Friday, March 1, 2019

New guidelines for preventing peanut allergy in babies

The 21st Century Cures Act speaks to a huge arrangement of activities went for improving the consideration of individuals with mental and substance use issue. It expands on imperative advancements presented in the Mental Health Parity and Addictions Equity Act and the Affordable Care Act. It without a moment's delay tends to vexing issues that request prompt consideration, endeavors to completely actualize existing approaches and projects, makes new interests in longer-term results, and assumes the testing collaborations of individuals with mental and substance use issue with the open security framework.

The Act calls for new spending of $1 billion in gifts to states to help endeavors to avert and treat the results of narcotic abuse and misuse. The awards are fixing to states and the systems used to convey substance misuse anticipation and treatment square allow reserves. The Act isn't extremely prescriptive and depends on bearing from the Department of Health and Human Services. President Obama's 2017 spending plan asked for marginally more than $1 billion to be guided essentially at endeavors to close the treatment hole. Other prompt reactions to social wellbeing challenges in the Act incorporate new spending for suicide anticipation ($30 million), growing emergency reaction abilities ($12.5 million), and distinguishing proof and treatment of maternal melancholy ($5 million).

The Act reauthorizes the Substance Abuse and Mental Health Services Administration (SAMHSA) and puts extraordinary accentuation on proof based projects and assessment. It additionally gives unique thoughtfulness regarding the usage of the Mental Health and Addictions Equity Act. It expands on suggestions from an ongoing Presidential team and accentuates prerequisites for back up plans to uncover the procedures and proof they use to oversee care, requirement exercises, and to make data and the cure procedure more purchaser neighborly.

Longer-term ventures are reflected in another $20 million program concentrated on emotional wellness advancement, counteractive action of ailment, and treatment for newborn children and the early youth time frame. Other farsighted endeavors incorporate another National Mental Health and Substance Use Policy Laboratory supported at the $14 million dimension. The research facility is to concentrate on assessing promising beginning period, proof based practices and administrations conveyance models for scaling. At long last, the Act starts to address national and restricted workforce deficiencies through help of preparing programs went for underserved regions and populaces.

The Act reauthorizes and alters the Mentally Ill Offender Treatment and Crime Reduction Act (MIOTCRA) at $50 million every year. Through this instrument, the Act pays to extend effective projects that redirect individuals with mental and substance use issue toward options in contrast to detainment. There are likewise new assets to help network reentry for individuals with mental and substance use issue leaving correctional facilites and penitentiaries. At last, new assets will be accessible for preparing cops in compelling reactions to individuals with psychological sickness.
In case you're similar to most nourishment disapproved of customers, "sound" on the facade of a bundle can be a major draw. "When you're stuck in a circumstance where prepared sustenances are the main thing accessible to you, it tends to be useful to know which nourishments are more beneficial than others," says Dr. Walter Willett, seat of the branch of sustenance at the Harvard T.H. Chan School of Public Health.

However nowadays you're on temperamental wholesome ground on the off chance that you depend on front-of-bundle claims like "solid" and "characteristic" to figure out which soup, sauce, oat (or other canned, packaged, boxed, or stowed sustenance) is the best decision. In 2015 Dr. Willett was one of twelve sustenance specialists to advise the Food and Drug Administration that its meaning of "sound" was obsolete and could lead shoppers off course. They appealed to the FDA to rethink "solid," and in September 2016 the office detailed that it was doing as such the FDA is additionally taking a shot at characterizing the expression "common" also.

What does "solid" mean?

"Solid" turned into a moving point a fourth of a century back, when the parity of proof showed that what we eat assumes an essential job in deciding how sound we are. Back then, the significant spotlight was on eating routine and coronary illness, and general wellbeing authorities underlined diminishing fat admission to keep our supply routes open, and controlling sodium to hold our circulatory strain within proper limits. In the mid 1990s, the FDA decided that sustenance producers could utilize the expression "solid" on the facade of a bundle as long as the substance contained not exactly a predefined measure of both sodium and fat per serving.

From that point forward, inquire about has established that eats less wealthy in unsaturated fats — those found in nuts, seeds, and fish — may really decrease the hazard cardiovascular ailment and diabetes. Research has additionally demonstrated that eating a great deal of refined starches — which were frequently added to low-fat sustenances as flavor enhancers — may expand the danger of those conditions. The specialists who created the 2015-2020 Dietary Recommendations for Americans exhorted evacuating the point of confinement on all out fat calories. Rather, the new proposals limit just trans and soaked fats (to 10% of calories), included sugars (to 10% of calories), and sodium (to 2,300 grams for each day).

Nourishment Facts marking is likewise being refreshed to mirror the ongoing dietary proposals. By July 26, 2018, most sustenance bundles will show a refreshed Nutrition Facts box that will incorporate the measure of included sugars—a wellspring of void calories. They will likewise incorporate sensible serving sizes, and will never again single out calories from fat.

What would you be able to do?

In spite of the fact that sustenance marking isn't perfect, regardless it offers valuable data. To get the best thought of what you're getting you might need to do the accompanying:

Trust, however confirm. On the off chance that the front of the bundle says "solid," check the Nutrition Facts on the back to ensure you're not getting such a large number of calories from sugars. Keep in mind: every gram of sugar has four calories.

Figure it out. The serving size on the bundle is probably going to be a think little of what you'll eat. For a progressively reasonable thought of your potential calorie consumption, duplicate the quantity of calories in a solitary serving by the quantity of servings in the bundle. At that point gauge the amount of the bundle you're probably going to expend. For instance, a holder of hummus may have 17 servings at 35 calories each. In the event that you as a rule utilize a fifth of the holder in a sandwich wrap, you'll be getting around 120 calories. This methodology works for different fixings like sugar and sodium. On the off chance that it sounds overwhelming, swing to the adding machine application on your cell phone.

Cut back on bundled nourishments. On the off chance that you make your own sauces, dressings, and soups from crisp produce, flavors, and vegetable oils, you'll have more affirmation that you're eating for good wellbeing — and you'll likely show signs of improvement enhances in the deal. January is a motivating time to make goals about eating a sound eating routine and practicing more, perhaps in light of the fact that you need to look or feel much improved. Actually, those reasons aren't in every case enough to shield me from avoiding an exercise in the event that I have a lot on my calendar. I surmise I'm a commonplace mother, putting my family and my activity first.

However, this year, I have a lot of reestablished motivation to put my wellbeing first, and the benevolent will keep me up during the evening on the off chance that I don't stick to it: proof proposes that receiving more advantageous way of life propensities may enable you to foil or even keep the improvement of Alzheimer's ailment. Dementia keeps running in my family.

About Alzheimer's

Alzheimer's ailment, the most widely recognized type of dementia, is portrayed by the amassing of two sorts of protein in the mind: tangles (tau) and plaques (amyloid-beta). In the end, Alzheimer's murders mind cells and ends individuals' lives.

What causes Alzheimer's? Despite everything we aren't sure. "For 1% all things considered, there are three qualities that decide conclusively whether you will have Alzheimer's, and every one of the three identify with amyloid-beta creation, which in these cases is likely the reason for Alzheimer's," says Dr. Gad Marshall, partner medicinal executive of clinical preliminaries at the Center for Alzheimer Research and Treatment at Harvard-associated Brigham and Women's Hospital. "For the other 99%, amyloid and tau are intently connected with Alzheimer's, yet numerous things may add to the improvement of side effects, for example, aggravation in the cerebrum, vascular hazard components, and way of life."

Promising proof

Up until this point, proof proposes that few sound propensities may help avoid Alzheimer's. Think about the accompanying advances.

Exercise. "The most persuading proof is that physical exercise keeps the improvement of Alzheimer's or moderate the movement in individuals who have side effects," says Dr. Marshall. "The proposal is 30 minutes of decently incredible oxygen consuming activity, three to four days out of each week."

Eat a Mediterranean eating regimen. "This has been appeared to help frustrate Alzheimer's or moderate its movement. An ongoing report demonstrated that even halfway adherence to such an eating regimen is superior to nothing, which is significant to individuals who may think that its hard to completely stick to another eating regimen," says Dr. Marshall. The eating regimen incorporates crisp vegetables and organic products; entire grains; olive oil; nuts; vegetables; fish; moderate measures of poultry, eggs, and dairy; moderate measures of red wine; and red meat just sparingly.

