming and misinterpreted. The language used when discussing COVID-19 should be clear, direct, and adapted to the person’s cognitive ability. It may be helpful to use a visual aid. Many people also have misperceptions and catastrophic fears about COVID-19, so it can be helpful to ask directly: “What do you know about COVID-19?” and “What worries you most about COVID-19?” Allow the teenager or young adult with ASD to guide how much or how little he/she would like to know and when he/she would like to talk about it.

Keep the routines that you can keep. Routines are very important to people with ASD. While many of our routines have dramatically changed, there are also many routines and rituals that we can help keep the same, such as mealtimes, bedtime, and other schedules (for example, “I always call Grandma on Sundays.”).

Create new routines. It can be helpful to replace the activities that are no longer possible with new routines to help create a new normal. When possible, these routines should incorporate social connectedness, fun, and physical exercise (like family dance parties after dinner).

Practice old coping skills and learn new ones. This is the time to recall and remind the teenager or young adult of coping skills that helped him/her manage challenging situations in the past. These may include listening to familiar music, visual aids to bolster communication, engaging in hobbies, or talking with friends and family.

Increase communication. It is natural for parents and children to worry about one another, particularly when in-person contact is limited, as it is for those who live in group homes. Open and frequent communication between group home staff and family members about policies and practices to optimize infection control, as well as how residents are doing, can help alleviate these worries.

Plan something to look forward to. Since many spring events including vacations and family holidays have been cancelled, it can be helpful for families to plan delayed events or celebrations. Planning these events not only creates something positive for a family to look forward to, but they can also serve as a powerful reminder that this too shall pass.

Seek mental health services. If your teenager or young adult is having difficulty coping or is exhibiting increased aggression or self-injury, it is important to seek mental health services. Many clinics are continuing to provide care through telehealth, including talk therapy and medication management.

Teenagers and young adults with ASD can learn valuable life lessons

If teenagers with ASD are well-supported and socially connected during these difficult times, this period of social distancing may serve as a catalyst for personal development rather than a time of regression and loss of skills. If we engage with teenagers with understanding and good role modeling, we can help young people with ASD to tolerate uncertainty, accept what is beyond their control, and build their resilience and resources — things they can control.

Resources

Guide to Mental Health Resources for COVID-19, Massachusetts General Hospital Department of Psychiatry.

COVID-19 information, Center for Autism Research and Treatment, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles.

Coronavirus/COVID-19 Resource Library, American Academy of Child & Adolescent Psychology.

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No spleen? What you need to know to stay healthy

Due to injury or necessary surgery (splenectomy), some people are lacking a spleen, the organ that filters the bloodstream and helps the body fight infection. You do not need your spleen to live a normal, healthy life. However, since the spleen performs some important tasks, people who do not have one are urged to take certain precautions.

What is a spleen?

The spleen is a fist-sized organ that sits under your rib cage on the left side of your abdomen. Unlike the stomach, liver, or kidneys, it is not directly connected to the other organs in your abdomen. Instead, the spleen is connected to your blood vessels, with an artery that brings blood to it and a vein which takes the blood away.

The spleen is composed of two types of tissues: the red pulp, which filters the blood, and the white pulp, which contains white blood cells that regulate inflammation and the body’s response to infection. Both types of tissue play roles in fighting pathogens (bacteria, viruses, fungi, or parasites) that cause infections.

What does red pulp normally do?

The red pulp removes red blood cells — which carry oxygen — when they are old, damaged, or infected. It harvests the iron from the old red blood cells for recycling into new blood cells. Usually new red blood cells are created by the bone marrow, but when blood counts are low or the bone marrow is not working well, the spleen can also make new red blood cells.

The loss of the spleen’s ability to filter out infected red blood cells increases risks associated with two parasitic infections, malaria and Babesia. Malaria is spread by mosquito bites in many parts of Africa, Asia, and South and Central America. Babesia is spread by tick bites in the Northeastern and upper Midwestern part of the USA (a different species of Babesia is found throughout Europe). People without a spleen should take extra precautions to avoid these infections if they live in or visit a region where malaria or Babesia are common.

An area in the red pulp called the marginal zone contains special white blood cells known as splenic macrophages that filter pathogens out of the blood. This is a particularly important defense against a type of bacteria coated in a capsule that resists many of the body’s other defenses. These bacteria can be tagged by antibodies produced by the white pulp of the spleen, then killed by the splenic macrophages.

Someone without a spleen is at increased risk of severe, or even deadly, infections from these encapsulated bacteria. Fortunately, vaccines significantly decrease the risk of these infections, and are available against the most common types (Streptococcus pneumoniae, Haemophilus influenza, and Neisseria meningitidis). Additionally, it is usually recommended that people without a spleen have antibiotics that they carry with them (often referred to as “pill in pocket”) and can take at the first sign of an infection, such as fevers or chills. For children without a spleen, their doctors may even recommend they be on antibiotics all the time. Talk to your doctor about this.

What does white pulp normally do?