Get enough rest. "Developing proof proposes that improved rest can help keep Alzheimer's and is connected to more noteworthy amyloid freedom from the cerebrum," says Dr. Marshall. Go for seven to eight hours of the night.

Not as certain

We have a few — however insufficient — proof that the accompanying way of life decisions help avert Alzheimer's.

Adapt new things. "We feel that intellectually invigorating exercises might be useful in averting Alzheimer's, however the proof for their advantage is frequently restricted to progress in a scholarly assignment, for example, a reasoning aptitudes test, that does not sum up to by and large improvement in speculation abilities and exercises of every day living," says Dr. Marshall.

Interface socially. "We believe that more noteworthy social contact anticipates Alzheimer's," clarifies Dr. Marshall, yet up until this point, "there is just data from observational investigations."

Drink — however only a bit. There is clashing proof about the advantage of moderate liquor consumption (one beverage for each day for ladies, a couple for men) and diminished danger of Alzheimer's. "It is felt that wine specifically, and not different types of liquor, might be useful, yet this has not been demonstrated," says Dr. Marshall.

What you ought to do

Despite the fact that we don't have enough proof that all sound way of life decisions forestall Alzheimer's, we do realize they can avert other ceaseless issues. For instance, restricting liquor admission can help decrease the hazard for specific tumors, for example, bosom malignant growth. So it's savvy to settle on the same number of solid way of life decisions as you can. "They're all valuable, and on the off chance that they end up helping you stay away from Alzheimer's, all the better," says Dr. Marshall.

In any case, don't feel like you have to hurry into an inclined up routine of carrying on with a more advantageous way of life. Everything necessary on the off chance that one little change at once, for example,

practicing an additional day of the week

disposing of one undesirable sustenance from your eating regimen

hitting the hay 30 minutes sooner, or closing off electronic contraptions thirty minutes sooner than ordinary, to enable you to slow down

tuning in to another sort of music, or tuning in to a digital recording about a subject you're new to

or then again eating with a companion you haven't found in some time.

When you roll out one little improvement, have a go at making another. After some time, they will include. My change is that I'm going to add 15 additional minutes to my activity schedule; that way, I'll rack up more exercise minutes out of each week, and I won't feel awful in the event that I need to avoid an exercise now and, at that point. By putting my wellbeing first, I'll be fit as a fiddle for my family and my activity, and ideally, I'll be in an ideal situation in more seasoned age. "Individuals neglect to get along in light of the fact that they dread one another; they dread each other in light of the fact that they don't have any acquaintance with one another; they don't have any acquaintance with one another on the grounds that they have not spoken with one another."

— Martin Luther King, Jr.

A patient of mine as of late imparted a story to me about her visit to a zone crisis room a couple of years ago.* She had an excruciating ailment. The crisis room staff not exclusively did not treat her agony, however she described: "They treated me like I was attempting to play them, similar to I was simply endeavoring to get torment medications out of them. They didn't attempt to make any finding or help me whatsoever. They couldn't dispose of me quick enough."

There was nothing in her history to propose that she was torment medicine chasing. She is a moderately aged, churchgoing woman who has never had issues with substance misuse. Inevitably, she got a determination and fitting consideration elsewhere. She is persuaded that she was dealt with inadequately by that crisis room since she is dark.

Also, she was likely right. It is entrenched that blacks and other minority bunches in the U.S. experience more sickness, more regrettable results, and sudden passing contrasted and whites.1,2 These wellbeing inconsistencies were first "authoritatively" noted, thinking back to the 1980s, and however a purposeful exertion by government organizations brought about some improvement, the latest report indicates continuous contrasts by race and ethnicity for all measures.1,2

For what reason are sure gatherings of patients getting distinctive consideration?

Specialists make a vow to treat all patients similarly, but not all patients are dealt with similarly well. The response to for what reason is confused.

Cases like my patient's above represent the negative suppositions and affiliations we can name bigotry, yet "most doctors are not expressly supremacist and are focused on treating all patients similarly. Nonetheless, they work in a naturally bigot system."3 likewise, we realize that our very own intuitive preferences, additionally called verifiable predisposition, can influence the manner in which we treat patients.4 Basically, there are such huge numbers of layers and levels to this issue, it's difficult to fold our heads over it. In any case, we'll attempt.

We currently perceive that prejudice and segregation are profoundly imbued in the social, political, and monetary structures of our society.3,4 For minorities, these distinctions result in unequal access to quality instruction, solid sustenance, bearable wages, and reasonable lodging. In the wake of numerous very advertised occasions, the Black Lives Matter development has picked up force, and with it have come increasingly strident calls to address this imbued, or basic, bigotry, just as certain predisposition.

At that point, there was the 2016 presidential decision. Unequivocally communicated prejudice and religious bigotry has turned out to be typical. A week ago, a more seasoned Muslim patient of mine* related that of late she has been bothered by outsiders for wearing a headscarf. "I don't feel safe notwithstanding strolling around my neighborhood," she sobbed. "I used to cherish strolling in the mornings or after work … it's been a very long time since I believed I could do that."

Because of the talk of the race and this disturbing increment in despise discourse, an expansive gathering of doctors distributed an open letter looking to console patients. The letter is an announcement of pledge to wellbeing as a human right, ladies' wellbeing, psychological wellness, LGBTQ wellbeing, proof based prescription, disassembling basic bigotry, and completion race-based violence.5 It's all that I need to tell my patients at the present time.

For what reason are specialists once in a while the objectives of inclination and bigotry?

An associate of mine, Dr. Altaf Saadi, as of late expounded on her encounters treating patients at our very own medical clinic. She has been addressed, offended, and even assaulted by patients, since she is a Muslim lady who wears a headscarf.5 She isn't the only one. Later distributed reports incorporate unmistakable fanaticism communicated towards specialists of dark, Indian and Jewish heritage.6,7,8 Several therapeutic diaries have recently distributed rules for specialists with titles like "Managing Racist Patients" and "The Discriminatory Patient and Family: Strategies to Address Discrimination Towards Trainees."9,10 It's dismal that we need these aides.

Furthermore, would we be able to fix this?

Articles tending to prejudice in drug recommend a large number of similar things. To battle prejudice and segregation, we as a whole need to perceive, name, and comprehend these mentalities and activities. We should be available to recognizing and controlling our own verifiable inclinations. We should almost certainly oversee obvious fanaticism securely, gain from it, and instruct others. These topics should be a piece of therapeutic training, just as institutional approach. We have to practice and model resistance, regard, receptiveness, and harmony for one another.

It is imperative to connect these objectives and activities together, as they are layers of the equivalent colossal issue. The guileful auxiliary prejudice, subliminal understood predisposition, and clear, outer segregation originate from a similar spot. Dr. Saadi's words hold genuine:

"We — as doctors and society all the more for the most part — must understand that the battles of one underestimated network are battles of us all. My battle as a Muslim-American specialist to serve my patients without dread of prejudice, and the battle of an African-American patient to be treated with pride and regard, ought to likewise be your battles."

Keeping that in mind, the invitation to take action to address bigotry and separation in drug is for us all, suppliers and patients.
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Ways to hold on to optimism and reap health benefits

In spite of the fact that the winter season starts with a touch of seasonal joy, numerous individuals feel somewhat "off" as the virus climate delays. I've just observed a couple of patients who are bewildered by how effectively they end up aggravated. "Is there some kind of problem with me?" "For what reason am I so miserable?" Often, their bodies are simply reacting to the darker and colder days.

We are represented by circadian rhythms, our body's regular clock that controls critical capacities including rest/wake cycles and mind-set. These rhythms can be thrown off by the winter season.1 The sky gets brilliant later toward the beginning of the day, and dim prior at night; yet, our feverish calendars expect us to prop up as though nothing has changed. This move, alongside different variables – including hereditary qualities and body science – may influence your emotional wellness.

Looking after health

Working out, eating nutritious sustenances, rehearsing care, and keeping up social emotionally supportive networks are center parts of keeping up a sound way of life. Not exclusively is physical action an awesome outlet for stress, practicing 30 minutes every day may enable your body to discharge endorphins, your regular "cheerful hormones." It might test amid the occasions to eat healthy, yet attempt to top off first on solid products of the soil to keep up a reasonable eating regimen at that point have the intermittent liberality.