The white pulp is composed of lymphoid tissue, which contains white blood cells, the body’s primary means of fighting pathogens and regulating inflammation. White blood cells act as the body’s police force — patrolling the bloodstream to find infections or damage to the body, and working together to combat it. There are many types of white blood cells that function in different and often complex ways. Some fight infections directly, by releasing substances that are toxic to pathogens or by “swallowing” them (called phagocytosis). Some fight infections indirectly, by assisting the direct fighters or by producing antibodies that mark pathogens for destruction by other white blood cells.

Fortunately for people who do not have a spleen, the body has other lymphoid tissues containing white blood cells, such as lymph nodes. For many types of infections, the remaining lymphoid tissues are able to mount an adequate response. However, with the loss of the lymphoid tissue in the spleen, the immune system fights infections with a bit of a handicap. That’s why the Centers for Disease Control and Prevention recommend that people without a spleen get vaccinated against preventable diseases, including influenza (flu). Discuss vaccinations with your physician.

COVID-19: Does not having a spleen affect ability to fight this illness?

At this point, we do not know for sure how lacking a spleen might affect a person’s ability to fight COVID-19. For most viruses, not having a spleen does not seem to be a major risk factor for illness.

So far this seems to be true for COVID-19 as well. New studies are being published constantly, but lack of a spleen has not been identified as a risk factor for acquiring COVID-19 or having worse outcomes. This is likely because the other lymphoid tissues in the body are able to produce an adequate response. However, it is likely that a person’s ability to fight any infection is at least a little diminished compared to what it would be if they did have a spleen. So with an infection like COVID-19 that can be severe and deadly even in healthy individuals, anyone without a spleen should be extra vigilant in following CDC recommendations to protect themselves and others.

The bottom line

If you do not have a spleen, ask your doctor what steps to take to prevent infection or illness. This might include precautions about mosquito bites and tick bites, vaccinations, and whether you should carry antibiotics (“pill in pocket”). If you have a fever of 100.4° F or more, you should take your pill in pocket if you have it, and seek urgent medical attention.

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No room to exercise? Tiny space workouts have never been more important

For many of us, the loss of our fitness routines — the social aspects of a regular exercise class, scheduled walks with friends — is one of the stresses imposed by COVID-19 restrictions. Yet maintaining, or possibly increasing, your physical activity level seems even more important than usual in the face of this new coronavirus. While we don’t know exactly how fitness and exercise affect this particular virus, we do know that regular physical activity boosts the immune system. One study shows just a single dose of moderate- to high-intensity exercise can bolster the immune system. And a strong immune system can help fight off the effects of viral illnesses.

Also, exercise confers multiple benefits on essentially all of your body’s systems, from your muscles, bones, heart, and lungs to your brain. Importantly, it increases insulin sensitivity and reduces stress hormones, which further helps your body fight infections. Significantly, exercise helps people manage anxiety and depression. Even a single bout of exercise can help if you’re feeling anxious or depressed, perhaps due to the fear of becoming ill, financial concerns, and worry about the well-being of loved ones. But how can you get enough physical activity in a confined space and without access to your usual exercise machines or classes?

Be flexible about the types of exercise you choose

Switching your exercise to a more confined space may require some flexibility on your part. When I counsel my patients about exercise and suggest flexibility, they often think of yoga or stretching. But in this case, I am suggesting being more flexible about your choice of exercise and less rigid about holding onto prior habits. Keep in mind:

• Change may be good for you and your body. Perhaps your usual activity is a barre class, yoga, Pilates, indoor cycling, or a boot camp. Your body is accustomed to the muscles worked and the intensity of your accustomed activity. Varying your choice of exercise reduces boredom, and lessens your chance of musculoskeletal injury from repetitive movements. It may also engage new muscle groups.
• Your muscles are agnostic. They don’t know, nor do they care, what kind of workout clothes you are wearing, what kind of space you are in, or what kind of music is playing. Your muscles are highly adaptable. Simply put, if you apply a specific demand, such as lifting weights or doing squats, your muscles will become stronger to allow you to meet the new requirement. And you can do that even in a very small area.

If you feel confined in your available exercise area — and, as some people complain, like a prisoner in your home due to stay-at-home orders — consider that exercise actually has been shown to improve depression, stress, and anxiety in people who are in prison. Even within limited space, people can do body weight exercises similar to these workouts, such as push-ups, bridges, squats, yoga poses, and mat Pilates. Want more? Try challenging your standing balance and performing agility work by hopping from side to side or front and back.

Reshape your exercise routine during stay-at-home orders

Here are four ways to reshape your exercise routine during the COVID-19 pandemic:

• Go online to find classes and specific exercises. Join one of the many exercise class recordings from the YMCA or commercial trainers designed for in-home exercise with minimal or no equipment. Check out a library of exercises for every muscle group and level of difficulty offered by the American Council on Exercise.
• Consider taking a live exercise class online. This adds a bit of social connection (ask a friend to join so that you can see them in class). Also, for many of us, setting an appointment for a live class will improve compliance compared to on-demand videos, which can be watched — or avoided — at any time of day.
• Get outside. One of few excuses for leaving your home, other than to get food and medicine, is to exercise. Exposure to nature is particularly beneficial to combat the blues from staying inside.
• Have fun and try something new. If you were never comfortable joining a Zumba or dance class, this may be your opportunity to try it out at home. You can choose to turn off your camera (at least until you get the moves down).