Reflection has been appeared to improve side effects in individuals experiencing dejection and nervousness, and may likewise assist you with staying great. Contemplation can be as short as a 10-minute session each other day when you set aside the opportunity to be careful and check in with your body. A few people, particularly the individuals who think that its hard to calm their psyches, may discover guided reflection accommodating. There are a lot of applications, for example, Headspace and digital recordings accessible to support you. Other thoughtful practices, for example, yoga, going for a calm walk in a recreation center, or notwithstanding shutting your eyes to concentrate on tuning in to your main tune can likewise be useful.

Staying in contact with your family, companions, and other minding individuals throughout your life reinforces your feeling of network, and gives you a solid emotionally supportive network to approach when you feel down.

Light treatment

Some studies2 have appeared light treatment may profit those with gloom, particularly in the event that it is identified with the season. An audit article3 demonstrated that light boxes that produce light powers of in excess of 2,500 lux are useful (to look at, an overcast winter day gives around 4,000 lux though a bright day gives 50,000– 100,000 lux!). We more often than not prescribe that light treatment be utilized early morning when you wake up, utilizing a fluorescent white light box of 10,000 lux without bright wavelengths4 (these are sold explicitly for occasional mind-set issues). You should position the light 12-18 crawls from yourself for around 30 minutes, keep your eyes open however don't look straightforwardly into the light. Numerous individuals will put it close-by as they have breakfast or start their daytime tasks. Albeit light treatment is commonly very much endured, you ought to counsel your specialist before beginning the treatment, particularly on the off chance that you have previous conditions, for example, eye illness. Conceivable symptoms incorporate cerebral pain, eye strain, sickness, and even fomentation or rest aggravation, in spite of the fact that this is typically identified with utilizing the light later in the day. In these tempestuous occasions, it might be a battle to keep up a glass half full perspective on life. A survey just discharged by the Associated Press on New Year's Day demonstrated that most Americans left 2016 inclination truly debilitated. Just 18% feel things for the nation showed signs of improvement, 33% said things deteriorated, and 47% trust things were unaltered from 2015.

Be that as it may, 55% of those reviewed said they anticipate that their own lives should improve in 2017. In the event that you are among this larger part, it might work well for you. A developing assortment of research demonstrates that good faith — a sense there is no reason to worry — is connected to a diminished danger of creating mental or physical medical problems just as to an expanded shot of a more drawn out life.

One of the biggest such examinations was driven by scientists Dr. Kaitlin Hagan and Dr. Eric Kim at the Harvard T.H. Chan School of Public Health. Their group examined information from 70,000 ladies in the Nurses' Health Study, and found that ladies who were idealistic had a fundamentally diminished danger of passing on from a few noteworthy reasons for death over an eight-year time frame, contrasted and ladies who were less hopeful. The most hopeful ladies had a 16% lower danger of kicking the bucket from malignancy; 38% lower danger of biting the dust from coronary illness; 39% lower danger of passing on from stroke; 38% lower danger of biting the dust from respiratory sickness; and 52% lower danger of biting the dust from disease.

Indeed, you can secure confidence.

Regardless of whether you see yourself as a worrier, there's expectation. Dr. Hagan takes note of that a couple of straightforward changes can help individuals improve your point of view. Past examinations have demonstrated that confidence can be imparted by something as basic as having individuals consider the most ideal results in different aspects of their lives," she says. The next may enable you to see the world through rosier glasses:

1. Highlight the positive. Keep a diary. In every passage, underline the beneficial things that have occurred, just as things you've delighted in and focus on them. Think about how they occurred and what you can do to keep them coming.

2. Take out the negative. On the off chance that you wind up ruminating on negative circumstances, accomplish something to impede line of reasoning. Turn on your most loved music, rehash a novel you adore, or connect with a decent companion.

3. Act locally. Try not to fuss about your powerlessness to impact worldwide issues. Rather, accomplish something that can make a little positive change — like giving garments to an alleviation association, helping clean or replant an area park, or volunteering at an after-school program.

4. Be less demanding on yourself. Self-sympathy is a trademark shared by generally confident people. You can be benevolent to yourself by taking great consideration of your body, eating admirably, working out, and getting enough rest. Consider your advantages and focus on them. At long last, endeavor to pardon yourself for past transgressions (genuine or envisioned) and proceed onward.

5. Learn care. Embracing the act of deliberately concentrating on the present minute and tolerating it without judgment can go far in helping you manage unsavory occasions. On the off chance that you need assistance, numerous wellbeing focuses now offer care preparing. There are likewise a large number of books and recordings to direct you.
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What is prediabetes and why does it matter?

Right off the bat in December, Ms. Silva (not her genuine name) went to the medical clinic for a bladder contamination that simply continued deteriorating. She'd been having manifestations — torment when she peed, feeling continually like she needed to go to the washroom — for about seven days. She did all the correct things. She called her specialist, grabbed her medicines at the drug store, saw her specialist for a subsequent arrangement before long, and swore that she was taking her anti-microbial. Be that as it may, the torment kicked more regrettable and she off having fevers. She should have been admitted to the clinic.

Ms. Silva was an old woman in her 60s from Brazil. Absent much silver hair, she looked a lot more youthful than her 60 years, yet the disease had cleared her out. She looked depleted. As she came back from the restroom, she endeavored to twist her medical clinic outfit in a vain endeavor to inspire it to cover a greater amount of her body. "For what reason wasn't the anti-toxin working?" she asked, expressing the inquiry at the forefront of everybody's thoughts that night.

At first I was stressed over medication safe microscopic organisms. The microbes causing her disease ought to have been slaughtered by the anti-infection that she was given. In the event that she had accepted them as endorsed, at that point medicate safe microscopic organisms would be the main clarification for why she was deteriorating.

Along these lines, we talked about the anti-microbial. She said she took each pill and was additionally taking something for the torment, that unwavering, pressing sentiment of criticalness. She removed the pill bottles from her tote, saying, "see, this was the container of the anti-infection agents," demonstrating to me an unfilled jug of pyridium (phenazopyridine). "What's more, this container is the drug for the urinary torment," she stated, demonstrating to me a jug still brimming with anti-toxin pills.

This explained the riddle. She didn't have safe microorganisms. Ms. Silva's contamination declined in light of the fact that she had befuddled the anti-toxin pills for the pills for agony, taking the last with consistency while the disease kept on seething.

Specialists and patients are not generally in agreement with regards to which drugs are critical

Ms. Silva's story helped me to remember an article distributed this past fall in the Annals of Family Medicine that demonstrated an extensive contrast among patient and doctor recognitions about which prescriptions are critical. The investigation found that up to 20% of prescriptions considered vital by specialists were not effectively taken by patients. Accepting meds as endorsed is called medicine adherence, as this is holding fast to the specialist's suggestions that are endeavoring to boost the medications' advantage while limiting its symptoms. About a fraction of the time, patients overlooked, came up short taking drugs, or were indiscreet about when they took the medicine, a circumstance the examination creators called unexpected non-adherence. The other portion of the time, the patients purposely decided not to take the medicine effectively.

The investigation creators bring up that this disparity among patients and specialists is a side effect of a bigger issue in human services. It originates from testing center conditions that make it troublesome for patients and specialists to accomplice together in shared basic leadership. They call attention to that great specialist understanding correspondence requires a decent specialist quiet relationship, however a few examinations demonstrate that as a doctor's duties increment through restorative school, residency and on to rehearse, that their relational abilities decay. So does their sympathy.

Contrasts in sexual orientation, race, or financial class can likewise impact specialist tolerant correspondence. At times patients are shy about telling their specialist they don't comprehend or that they can't peruse. Besides, it's difficult for anybody to consider and ask all the essential inquiries when a surged specialist has his or her hand on the doorknob.

In any case, it's difficult to state precisely why the misconception happened in Ms. Silva's case. While she communicates in Portuguese, the medical attendant Ms. Silva addressed on the telephone recorded that a mediator was utilized. The specialist she found in the workplace communicates in Portuguese.

In the meantime, Ms. Silva had never completed grade school. It wasn't evident that she could peruse, and regardless of whether she could, her pill bottle was marked with neither the name of the medicine, nor its motivation. Without knowing a great deal about meds, she wouldn't realize which sedate was the anti-microbial. It additionally isn't clear what she was told and what she comprehended at that basic minute when she got the prescriptions at the drug store.

Step by step instructions to fix correspondence holes

Hopefully we will unravel the majority of the bunch factors prompting correspondence issues in a single specialist visit. In any case, that is unrealistic reasoning. In this way, the examination creators propose drawing in with other wellbeing experts, similar to drug specialists, attendants, and doctor collaborators, to help connect these correspondence holes by checking a patient's comprehension of their prescriptions and filling in learning holes when they emerge.

Drawing in other wellbeing experts may have helped Ms. Silva. Her experience demonstrates that between the specialist's office and the drug store, there were various botched chances to ensure she comprehended which medicine was the anti-toxin. Working with relatives may have helped also. Ms. Silva's little girl conveyed her to the clinic and may have been a helpful accomplice to stay away from misconceptions.

Fortunately, after a short remain in the clinic (being certain she was taking the correct prescription), Ms. Silva improved and returned home. In any case, her postponement in getting great is a disastrous case of exactly what amount can turn out badly between a specialist's remedy and a patient showing signs of improvement, particularly when there are mistaken assumptions about drugs. When I'm seeing another patient, I am particularly aware of specific bits of their history. Do they have a solid family ancestry of diabetes? It is safe to say that they are of Latino, Asian, Native-American, or African-American ethnicity? Did they have diabetes in pregnancy? Is it accurate to say that they are overweight or stout? Do they have polycystic ovarian disorder (PCOS)?

For what reason do I care about these things? Since they might be signs that the patient is in danger for creating grown-up beginning (type 2) diabetes, and that can prompt numerous real medicinal issues.

Numerous individuals have known about sort 2 diabetes, a sickness where the body loses its capacity to oversee sugar levels. Grown-up beginning diabetes frequently influences individuals with realized hazard factors and can take a long time to completely create, in contrast to adolescent (type 1) diabetes, which can grow arbitrarily and rapidly.

Here is the reason high glucose is an issue

Untreated or undertreated diabetes implies tirelessly high blood sugars, which can cause appalling blood vessel blockages, bringing about strokes and heart assaults. High blood sugars likewise cause nerve harm, with consuming leg torment that inevitably offers approach to deadness. This, joined with the blood vessel blockages, can result in disfigurements and dead tissue, which is the reason numerous individuals with diabetes end up with removals. The small veins to the retina are likewise influenced, which can cause visual deficiency. What's more, remember the kidneys, which are particularly helpless to the harm brought about by high glucose. Diabetes is a main source of kidney disappointment requiring dialysis and additionally kidney transplant. Be that as it may, pause! There's additional. High glucose impedes the white platelet work basic to a solid invulnerable framework, and sugar is an incredible wellspring of vitality for attacking microorganisms and parasites. These components put people in danger of terrible diseases of different sorts.

These realities alarm me. Not on the grounds that I'm the specialist who gets the chance to help deal with these awful issues, but since I'm of Latina plunge and diabetes keeps running in my own family. I'm in danger as well.

Anyway, what would we be able to do? On the off chance that we realize who is in danger for diabetes, and it takes a very long time to create, we ought to probably anticipate it, isn't that so? Right!

Keeping prediabetes from getting to be diabetes

An ongoing top to bottom article by endocrine specialists pronounces prediabetes an overall pestilence (which it is).1 Prediabetes is characterized by fasting blood sugars somewhere in the range of 100 and 125, or a strange outcome on an oral glucose resistance test. What would we be able to do to treat prediabetes? The creators checked on numerous vast, very much directed investigations, and all demonstrated that prediabetes can be focused on and diabetes deferred or averted.

One of the biggest examinations was led here in the U.S.2 Over 3,000 individuals from 27 focuses who were overweight or corpulent and had prediabetes were haphazardly appointed to one of three gatherings:

standard way of life suggestions in addition to the medicine metformin (Glucophage);

standard way of life suggestions in addition to a fake treatment pill;

a concentrated program of way of life alteration.

The concentrated program included individualized dietary advising, just as guidance to walk energetically or do other exercise for 120 minutes of the week, with the objective of some unassuming weight reduction.

Examiners pursued the subjects more than three years, and the outcomes were steady with those from numerous different examinations: the general population in the concentrated way of life alteration gathering (sustenance directing and practice direction) were far more averse to create diabetes in that time length than those in both of the other groups.3,4,5 Want numbers? The assessed combined frequency of diabetes at three years was 30% for fake treatment, 22% for metformin, and 14% for way of life change. The occurrence of diabetes was 39% lower in the way of life change assemble than in the metformin gathering. Actually, they shut down the investigation early on the grounds that it was considered dishonest to keep the subjects in the fake treatment and metformin-just gatherings from legitimate treatment.

The creators of the prediabetes audit likewise took a gander at the huge number of different investigations that all the more intently inspected what sorts of eating regimens are valuable and inferred that "The accord is that an eating routine wealthy in entire grains, vegetables, natural product, monounsaturated fat, and low in creature fat, trans fats, and straightforward sugars is useful, alongside support of perfect body weight and a functioning way of life."

It's extremely simply presence of mind. What's more, that is the reason my better half and I significantly limit our admission of sugar and carbs, get four or more servings of plant-based nourishments day by day, and exercise.

A word about drug

For my patients who for reasons unknown can't change their eating routine and way of life, I do prescribe a prescription. For patients who are on the cusp of diabetes and who have various hazard factors or different illnesses, drug truly is demonstrated. There are additionally individuals who need to add a medicine to slim down and practice so as to help weight reduction and further abatement their hazard, and that is reasonable too.

I realize that utilizing meds for prediabetes is disputable. Different specialists have cautioned that the name "pre-diabetes" is over-comprehensive and that it's every one of the an immense huge pharma promoting scam.6 It's valid that we must be educated about what we're endorsing and why. In any case, in light of what I've found in my profession, I unquestionably would prefer not to create diabetes myself, and in case you're in danger, trust me, you don't either. In this way, consider the upsides and downsides of everything, converse with your specialist, and choose for yourself what move you need to make. And afterward, make a move.
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Wednesday, February 27, 2019

The symptoms and dangers of untreated sleep

In September 2016, a woman in her 70s died of septic shock in Reno, Nevada, from an infection which was fully resistant to 26 different antibiotics. She had spent much of the previous two years in India, where she was treated for a hip fracture. The hip became infected, and after several more hospital stays, she returned to her home in Nevada.

Within weeks, she was desperately ill, and back in a hospital in Reno. A sample from her hip wound revealed a strain of the bacteria Klebsiella pneumoniae which was not sensitive to any antibiotics. It was even resistant to a drug called colistin, an old-fashioned, somewhat toxic, and rarely used antibiotic that is considered the last line of defense against antibiotic-resistant bacteria. Before she died, the patient was isolated and kept in a private room. There is no indication that her resistant bacteria had spread to other patients in the hospital or in the Reno area.
How these bacteria outsmart antibiotics

The Klebsiella bacteria that killed her had a powerful enzyme that breaks down antibiotics, known as New Dehli metallo-beta-lactamase (NDM), because it was first found in a patient who had travelled to that Indian city. Indian politicians have disputed the link between their capital and a deadly superbug, and the local tourism board and chamber of commerce probably aren’t too thrilled about it either. In any case, it is probably unfair to focus too much on the Indian origin of this resistant bacteria. Klebsiella bacteria with a slightly different, but equally fearsome form of antibiotic resistance known as KPC have already become entrenched in the United States, as well as in Brazil, China, Israel, Colombia, and Italy.

The vast majority of cases of resistant Klebsiella infection in the United States involve patients who have been hospitalized. But alarmingly, highly resistant bacteria have started to percolate down into the community. A recent outbreak of NDM-positive Klebsiella in Colorado involved patients without health care exposures. A woman in Pennsylvania presented to a clinic in May 2016 with a urinary tract infection with bacteria resistant to colistin, which she had probably picked up during a recent hospital stay.
Is it the end of antibiotics as we know them?

Hand-wringing about antibiotic resistance has been around almost as long as antibiotics. Newsweek somewhat prematurely proclaimed “The End of Antibiotics” in 1994, and the New England Journal of Medicine bewailed the rising tide of antibiotic resistance as early as 1960. All the way back in 1945, scientists had discovered it was relatively easy to create antibiotic-resistant bacteria by exposing them to very small amounts of antibiotics, and then gradually increasing their degree of antibiotic exposure. In retrospect, this shouldn’t be so surprising. Penicillin and cephalosporin antibiotics are derived from molds, which used these compounds for millennia to suppress competition from bacteria. So bacteria, in turn, have developed ways to neutralize and break down antibiotics. Overuse of antibiotics has favored the spread of bacteria carrying these resistance mechanisms.