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How can you support your teenager with autism spectrum disorder if they are depressed?

As every parent knows, teenage life is full of challenges, from stress over academics to social relationships and physical changes due to puberty. This stage of life can be particularly challenging for those with autism spectrum disorder (ASD). A recent study found that teenagers and young adults with ASD are nearly three times more likely to develop depression than same-age peers without ASD.

What are typical symptoms of depression?

While occasional sadness is a normal part of life, persistent sadness can be a sign of depression. Other common signs and symptoms of depression can be grouped into thinking patterns, changes in behavior, and physical symptoms. Common thinking patterns seen in depression include guilt, hopelessness, worthlessness, excessive worrying, and thoughts of death or dying. Behavioral changes include social withdrawal, increased irritability, and decreased interest in preferred activities. Physical symptoms include appetite changes, sleep problems, and low energy.

If someone has ASD, recognizing their symptoms of depression can be challenging

There are several aspects of ASD that overlap with symptoms of depression, including difficulty identifying and accurately reporting mood, constricted range of facial expression, sleep problems, and social withdrawal. Because of this overlap, an assessment of depression should involve multiple observers (caregivers who understand a teenager’s ASD, teachers, healthcare providers). An assessment should also take into account whether there is a change in your teenager’s usual behavior and functioning. Symptoms of depression typically persist for at least two weeks and represent a clear change from their typical behavior.

Some features of depression that may be more prominent in teenagers with ASD include an increase in ASD-related behaviors, irritability, and self-injurious behaviors. Many teenagers with ASD have very specific interests. These interests can become less appealing to the teenager, or shift to become more morbid during depression; for example, someone who enjoys drawing cartoon characters may draw more unhappy characters. You may also notice more crying, aggressive behaviors, and a decline in self-care, like refusing to bathe or eat meals. Although many parents worry that puberty itself may cause worsened aggression, this is often not the case, and the possibility of depression should be taken seriously.

What should parents and caregivers do if they are concerned a teenager with ASD may be depressed?

If parents suspect their teenager with ASD is depressed, they should try asking about his/her mood. Some teenagers with ASD will be able to say how they are feeling, while others may have difficulty with this. It is common for teenagers with ASD to respond by saying they feel hungry, tired, or bored. If parents remain concerned about depression, a pediatrician or mental health clinician can conduct a more in-depth evaluation.

It can be helpful to prepare your teenager for an evaluation by telling him/her that the goal of the visit is to develop a treatment plan that will help him/her feel better. The assessment will include an evaluation of mood, a discussion of recent life changes or stressors, a review of past medical and mental health conditions, family history of mental illness, and a safety assessment. Since some people with depression many have thoughts of death or of wanting to kill themselves, it is very important for the evaluation to assess for these types of thoughts, so that the treatment team can work with your teenager and family to decrease the risk of self-harm and suicide.

Having ASD increases the risk of depression in teens, but effective treatments are available

Fortunately, there are many treatments available for depression. A comprehensive treatment approach for depression can address home, social, and educational stressors, and may include lifestyle changes, talk therapy, and medications. General lifestyle strategies that can enhance resilience and mental wellness include regular exercise, adequate sleep, good nutrition, and helping your teenager problem-solve stressful situations.

Because many teenagers with ASD dislike change, they may resist these lifestyle changes. Two types of talk therapies which have been demonstrated to be effective for treating depression in teenagers with ASD include cognitive behavioral therapy (CBT) and behavioral activation (BA). CBT focuses on helping change unhelpful thinking patterns and behaviors to improve mood; BA improves mood by helping a person plan enjoyable activities to increase opportunities for positive experiences.

Since teenagers with ASD who do not see themselves as depressed may be resistant to trying talk therapy, a therapist may begin by collaborating with the teen to identify relevant treatment goals. Medications can also be helpful; however, there are no published studies of antidepressants specifically for depression in ASD. It is important to start antidepressants at low doses and increase the dose slowly, since those with ASD may have more difficulty communicating side effects. That said, it is important to work with the prescriber to continue to gradually increase the dose of the medication if your teenager remains depressed and is not experiencing side effects. Common side effects of antidepressants include headaches, digestive problems, increased anxiety, and changes in sleep or energy. If the first antidepressant is not effective, then it is worth trying another type of antidepressant.

Although teenagers and young adults with ASD may be at higher risk for depression, it is a treatable condition with many treatment options to help build resilience, decrease the severity of symptoms, and restore quality of life.

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Get your affairs in order, COVID-19 won’t wait

The scourge of COVID-19 is spreading. Thousands of Americans are dying.

What can you do to help? Yes, practice social distancing, wash your hands, and donate masks to local hospitals. Also, talk to your loved ones about advance care planning.

What is advance care planning?