Another sobering development is that the antibiotic pipeline is drying up, with dim prospects of new drugs coming along to replace the old ones that are losing potency. The economics of antibiotic discovery are bad. Many pharmaceutical corporations have gotten out of the business of developing new antibiotics altogether. The cost of bringing new drugs to market can ratchet up into the billions. The anticipated payoffs are small, as infectious diseases practitioners only use new and powerful antibiotics when absolutely necessary, in an effort to have them retain their effectiveness for as long as possible.
Here’s what you can do

You can take a number of steps as a patient, a consumer, and a citizen to help keep the flood waters of antibiotic resistance from breaking through the levee.

Don’t press your doctor to prescribe antibiotics if they believe it is unnecessary. Taking antibiotics increases your risk of acquiring drug-resistant bacteria, kills off your beneficial gut bacteria, known as your “microbiome,” and exposes you to the potentially deadly bowel infection, Clostridium difficile colitis.

About 80% of the antibiotic use in the United States is in agriculture, not medicine. In particular, low doses of antibiotics are added to livestock feed in factory farms to prevent infections and promote growth. This constant, low-level antibiotic exposure is an excellent way to create drug-resistant bacteria. At least some of these bacteria probably work their way up the food chain to affect humans. You can support the responsible use of antibiotics in agriculture by only purchasing meat raised without antibiotics. And consider calling your congressperson to ask their support for greater public funding for new antibiotic discovery.

And while this sounds bleak, there are other things you can do as a consumer and as a patient to help. You can start by paying attention to the food you eat and by not pressing your doctor for unnecessary antibiotics. “Doesn’t it typically happen during the summer?” asked a worried lady that had walked into my clinic in November with a growing circular rash on her wrist. She was referring, of course, to Lyme disease, that scourge of outdoor enthusiasts. While the peak season for Lyme disease is indeed summer, the ticks that transmit it are active March through December. And, while this may be off-season for the ticks, it is a good time to catch up on how to stay safe in the not-so-distant spring.
What is Lyme disease, and how do you treat it?

Lyme disease is caused by a bacterium called Borrelia burgdorferi which is spread to people through the bite of infected black-legged ticks, also popularly known as “deer ticks.” Early symptoms include a typical enlarging red rash (“bullseye rash”) at the site of the tick bite. This is common, but not everyone with Lyme disease gets this rash. Other signs of Lyme include flu-like symptoms (fever, fatigue, and headache). If left untreated, over time the infection can lead to Bell’s palsy (paralysis or weakness of facial muscles on one side), meningitis (inflammation in the brain and spinal cord), heart rhythm problems, and joint pain and swelling. Additional symptoms can include headaches and stiff neck, tingling and numbness (often in the hands and feet), and rarely, inflammation of the eyes.

The diagnosis is usually based on a person’s symptoms, the presence of the typical rash, and a history of likely exposure to infected ticks. Lab tests for Lyme disease do not turn positive until three to four weeks after the infection. Usually doctors do not wait for the results of these tests during the early stage of the disease, to begin treatment.

Once diagnosed, Lyme disease can be successfully treated with a few weeks of oral antibiotics. Doxycycline is the antibiotic prescribed to all but pregnant women and children, who usually get the antibiotics amoxicillin or cefuroxime. For people with severe heart or neurological symptoms of Lyme, intravenous antibiotics are usually necessary.
Here’s what you can do to keep from getting Lyme disease

As always, prevention is superior to cure. Right now, there is no Lyme vaccine available for people. There is a Lyme vaccine available for dogs! However, it does not protect against other tick-borne diseases, hence preventive measures against ticks are still necessary. Most dogs exposed to Lyme disease do not have symptoms. Some develop fever, lack of appetite, lameness, and joint swelling. Therefore, staying safe requires preparation and vigilance. The ticks that transmit Lyme disease are tiny, and you can’t feel it when a tick attaches to you. They may even make their way into your home by attaching themselves to pets. Here are some steps to follow to remain safe.

    Avoid wooded and bushy areas with tall grass and stick to the center of trails when hiking.
    Wear light clothing to make ticks easier to detect.
    Wear long pants tucked into socks to keep ticks on the outside of clothes.
    Use DEET or a permethrin-based tick repellent on clothing and outdoor gear.
    Pesticides like permethrin, fipronil, or amitraz may be used on dogs. These are available in the form of powders, impregnated collars, sprays, or topical treatments.
    Do remember to never use tick repellents that are intended for dogs on a cat! Cats are extremely sensitive to a variety of chemicals.
    When back home, shower or bathe as soon as possible and carefully inspect the entire body to remove any attached ticks. It takes up to 36 hours for the bacterium to be transferred after the tick bite. Prompt removal of the tick will reduce the chance of infection.
    Tumble dry clothes on high heat for at least 10 minutes to kill ticks.
    Carefully examine children and pets after outdoor activity.

 If you find a tick along for the ride, here’s what you need to do

Use thin tipped tweezers to grasp the tick as close to the skin surface as possible. Pull the tick straight upward with steady even pressure to remove the tick with the mouthparts intact. Squeezing the tick will not increase the risk of infection. Adult ticks are a lot more difficult to remove intact. If the mouthparts break off, the chance of getting Lyme disease is the same as if you hadn’t removed the tick at all. After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water. Watch for signs and symptoms of Lyme disease for up to 30 days.

See your doctor within 72 hours of the tick removal and if the tick removed was swollen. You may benefit from preventive antibiotics. This is especially important if you live in (or have visited) an area where deer ticks are common.
Create a tick-free zone around your home

Need a little more motivation to mow the lawn or rake the yard? Remember that ticks lurk in tall grasses, brush, and weeds around homes and at the edge of lawns. Remove any old furniture, trash, or mattresses from the yard that may give the ticks a place to hide. Place a three-foot-wide barrier of wood chips or gravel between lawns and wooded areas and around patios and play equipment to restrict tick migration into recreational areas. Stack wood neatly in a dry area (this discourages rodents that carry the ticks). Keep playground equipment, decks, and patios away from yard edges and trees, and place them in a sunny location if possible.
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The tricky thing about asthma

Can we make humans healthier by growing healthier places? A 2016 analysis found that women living in areas with higher levels of green vegetation had lower rates of mortality. Researchers at the Harvard School of Public Health conducted a nationwide study of approximately 100,000 women from the Nurses’ Health Study. Those women that had homes in areas with the highest level of greenness in the surrounding 250 meters (roughly 820 feet, or a little over 1/10 of a mile) had a 12% lower rate of death compared to the women whose homes had the lowest level of greenness. Specifically, there was a 13% lower rate for cancer mortality, 35% lower respiratory disease-related mortality, and 41% lower rate for kidney disease mortality in the women living in the areas with the highest levels of green vegetation.
Just how does being in green spaces increase longevity?

When trying to figure out just how the greenness was protecting women against death, researchers found a combination of factors that came into play. These included lower levels of depression, increased social engagement, higher levels of physical activity, and lower levels of pollution. There are probably many reasons why being in green spaces might decrease depression. Perhaps people who live in greener areas are more likely to go outside. Exposure to sunlight helps people to make vitamin D, and low levels of vitamin D are associated with depression. Spending time with friends and participating in social activities were also associated with greener areas, and these things can decrease feelings of loneliness and depression. Being outside and experiencing nature has been known to increase feelings of well-being. In fact, some research suggests that even images of nature can lead to increased positive mood.

Exercise is medicine, and the more physically active a person is, the more fit they will be and the healthier they will be. Green spaces invite people to enjoy the outdoors and encourage people to walk, bicycle, or jog for physical activity. When the space around a home is green and full of vegetation, there are likely paths or trails that are in safe and beautiful places. In this study, those women that lived in greener spaces were more physically active.

Living among trees, plants, grass, and flowers provides an environment with less pollution than one with low levels of vegetation. The plants can reduce levels of nitrogen dioxide and particulate matter, which lowers the level of pollution. In this study, death from respiratory disease was reduced by about one third in those women who lived in the homes with the highest amount of vegetation. Breathing clean air matters, and plants help to clean the air.
Take advantage of green spaces

If you live in an area with heavy vegetation, this is good news for you. Take the opportunity to improve your health. Get outside and breathe the clean air, walk around the neighborhood, find some friends to walk with you, and enjoy the great, green outdoors. If you do not live in an area with a lot of greenery around you, consider planting some trees, plants, or shrubs. If you live in a highly urban area, you can get involved with local policy to work to encourage your community to increase green spaces. Spend time with friends who live in areas with lots of trees and greenery, consciously seek out green areas as often as you can, and consider vacationing in areas with lots of vegetation. When people feel that their lives have meaning, they perceive their lives as significant, purposeful, and valuable. This is critical for psychological well-being. People who feel that their lives have meaning feel less depressed and even have better outcomes in psychotherapy. Feeling that one’s life has meaning can also ease the psychological burden of medical illnesses. For example, people who have medical conditions such as a spinal cord injury cope better when they feel that their lives have meaning, and having a sense of meaning can improve the quality of life in cancer patients.
What to do when your sense of meaning slips away

Anything that makes you feel less safe — the death of a loved one, an illness, sudden financial burdens — can create a kind of anxiety that obscures all meaning. That’s when you may start to ask, “Why am I working so hard?” or “Why do I actually care about anything?” You may start to search for meaning frantically. While meaning is the “primary motivational force in man,” searching for meaning does not guarantee that you will find it. When you feel psychologically adrift and disconnected from meaning, how can you increase the chances that you will find it?

You might be surprised to learn that reconnecting with meaning may not involve a set of techniques, but a set of spontaneous actions removed from the humdrum of life’s everyday routines. As helpful as “psychological techniques” such as reframing or positive thinking can be, they often miss the mark in the search for meaning. Stanford psychiatrist Irvin Yalom explained that it is the intangibles and “off the beaten track” thoughts and activities that can make the greatest difference, much like the cook who spontaneously throws in a handful of spices into a dish without thinking much. When we examine the psychological elements that underlie the cook’s instinctive “throw-ins,” we find clues as to how we can jump-start meaning in our lives. Here are three ways to open yourself to rediscovering meaning.
Be curious

Seasoned cooks are capable of these precise “throw-ins” without much thinking because they are willing to be curious and follow their instincts. As much as the cook may follow a recipe, it is curiosity that drives the exceptional touch and activates the intangible taste that results from it. As Samuel Johnson said, “The gratification of curiosity rather frees us from uneasiness than confers pleasure; we are more pained by ignorance than delighted by instruction.” Curiosity, defined as the desire to know, see, or experience new things, can activate a sense of purpose and meaning. Adding this vital ingredient to your life by literally walking a safe path you’ve never walked before or tasting a brand-new dish may get you back to the road of meaning. It is this “unfocus” from learned daily habits that is necessary to activate meaning.
Understand that we want to be independent and connected all at the same time

Underlying the cook’s “dare” are two well-known psychological attributes that shape how we relate to the world: agency (a feeling of independence) as well as communion (a feeling of connection to others). These are contrasting, yet important aspects of who we are, and having enough of both in our lives can also help to activate meaning. By doing so, we acknowledge our two-sided selves. Too much independence can lead to isolation. Too much communion can lead to loss of a sense of self. Living life fully requires switching between the two and organizing your day so that you have enough of both. In the cook’s dare, she is independent, but she is motivated by feeding and tantalizing the palates of others too. Learning to accept your contradictions is central to experiencing a sense of meaning and more rewarding that choosing to be “one” or “the other” thing.
Notice when “meaning” appears

When you feel that sense of meaning, it is like a taste that “hits the spot” with the first mouthful. What you are tasting is not just a carefully crafted combination of ingredients, though you can be sure that that is part of the picture. In addition, you are the beneficiary of the cook’s spontaneous insight — an important factor in meaning-making. When you make time for spontaneous insights in your day, you can jump-start the flow of experience, which is characteristic of meaning-driven activities. You can’t have such insights if your day is run like clockwork or if it is jam-packed or if your calendar dictates your meaning (unless, of course, your calendar leaves room for spontaneous whims and fancies — these moments can require space too). Setting aside time for doing something with no particular goal in mind adds a vital ingredient to your life that can bring back the very meaning for which you were searching.

In essence then, when you are psychologically adrift, you may be tempted to try to ground yourself with rational approaches to life. In fact, what you may need is to also find your “psychological wings” so that you may catch the breeze of life and enjoy gliding into it before you land. In mid-January, health headlines announced that nearly one-third of adults diagnosed with asthma don’t actually have this respiratory condition at all. This announcement appeared everywhere from Fox News Health to the Chicago Tribune.

As a primary care doc, a medical writer, and an asthma sufferer, I was very skeptical of these dramatic announcements, and with good reason. An editorial that accompanied this study provides important perspective that suggests the news headlines were exaggerated and misleading.
Taking a closer look at the study

Let’s talk about the study, which is a good one, and has merit. Canadian researchers recruited 615 random people who had been given a diagnosis of asthma, and performed formal testing to see if they still had it. And in fact, 33% of those tested did not meet criteria for the diagnosis of asthma at the time of testing. The lead author of this study is then quoted as suggesting that doctors diagnosed these patients with asthma without doing the necessary tests.

Okay. As a physician who diagnoses and treats asthma (and its many variants), a medical writer and researcher who dissects these articles, and someone who is currently experiencing an awful asthma flare (or exacerbation), I take major issue with these headlines and the lead author’s press statements.
Looking a little deeper

The data tell the story. Of the one-third of patients who tested negative for asthma in the study, 24 (or 12% of them) actually did have appropriate testing (that confirmed asthma) when they were first diagnosed. What’s more, 22 of the participants who tested negative for asthma at the time of the study, tested positive months later (again using appropriate testing).

What this really tells us is that asthma has many forms and, like many chronic disease, symptoms may come and go. This is consistent with what I know from professional — and personal — experience.

The study authors themselves recognize at the start of the study how tricky asthma can be, pointing out that there are many types of asthma that can look a little different, and have different triggers. They go on to say (as mentioned in the editorial) that symptoms of asthma can relapse (come back) and remit (go away).
Let’s get real about asthma

When I see a patient with wheezing and/or coughing spasms, and especially whose symptoms improve after a breathing (nebulizer or neb) treatment in the office, I will tell them that they at the very least have reactive airways syndrome. This is not exactly asthma. It just means that something triggered them to wheeze — maybe an allergic reaction, or a virus. They may never wheeze again. But in my office, right then, because they are wheezing at that moment, they will probably benefit from an inhaler. If an inhaler has been helpful in the past or the neb provided immediate relief, I’m not going to say, oh wait, we need to have formal testing first, before we treat you. Nope.

But, if symptoms continue and we are worried that this is more than a one-time or occasional thing, then we may want to pursue a formal, official diagnosis of asthma.
How do you know for sure if it’s asthma?

A diagnosis of asthma requires two things: a history of respiratory symptoms consistent with asthma (chest tightness, wheezing, coughing spasms, particularly nighttime cough), along with proof of “variable expiratory airflow obstruction.” What the heck is that?

Lung function tests can show whether inflammation and narrowing of the airways is impeding your ability to breathe out. A key piece of equipment for doing this is called a spirometer, and it’s not something that you will generally find in any primary care office (it is not the same as a peak flow meter you can buy at the drug store). We refer patients to a pulmonary function lab for this sort of testing. The person breathes into the spirometer while the machine measures total lung capacity, as well as various measures of exhalation speed. They may also receive inhaled medications that can help to make the diagnosis of asthma. Sometimes medications (bronchodilators like albuterol) may be used to see if they relieve symptoms (or a different medication called methacholine can be used to carefully provoke an asthma attack). If the albuterol helps or the methacholine triggers an asthma attack — diagnosis made.

For some patients, the formal testing may be too expensive. Or maybe they can’t get it scheduled in a timely manner. If their history is as clear as mine, it may make sense to simply give them the asthma diagnosis, so that things like a nebulizer machine can be covered by insurance. Even if formal testing confirms asthma, it can resolve on its own, and repeat testing may be negative later on. Was this a misdiagnosis? No, this was just asthma.
Asthma in real life

Me? I was in my doctor’s office today with wheezing. I had the flu last week (more on that in another post) which triggered a prolonged wheezing/coughing episode. My doctor saw that I was struggling to breathe, measured my oxygen levels, which were low, and heard wheezing when listening to my lungs. She also tested my peak flow, which improved with a nebulized albuterol treatment in her office. This all supports a diagnosis of asthma, but for now, I’m labeled as having reactive airways, because I haven’t had any formal evaluation with a pulmonologist and I have never had spirometry.
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Tuesday, February 26, 2019

Better parenting, or more smartphones?