Advance care planning means contemplating and deciding the type of medical care you would want if you had a life-threatening illness; you are never too young or too healthy to start these conversations. It involves identifying your goals and values, learning about life-sustaining interventions — such as cardiopulmonary resuscitation (measures to restart your heart and breathing), intubation (use of a ventilator to help you breathe), or artificial nutrition (being fed through a tube in your nose or stomach) — and sharing with loved ones and your doctors your preferences. An advance directive is written documentation of these preferences.

These preferences are not set in stone and can be revised. Doctors will ask you about your care as long as you can communicate. If you are unable to communicate, doctors will ask your loved ones. Advance care planning empowers loved ones to advocate for the type of care you would have wanted and doctors to provide care honoring your wishes.

The urgency of advance care planning in the COVID-19 pandemic

COVID-19 can affect the chronically ill and the healthy, the elderly and the young. Patients with severe COVID-19 pneumonia can struggle to breathe and deteriorate rapidly. Decisions regarding CPR, intubation, or transition to comfort care are made quickly. When patients are too sick to respond, their loved ones are asked to speak on their behalf. Protective isolation measures for COVID-19 preclude loved ones from sitting at the bedside for these decisions, making an already challenging discussion more difficult. If a loved one cannot be reached, the breathless patient will be intubated, and resuscitation will be attempted.

In this crisis, where patients are sick, distressed, and isolated, knowing what interventions a patient would want and making these wishes clear is critical.

Key components of advance care planning

While you are home with family during this time of social distancing, do your homework. Discuss these three key components of advanced care planning with your loved ones.

1. Name and document a health care proxy. This is also known as a medical power of attorney or a surrogate decision maker. If you are unable to make medical decisions for yourself, your health care proxy will make decisions on your behalf, based on your wishes and values. After designating a health care proxy, make sure they are comfortable with this role and understand the responsibilities. Document your health care proxy utilizing your state’s form and share this documentation with your doctor.
2. Discuss your values and wishes. If you are unable to communicate, the health care proxy may be asked questions like “Your father has pneumonia and is having a hard time breathing. Would he want a breathing tube?” or “If your father is intubated he may never come off the breathing tube. Would he prioritize living longer with a breathing tube that could be uncomfortable, or would he prioritize comfort, even if it meant having a shorter life?” Knowing your values and beliefs — and communicating them to your health care proxy — empowers your health care proxy to make the best decisions for you. Consider the following questions:

• If time was short, how would you want to spend it?
• Are there any kinds of treatment you want or don’t want (i.e., CPR, ventilator, artificial nutrition)?
• When would it be okay to transition from curative care to comfort care?

Ease into the conversation by utilizing free guides at The Conversation Project and the National Hospice and Palliative Care Organization. It doesn’t have to be morbid; turn the conversation into a game night (over FaceTime or Zoom if needed) by playing Go Wish or a socially-distant Death Over Dinner party.

3. Decide on a do not resuscitate (DNR) order. This is a written instruction to forego CPR, involving chest compressions and ventilator support when a person’s heart or breathing stops. Pursuing or foregoing resuscitation should reflect your goals and values, and should be made in collaboration with your doctor. This order has no bearing on other medical interventions such as antibiotics, dialysis, or fluids, which will be provided or withheld based on a patient’s wishes. Older individuals with chronic illness are more likely to develop severe illness from COVID-19, and it is exactly these individuals who may want a natural death, or for whom there is no expected medical benefit, or for whom quality of life after CPR would be unacceptable.

The bottom line

Advance care planning brings up challenging emotions, and these conversations can be hard. But the day your loved ones are asked what you would want, this planning will make those conversations less distressing, and will enable your doctors to provide the best care for you.

During this pandemic, do your part to help. Get your affairs in order now, because COVID-19 won’t wait.

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U=U: Ending stigma and empowering people living with HIV

Today, about 1.1 million people in the US are living with HIV (human immunodeficiency virus). Every year, almost 40,000 people are diagnosed with HIV. A diagnosis of HIV was once presumed to be fatal, and many lived in fear of transmitting the virus to others. This contributed to decades of stigma for those living with HIV.

What is the U=U campaign?

U=U means “undetectable equals untransmittable.” More specifically, it means that people living with HIV who have an undetectable level of virus in their blood due to treatment are unable to transmit the virus to others.

The U=U campaign hopes to spread awareness that medications for HIV are extremely effective. If you are a person living with HIV and the virus level in your blood is suppressed by effective treatment, you cannot pass on the virus to others.

This campaign was launched after three large studies on sexual transmission of HIV were performed in thousands of serodiscordant couples (meaning one partner was living with HIV and the other was not). Not a single case of HIV was transmitted from someone who was virally suppressed to his or her HIV-negative partner (see here, here, and here for the studies).

Remarkably, this held true for all people living with HIV, including heterosexual women, heterosexual men, and men who have sex with men. It represents a dramatic shift from decades of fear experienced by those living with HIV. Now, people living with HIV can live long, healthy lives with no chance of passing on the virus to others if they are on appropriate treatment.

What does it mean for HIV to be undetectable?

The amount of the virus found in the blood is known as the HIV viral load. Research shows that having high levels of virus in the blood is associated with a greater risk that people will transmit the virus to others.

If you have HIV, taking medication every day as directed by your healthcare provider helps to suppress the HIV viral load and keep it suppressed. Medications to treat HIV can be taken daily for years with few side effects. It is important to work with a primary care provider or infectious disease specialist to make sure the virus is being treated correctly.

If the virus is untransmittable, do I still have HIV?

Yes. For now, there is no cure for HIV. It is a lifelong condition that requires treatment every single day to keep the virus suppressed. As long as the virus is suppressed, you are unlikely to have serious complications or infections and can go on to live a healthy life.

How can you make sure the virus stays untransmittable?

The most important way to prevent virus transmission when living with HIV is by taking HIV medications that are effective for you every day, and working with your HIV provider. The risk that you will transmit HIV goes up substantially if you miss doses of HIV medicines or stop taking them.

It’s important to know that HIV treatment does not keep people from passing on other sexually transmitted infections(STIs). Wearing condoms reduces the risk of passing on other STIs like chlamydia, gonorrhea, syphilis, and hepatitis C.

Additionally, for people who are HIV-negative, there are effective medications to help prevent HIV called PreP — you can read more about it here.

If you are living with HIV, it is important to talk with your healthcare provider about what treatment is best for you, and get specific advice. They can also answer questions about your partner or partners, and any questions you might have about living with HIV.

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As the pandemic drags on, when can we get back to work?

Along with widespread illness and death, the COVID-19 pandemic is also causing massive economic disruption. Stay-at-home measures and business shutdowns have prevented millions of people from working. In just four weeks, between mid-March and mid-April, 22 million Americans filed for unemployment benefits. These numbers are bound to spiral higher.

Given all the hardships — and new predictions that cases of COVID-19 will begin falling in most states in the coming weeks — when might people be able to return to work? Thus far, the answers are quite uncertain.

Although the Centers for Disease Control and Prevention (CDC) has issued some federal guidelines, you may need to follow stricter state or local regulations and employer policies. Some experts have suggested serologic (antibody) tests to determine who has had the virus and to guide decisions about returning to work. And the experiences of countries that have successfully slowed cases of COVID-19 and loosened restrictions on work will come into play, too. Below I’ve explained a bit about each approach.

Return-to-work recommendations from the CDC

Recent return-to-work guidelines from the CDC apply to relatively few American workplaces:

• For workers in healthcare or outside of healthcare who have confirmed or suspected COVID-19: The guidelines allow discontinuation of isolation and returning to work once fever has resolved, symptoms have improved, and swab tests for SARS-CoV-2 are negative twice at least 24 hours apart. If testing is not available, those who had COVID-19 should wait until they’ve had three or more days of improved symptoms without fever and seven days have passed since symptoms began.
• For critical infrastructure workers (such as healthcare workers and people who work in law enforcement) who were exposed to someone with confirmed or suspected COVID-19: New guidelines now permit continuing to work if people have no symptoms, no fever, wear a mask for 14 days, maintain six-foot physical distancing from others (“as work duties permit”), and disinfect and clean work spaces well. These new guidelines relax prior requirements that urged such workers to remain in quarantine for 14 days before returning to work.

As you might expect, there are caveats. As mentioned, local regulations or employer policies may be more stringent than these recommendations, so check with your employer and primary care physician before going back to work. And a disclaimer notes the guidelines “cannot prevent all instances of secondary spread.”

What about using serologic (antibody) tests to guide our return to work?

Serologic tests identify antibodies in your blood that your immune system produced to fight off the virus and to be ready in case you’re exposed to it again. If present, they indicate that you were previously infected, even if you were unaware of it. These tests are quite different from nasal swab testing performed to identify current infection.

If you never had symptoms or your symptoms completely resolved, a positive serologic test likely indicates that you have some protection from re-infection (for at least a while) and are unlikely to be contagious. So, positive results might let you know that it’s safe for you to return to work (and to be around others at home or work who may be susceptible to the virus).

Additionally, if your body made antibodies in high amounts, you may be a plasma donor candidate, as your antibodies could be used to help someone who is struggling to recover from COVID-19.

Sounds great, right? It is if you are feeling well and your serologic tests are positive. But what if they are negative? And what else do we need to consider?

Negative antibody tests: Good news and bad news

A negative serologic test generally means you haven’t been exposed to the virus. So, congratulations, it seems you successfully avoided infection and were never a threat to spread it to others! On the other hand, you still may catch the virus from someone else. A negative result is not helpful in knowing when it’s okay to return to work or to relax certain physical distancing measures.

Until widespread serologic testing is performed, we won’t know how many people are already immune to the virus that causes COVID-19, but it’s possible that most people will have a negative result.

Why? For one thing, mitigation efforts seem to have been effective at limiting exposure. And while we tend to hear about the “hot spots” where infection is spreading rapidly, many areas of America and the world have had low infection rates.