You may have heard of the phrase “primum non nocere” — the Latin phrase that doctors are supposed to follow that instructs them to “first, do no harm.” Doctors also have an important ethical obligation to alleviate pain. But what happens when these two mandates collide? That, unfortunately, is the case with opioid pain relievers: powerful medicines like oxycodone, hydrocodone, and hydromorphone. These medications are potent pain relievers, but this relief comes at a serious, and sometimes deadly, cost.

The United States is now in the era of an “opioid epidemic” in which deaths from opioid overdose have reached alarming numbers. In 2015, it was the most common cause of accidental deaths among adults. Nearly 30,000 Americans died from opioid-related overdoses — more than from motor vehicle accidents or gun violence. We now know that this epidemic was likely caused by the large increases in the number of opioids prescribed by clinicians to their patients, which increased at least four-fold between 2000 and 2010.
It’s not just about how many opioids are prescribed…

Now, recent literature is further refining how we think about the opioid problem, which is not just about how many opioids are prescribed. A study by Dr. Michael Barnett and colleagues from Brigham and Women’s Hospital in Boston published in the New England Journal of Medicine in February 2017 had a surprising finding: becoming dependent on opioids is not just about patients, it’s also about the physicians that prescribe opioids. If a physician was more likely to prescribe opioids than his or her peers, then a patient under their care was more likely to be on opioids long-term.

This research focused on over 200,000 elderly patients covered by Medicare. The researchers wanted to determine the extent to which individual doctors vary in their prescribing of opioids, and if that had implications for long-term use of opioids by patients. The study looked at patients who had not been prescribed opioids in the prior six months who then were prescribed an opioid after a visit to an emergency department (ED). The ED was chosen because patients don’t choose their doctor when they go there.

The emergency department doctors were divided into “high intensity” and “low intensity” prescribers, based on how frequently they prescribed opioids compared with their peers in each hospital. Then, study investigators looked at patients who were still on opioids in the 12 months after the ED visit. Low-intensity prescribers prescribed opioids to about one out of every 13 patients, while high-intensity prescribers prescribed opioids for about one of every four patients. Patients treated by doctors who were more likely to prescribe opioids (or to consistently prescribe higher doses of opioids) were more likely to still be on them long-term.
The study’s limitations and lessons

The study had some limitations. The authors couldn’t say for sure that all the opioids these patients ended up taking were actually prescribed by the emergency department doctor. They also didn’t take into account the types of patients some emergency physicians see. For example, some days I see lots of patients with painful fractures and other days I don’t. There is a component of randomness, in which physicians in the ED don’t choose their patients or the problems they have. Also, some physicians are more frequently assigned to “fast track” areas of the ED where injuries are treated more frequently, and those doctors more commonly prescribe opioids for reasons that would justify a patient being on long-term therapy. Finally, the data are from 2008-2011, now several years old. We know that opioid prescribing has started to taper off in the past few years. In my own department, for example, we found that our prescribing of opioids decreased by half between June, 2015 and December, 2016.

Still, the study provides an important lesson for patients. Whether it’s a visit to the ED, dentist, orthopedic surgeon, or even primary care physician, some doctors are more likely to prescribe opioids. Patients need to know about the potential harms of these medications and that for some people, a small initial prescription will lead to long-term use. Patients should be encouraged to try every non-opioid method to cope with pain first before taking opioids. This includes trying medications like acetaminophen and ibuprofen (if appropriate), heat/ice packs, lidocaine patches, physical therapy, etc. If a person ends up taking an opioid, she or he should use the smallest dose needed to feel comfortable. And once the prescription is finished, it is important to dispose of the medication safely — most pharmacies and police stations will take back medications, no questions asked. That’s the news from the Monitoring the Future study, which has been surveying more than 40,000 eighth, 10th and 12th graders about their drug use for more than four decades. While marijuana use has been steady, use of all other illicit drugs (including prescription amphetamines or narcotics being used outside of medical supervision) is down.

In 1996, 13% of eighth graders reported using illicit drugs (besides marijuana) in the previous year; in 2016, it was 5%. For 10th graders the number went from 18% to 10%, and for 12th graders it went from 20% to 14%. The marijuana news isn’t all bad, either; over the same 20 years, use by eighth graders went from 18% to 9%, and by 10th graders from 34% to 24%. It’s in 12th graders that it hasn’t budged; it was 35% in 1996 and 36% in 2016.

Why are things better? There are likely lots of reasons, and they are likely different for some groups of teens than for others. But an interesting possibility is that instead of using drugs for gratification, excitement, and social connection, teens are using their smartphones.

This is not the whole explanation, of course. The iPhone, which got the smartphone movement started, was introduced in 2007. According to the Monitoring the Future data, in 2006 the numbers already looked better than in 1996: 8% of eighth graders, 13% of 10th graders and 19% of 12th graders had used drugs besides marijuana in the previous year (for marijuana, the numbers were 12%, 25%, and 32% respectively).

There has certainly been a concerted effort on many different fronts to decrease drug use. From the “This is your brain on drugs” TV commercials and other such public service campaigns to school health curricula to more education of parents and pediatricians on how to talk to youth about drug use, our society has taken the problem seriously and sought to make a difference wherever possible. The current opioid epidemic, which affects more adults than teens, is covered substantially by the media and likely serves as a cautionary tale for many teens.

But it’s interesting to think about the role of the smartphone. According to a Pew Research Center study from 2015, 24% of teens reported being on their smartphone almost constantly, and 56% report checking it several times a day. Teens report more than six hours a day of entertainment media time — and many report needing to have their phones with them, and needing to check them all the time. Smartphones have become how teens connect, communicate, socialize, learn about the world, and play. Could it be that the stimulation and excitement of the constant connection works just as well for them as drugs? Could it be that it keeps them busy in a way that makes drug use less important or inviting? Might teens who find themselves in social situations where there is drug use be able to retreat into their phones instead of using drugs — and have it be not only socially acceptable, but possibly more rewarding than getting high?

We don’t know, of course. Much more research needs to be done. And given that there are clearly downsides to spending six hours a day on your phone (think of all the exercise, homework, face-to-face socializing, and creative endeavors that one could do in six hours, not to mention the safety issues created when your attention is on your phone instead of your surroundings), it’s not like parents should be pushing smartphone use as a means of avoiding drug use.
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Climate change and Health living

Of the 358 children who died from influenza between 2010 and 2014, only 26% had been vaccinated against it, according to a study just released in the journal Pediatrics.

That means 74%, or three out of four of them, had not. And maybe if they had been vaccinated, they’d be alive right now.

Of all the vaccines I give as a pediatrician, the flu shot is the one that families refuse most. Parents don’t think they need it. They don’t think it works. They think it is dangerous. This frustrates me, because none of these reasons for refusing the flu shot are true.

Influenza can be a dangerous disease. Every year, it kills thousands of people. The 358 above is the number of children who died of what was proven to be influenza by testing; but testing isn’t always done, so the number is likely much higher. And many people die of complications of influenza, such as bacterial pneumonia — or, for people who have chronic conditions, the stress on their body of influenza leads to fatal problems from their condition. For this reason, it’s extremely difficult to know how many people influenza kills each year. But millions of people catch it, and hundreds of thousands end up hospitalized. While many people are just miserable with fever and cough for a few days, for some people it is far more serious.

Of those 358 children in the study, 153 had conditions that put them at higher risk of getting sicker from the flu. That means that more than 200 were healthy children. That’s the thing: being healthy doesn’t mean you will be fine if you get the flu. Again and again, parents tell me that their children don’t need it because they are healthy. Again and again, I try to explain that being healthy isn’t enough to keep you safe.

It’s certainly true that the flu shot doesn’t always work. As the study pointed out, 26% of those children who died had been vaccinated. On average, the flu vaccine is about 50-60% effective. Parents say to me sometimes: why bother, if it might not work? My answer is: why not get it, if it might work?

The only reason not to would be if it were risky, but the scientific truth is that the influenza vaccine is quite safe. It’s certainly possible that your arm can be sore, or that you could get a fever; according to data from the World Health Organization, “local reactions” such as redness or soreness can happen up to 50% of the time. Fevers happen in 12% of children under five who get the vaccine, and in 5% of older children. While uncomfortable, these are brief and manageable side effects.