In the US, projections in mid-April by the University of Washington suggest that we’ll have up to a million cases of confirmed COVID-19 by August 2020. If there are 10 times as many unconfirmed cases of COVID-19 as confirmed cases, as Angelo Borrelli, a government official in Italy, believes, another 10 million people were exposed to COVID-19, but were asymptomatic or never got tested. Given a US population of 330 million people, that means 3% may have positive antibodies and the remaining 97% of Americans may never have been exposed to the virus. All of the people who weren’t exposed would be expected to have negative serologic test results, which aren’t helpful in making decisions in the coming weeks and months about who can safely return to work.

Serologic testing raises several other issues, as well:

• Early testing has been plagued by inaccuracy
• It’s not yet confirmed that positive antibodies are protective
• Even if they are protective, it’s not known how long that protection will last
• And finally, it’s likely that we can’t do antibody testing for enough people in the near term to provide reassurance about the safety of returning to work soon.

Once enough people (perhaps 60% to 70% of the population) have protective antibodies due to infection or vaccination, there will be more confidence in the safety of returning to work. But a vaccine is a year or more away.

Where does this leave us in returning to work?

While there are no uniform guidelines to rely upon for most workers, here’s how some experts, public officials, and other countries have responded to the question of when employees might return to work:

• Spain recently allowed certain industries, including manufacturing and construction, to resume operations as long as protective equipment is provided and physical distancing measures are maintained. China is also beginning to relax restrictions, including in Wuhan, where the pandemic began.
• Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases and member of the White House’s coronavirus task force, recently predicted a gradual reopening of parts of the country, perhaps starting as soon as May 2020. However, he has repeatedly warned that the timeline depends on the behavior of the virus and the effectiveness of mitigation efforts.
• Relying on serologic testing to decide who can return to work has been a focus of government leaders, including those in New York (such as Governor Cuomo), Great Britain, and Italy. You can expect to see a big push in the coming weeks for widespread serologic testing, though as discussed above it remains unclear how helpful this will be.

“Reopening the economy” is likely something that will happen gradually, along with ongoing monitoring for renewed outbreaks. For example, restaurants and smaller offices might reopen at partial capacity, with employees hired back in gradually increasing numbers if all goes well. Later, sporting events and concert venues may reopen. This will probably vary by geography: areas with fewer cases of COVID-19 may ramp up toward higher employment levels more quickly than those hit hardest by the outbreak. As workers return to their jobs, many of the current precautions will likely remain in place, such as frequent disinfectant cleaning and avoiding unnecessary crowding and physical contact.

The bottom line

In the coming weeks and months, a drop in cases of COVID-19 is expected across the US, according to models from the University of Washington. Once that happens, public health experts and national, state, and local leaders will likely give the go-ahead for employers across many industries to gradually reopen, and employees will return to work. That could happen in some areas as soon as May or June.

But, the decision to allow businesses to reopen must be made despite considerable uncertainty: if businesses reopen too soon, the outbreak may flare up again. Wait too long and many businesses and the people who work in them may never recover financially.

Since you can’t return to your job until your place of work resumes operations, workers everywhere have to wait for that to happen. Even after it does, it may be a while before we know if it was too soon, too late, or the right move.

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Struggling with attention and organization as you age? It could be ADHD, not dementia

As we get older, occasional forgetfulness may become more worrisome. Is this the start of dementia, or are we just stressed? Has the loss of structure due to retirement led to this change? Or could we be suffering from another illness, maybe the same illness as our son or granddaughter, who also struggle with attention and organization?

What are the symptoms of ADHD in older adults?

Although the diagnosis of ADHD (attention deficit hyperactivity disorder) is often associated with school-age children, this condition may persist throughout adulthood and into old age. Older adults with ADHD struggle with attention, memory, and planning. They may struggle with finishing projects or remembering information consistently, and they may become distracted during conversations and experience difficulty maintaining relationships. When older adults lose the structure of employment, they may experience an exacerbation of symptoms, similar to when young adults with ADHD lose the structure of school. During retirement older adults may start to re-experience challenges with time-management and procrastination, which may result in feelings of anxiety or guilt.

Is it normal aging or ADHD?

When people share concerns with their doctor about their memory, attention, or difficulty completing tasks, they may receive a diagnosis of mild cognitive impairment (MCI), a stage between normal aging and dementia. However, older adults with ADHD may never have received a diagnosis of ADHD, especially if they had learned skills to compensate during their lifetime. To help doctors differentiate between mild cognitive impairment and ADHD in old age, the timing of symptoms and family history can provide good clues (after ruling out potential medical causes, such as thyroid or seizure disorders).

ADHD is one of the most heritable disorders in medicine, so having children, grandchildren, or siblings with this diagnosis should increase a doctor’s suspicion that their patient’s symptoms may be the result of ADHD. Understanding a patient’s timeline of symptoms is also crucial, as symptoms must have occurred in childhood to make the diagnosis of ADHD. Screening tools in adults may also be useful, such as the ADHD Self-Report Scale, although a positive screen doesn’t always mean you have ADHD.

What are effective treatments for ADHD in older adults?