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But serious reactions, such as severe allergic reactions, Guillain-Barre syndrome, or oculorespiratory syndrome, are extremely rare — only a few people in every million who get the vaccine will experience them. Of these, a severe allergic reaction is the only one that has a significant chance of being deadly — and those reactions happen less than once in every million doses.

While we are still seeing cases of flu, the season is winding down; soon we will stop giving the flu shot again until the end of summer or early fall. I hope that parents who have refused the flu shot in the past will take the time to learn more and talk to their doctor; I hope that when fall comes they won’t miss a chance to help keep their child healthy — and alive. Low back pain, the scourge of mankind: it is the second leading cause of disability here in the United States, and the fourth worldwide. It’s also one of the top five medical problems for which people see doctors. Almost every day that I see patients, I see someone with back pain. It’s one of the top reasons for lost wages due to missed work, as well as for healthcare dollars spent, hence, a very expensive problem.
Looking at two kinds of back pain

Let’s talk about the most common forms of back pain: acute (which lasts less than four weeks) and subacute (which lasts four to 12 weeks). Most of these cases (approximately 85%) are due to harmless causes. We lump them into the “mechanical back pain” diagnosis, which includes muscle spasm, ligament strain, and arthritis. A handful (3% to 4%) will be due to potentially more serious causes such as herniated discs (“bulging” discs), spondylolisthesis (“slipped” discs), a compression fracture of the vertebra due to osteoporosis (collapsed bone due to bone thinning), or spinal stenosis (squeezing of the spinal cord due to arthritis). Rarely, less than 1% of the time, we will see pain due to inflammation (such as ankylosing spondylitis), cancer (usually metastases), or infection.

When someone with acute low back pain comes into the office, my main job is to rule out one of these potentially more serious conditions through my interview and exam. It is only when we suspect a cause other than “mechanical” that we will then order imaging or labs, and then things can go in a different direction.

But most of the time, we’re dealing with a relatively benign and yet really painful, disabling, and expensive condition. How do we treat this? The sheer number of treatments is dizzying, but truly effective treatment options are few.
Analyzing a range of treatments for low back pain

The American College of Physicians (ACP), the second-largest physician group in the U.S., recently updated guidelines for the management of low back pain. Its physician researchers combed through hundreds of published studies of non-interventional treatments of back pain, and analyzed the data. Treatments included medicines such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen), opioids (such as oxycodone), muscle relaxants, benzodiazepines (such as lorazepam and diazepam), antidepressants (like fluoxetine or nortriptyline), anti-seizure medications (like Neurontin), and systemic corticosteroids (like prednisone). The analysis also included studies on non-drug treatments including acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (working the muscles that support and control the spine), progressive relaxation, biofeedback, low-level laser therapy, behavior based therapies, or spinal manipulation for low back pain.

That’s a lot of therapies!

Researchers were interested in studies that measured the effectiveness (usually measured as pain relief and physical functioning) as well as the harms of all these therapies.
Drugs are not part of the latest recommendations for treating “mechanical” back pain

What the researchers found was surprising: for acute and subacute low back pain, the best and safest treatments are not medicines. The ACP made the following strong recommendation:

Most patients with acute or subacute low back pain improve over time regardless of treatment and can avoid potentially harmful and costly treatments and tests. First-line therapy should include nondrug therapy, such as superficial heat, massage, acupuncture, or spinal manipulation. When nondrug therapy fails, consider NSAIDs or skeletal muscle relaxants.

Because most mechanical back pain improves no matter what, we don’t want to prescribe treatment that can cause harm. Because some medications carry significant risks, we really shouldn’t be recommending these right off the bat. Rather, we should be providing guidance on heating pad or hot water bottle use, and recommendations or referrals to acupuncturists, massage therapists, and chiropractors. These therapies were somewhat effective, and are very unlikely to cause harm.
Even the nonprescription pain relievers are not risk free

Medicines like ibuprofen and naproxen can be helpful, but they can cause stomach inflammation and ulcers, as well as possible bleeding, and even kidney damage, especially in the elderly. Muscle relaxants can be sedating, and can interact with other common medications. Benzodiazepines and opiates not only can cause sedation, making it hard to think clearly and function normally, they are also addictive. Basically, for acute and subacute low back pain, the risks of these medications outweigh the benefits. Other medications, like acetaminophen, steroids, antidepressants, and anti-seizure medications, were not significantly helpful for acute and subacute low back pain at all.
Here’s what the study couldn’t tell us

The study was missing a few potentially helpful low-risk medicines. Topicals such as the lidocaine patch or capsaicin ointment were not included, which is a shame, as these can provide relief for some people, and carry little risk. I would also be interested to know if over-the-counter topical therapies containing menthol and camphor are better than placebo for low back pain. Suggestions for the future research, and the next update! My husband Jay and I turn into super nerds on our brisk morning walk. We sport decidedly uncool but comfy clothes and sneakers, clock the times when we leave and return, count our steps, sometimes break into a run for interval training, and alternate routes in the neighborhood — all while flailing our arms (okay, that’s just me), gabbing away (me again), laughing, and analyzing the issues of the day. It’s fun — like a mini date — and it’s always interesting. The routine suits us. And that comfortable fit is key to sustaining an exercise program. “Finding an activity you enjoy is an incentive to keep doing it,” explains Madhuri Kale, a physical therapist at Harvard-affiliated Brigham and Women’s Hospital.  At first glance, climate change and personal health may not seem related. One is a global political and environmental concern, while the other deals ultimately with an individual’s well-being. However, climate change is already directly affecting human health in many parts of our world, including many areas of the United States. We are just beginning to understand, and to witness, the health effects of climate change.
The problem with a warmer planet

As human-made carbon dioxide levels in our atmosphere increase, we create a “greenhouse effect,” and our world warms. The three hottest years ever recorded in the United States were 2012, 2015, and 2016. As the temperatures rise, arctic ice sheets start to melt, and ocean levels rise. We’ve already seen coastal flooding in many parts of the world. Flooding leads to homelessness, dislocation, the spread of infectious diseases, poverty, and psychological trauma. Just think about the catastrophic flooding after Hurricane Katrina. Local healthcare resources were compromised and quickly overtaxed. Many of the neighborhoods in New Orleans are still trying to recover more than a decade later.

As our earth warms, weather patterns become unstable, and violent storms become more frequent, as do droughts, heat waves, and forest fires. Super Storm Sandy, in 2012, killed hundreds of people and cost tens of billions of dollars in property damage. Scientists warn that with climate change, such unusual storms are certain to become more frequent and more severe. Less affluent people and impoverished nations are affected disproportionately.

Droughts can cripple farming and food production, which leads to poverty, malnutrition, and starvation. As a result, we are seeing more environmental refugees. This, in turn, increases armed conflict and political instability, both of which are disastrous for human health. Areas that are expected to see worsening droughts are southern Africa, southern Asia, the Middle East, and the American Southwest. More carbon dioxide in the atmosphere increases acidity in ocean waters, which is damaging to marine life and affects fresh water fisheries as well.
Climate change and infectious diseases

As our climate changes, the patterns and territories of infectious diseases can be dramatically altered, straining the ability of healthcare systems and governments to contain them. Diseases affected by climate change include those carried by animals and insects — for example, tularemia, plague, Rocky Mountain spotted fever, West Nile virus, and Lyme disease. Others include Zika and dengue. Waterborne infections (for example cholera and other gastrointestinal infections) may become more common. Truly clean water may be harder to come by.
What to do?

Fortunately, almost all scientists agree that we need to aggressively counter climate change, and most governments of the world are dedicated to doing their part. Last year, 196 countries signed the Paris Agreement, which commits signatories to work toward keeping temperatures from rising more than two degrees Celsius (3.6 degrees Fahrenheit). This would at least prevent many of the worst-case scenarios of a “runaway greenhouse effect,” which would threaten human life on earth, and allow us more time to adapt to these changes.

Taking action to reduce your carbon footprint directly benefits your health as well as that of the planet. For example, walking or biking instead of driving avoids burning fossil fuels, provides exercise, and helps maintain a healthy weight. Eating less red meat is linked with a lower risk of heart disease and certain cancers. Growing and consuming produce locally can produce a great sense of community and lead to eating lots of healthy and delicious vegetables. Using renewable energy, and thus creating less air pollution, will result in fewer cases of asthma and lung cancer.
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