The most effective medications for the treatment of ADHD in older adults are stimulant medications such as methylphenidate or dextroamphetamine. These medications provide significant benefit to older adults, as well as children and younger adults. However, in older adults doctors must also consider the cardiac risks of these medications, including increased blood pressure and heart rate, as well as a potential increase in the risk of an irregular heartbeat, particularly in people with known heart blockage.

Nonmedication options are also valuable to help a person create structure and learn organization tools, such as use of a daily planner, alarms, and lists. Therapists or coaches can help older adults with ADHD through the use of behavioral therapies, which may lead to improved time and money management, increased productivity, reduced anxiety, and higher life satisfaction.

What can you do in addition to getting medical treatment?

If you suspect your symptoms may be the result of ADHD, especially if a close family member has received this diagnosis, do not hesitate to ask your primary care physician for a referral to a specialist with expertise in the diagnosis and management of ADHD in older adults. In addition, the following strategies can be useful in managing symptoms at home.

Exercise regularly. Physical activity increases brain neurotransmitters, such as dopamine, norepinephrine, and serotonin, which can affect attention.

Improve sleep. Set up a bedtime routine, avoid caffeine after noon, and try to avoid electronic devices within an hour of bedtime.

Enlist the help of others. Family members and other supports may help with creating structure and simplifying tasks.

Set reminders. Calendars, alarms, written notes, and lists can provide additional assistance in remembering tasks.

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A tale of two epidemics: When COVID-19 and opioid addiction collide

I am a primary care doctor who has recovered from — and who treats — opiate addiction. I work in an inner-city primary care clinic in Chelsea, Massachusetts, which currently has the highest rate of COVID-19 in the state, due, in part, to poverty. These two experiences offer me a clear view of how these two epidemics — COVID-19 and opioid addiction — can impact and worsen each other. Two great epidemics of our generation are intersecting in ways that are additively deadly, and which highlight the urgent ways we must respond to some of the underlying fault lines in our society that are worsening both crises.

Social determinants of health create greater vulnerability

People who suffer from the disease of addiction are particularly vulnerable to both catching the coronavirus and having a more severe disease when they do catch it. There are many reasons for this, but they boil down to something called social determinants of health, which according to the CDC are “conditions in the places where people live, learn, work, and play [which] affect a wide range of health risks and outcomes.^” In short, people suffering from addiction are vastly more vulnerable to coronavirus, as they are more likely to be homeless, poor, smokers with lung or cardiovascular disease, under- or uninsured, or have experienced serious health and socioeconomic issues from drug addiction. There are also millions of vulnerable incarcerated people, many of whom are stuck in jail due to their addictions and related nonviolent drug offenses.

Treatments and support systems may be disrupted

For someone struggling with addiction, virtually all of the services and treatments available to them have been disrupted by the COVID-19 epidemic. People are told to stay home, which directly contradicts the need to go to clinics to obtain methadone or other medications for treating addiction. Our government, in response, has relaxed regulations so that, in theory, clinics can give 14-day or even 28-day supplies to “stable” patients, so that they don’t have to wait in line and can adhere to social distancing for safety. Unfortunately, there are countless stories of patients not being granted this privilege, including at least one of my own patients.

Similarly, the government has relaxed some restrictions on buprenorphine prescribing, and has allowed some telephone prescribing, but this presupposes that there are doctors available that are healthy and certified to prescribe this medication, and that the pharmacies and doctors’ offices are functioning. Access to clean needles is affected as well. Additionally, may rehab facilities have limited new admissions, cancelled programs, or even shuttered their doors for fear of spreading coronavirus in a communal living setting.

Social isolation increases the risk for addiction

A common truism in recovery culture is that “addiction is a disease of isolation,” so it stands to reason that social distancing — in every possible way — is counter to most efforts to engage in a recovery community. It is important to remember that experts distinguish between physical distancing and social distancing, and actually emphasize that we keep physical distance, but make extra efforts to maintain social bonds during this time of enormous stress and dislocation.

The social isolation that is so critical to preventing the spread of coronavirus prevents people from attending peer-support groups, which are such a vital source of emotional and spiritual support to people struggling to stay in recovery.

Isolation may increase the risk of overdose deaths

Heightened anxiety is a near-universal trigger for drug use, and it is difficult to think of a more stressful event — for all of us — than this pandemic. Users who adopted harm reduction techniques and had been using drugs with a friend are now using them alone, and there is no one nearby who could administer naloxone or call 911 in the event of an overdose. As a consequence, police have been finding people dead in their apartments. When people do call 911, the health care system is overloaded, and first responders may arrive more slowly. We know that starting addiction treatment in the ED can help prevent relapse, but right now emergency room doctors are absolutely overwhelmed with COVID-19 cases, and might not have the time or resources available to start addiction medications following an overdose.

Sadly, the ugly face of stigma and discrimination is coming out as well, as there are reports surfacing of police departments across the country that are refusing to offer naloxone to patients who have overdosed, on the pretext that it is too dangerous because the “addict” might wake up coughing and sneezing coronavirus droplets.

Multiple health crises mean comprehensive solutions

 What we need to do now is reach out more than ever to those who are struggling with addiction, and provide them with the resources, such as online meetings, so that they are not alone and forgotten during this dual crisis of coronavirus and addiction. We need to make sure that they are getting the medications they need to recover, that they have access to clean needles if they are still using, adequate medical care, food, and housing — basic human needs.

If any good has come out of the misery of the combined COVID-19 and opioid epidemics, perhaps it is that a clear, bright light has been shined on the deadly social fissures — poverty, income inequality, lack of health insurance and access to healthcare, homelessness — that are the true social determinants of health we will need to address as part of an effective response to future pandemics.

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Knee arthroscopy: Should this common knee surgery be performed less often?

Imagine you’re walking along and suddenly experience excruciating knee pain. Though it initially seems stuck in one position, after a minute or two you can limp along home, but just barely. At your doctor’s visit, an x-ray is normal but symptoms continue for weeks. An MRI is performed and now you have an explanation: a torn meniscus. (Two menisci — rubbery cartilage pads that act as shock absorbers — separate the bottom of your knee bone from the top of your shin bone.) A month later, you’re no better despite rest, pain medicines, and physical therapy. It’s time for surgery to fix it, right? Maybe not.

Knee arthroscopy is among the most common surgeries performed

If you went ahead with surgery, you’d be in good company. Each year, an estimated 750,000 arthroscopic knee operations are performed in this country at a cost of $4 billion. Among the most common reasons for this surgery is a torn meniscus that causes intermittent and severe pain, catching, or locking.

During arthroscopy, an orthopedist inserts a hollow-tubed instrument with a camera and light on the end into an anesthetized knee. After examining the inside of the knee, instruments can be passed through the hollow tube to remove debris, smooth ragged edges, and cut away cartilage that is impairing knee function.

Many people have both a torn meniscus and osteoarthritis (the age-related, wear-and-tear type of arthritis). The combination is common, not only because these conditions become more common with age, but also because a meniscal tear is a risk factor for developing osteoarthritis. And arthroscopic surgery itself (often performed to treat a meniscal tear) may also promote osteoarthritis.

We already know that arthroscopy for osteoarthritis doesn’t help most people. But how good is it for the combination of osteoarthritis and a meniscal tear?

A new study re-evaluates the usefulness — and risk — of knee arthroscopy for meniscal tears

Past studies (such as this one) have raised the possibility that surgery provides little advantage over nonsurgical approaches for many people with meniscal tears, at least over the short run. A more recent study followed people with meniscal tears and osteoarthritis for five years  and compared how well they did with arthroscopic surgery or more conservative treatment, such as physical therapy and pain medications.

The study was published in Arthritis and Rheumatology and enrolled 351 people age 45 and older who had

• knee pain for at least a month with symptoms that seemed related to a meniscal tear (such as intermittent, sudden pain or catching)
• little or no improvement despite taking medications, limiting activity, and/or physical therapy
• osteoarthritis (confirmed by x-rays or MRI scan) and a meniscal tear demonstrated by MRI scan.

Half were randomly assigned to have arthroscopic surgery followed by physical therapy, while the other half received physical therapy for 12 weeks.

Arthroscopy has questionable benefits, many risks

Within the first few weeks and months, pain and function improved about the same amount in both groups, and at a similar rate.

But nearly 40% of the study subjects assigned to receive physical therapy “crossed over” into the arthroscopic surgery group due to lack of improvement. In addition, more study subjects receiving arthroscopy required knee replacement surgery during the study period.

Some study subjects (7% of the total) underwent knee replacement surgery during this study, including 9% of those assigned to arthroscopy and 5% of the nonsurgical group. This difference was not considered statistically significant. But a significant difference was noted when the cross-over subjects (those who were assigned to physical therapy but switched into the surgery group) were included in the surgery group: 10% of the arthroscopy group versus 2% in the physical therapy group had knee replacement.

While the numbers were too small to be confident about a true difference, these results raise the concern that arthroscopy increases the chances that arthritis will progress and knee replacement will be needed.

Additional downsides of surgery are well known, and include:

• pain, risk of bleeding, and risk of infection (as with any surgical procedure)
• cost — while prices and insurance coverage vary, the cost of arthroscopic knee surgery in the US commonly ranges from $5,000 to $10,000
• a recovery period that lasts weeks to months
• the possibility that the operation will cause arthritis to advance more rapidly than it would have, which could lead to the need for knee replacement.

The bottom line

Together with previous findings, this study suggests that among middle-aged and older adults with meniscal tears and osteoarthritis, nonsurgical treatment should be the preferred option over arthroscopic meniscal repair. Of course, the question remains: how long should you give nonsurgical treatments before giving up on them and scheduling surgery, especially if symptoms are severe?

Undoubtedly, there are people who are helped by arthroscopic knee surgery: someone whose knee is locked, or who cannot walk at all due to pain or catching, may need surgery sooner than later.

But if you don’t fall into this category, and if arthroscopic knee surgery is recommended to you, ask your surgeon about this study and whether it applies to your situation. The better plan may be to put surgery off for at least a while longer.

Follow me on Twitter @RobShmerling

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