Friday, 15 February 2019

Combination hormonal therapy boosts survival in men with aggressive prostate cancer

It’s no secret that alcohol affects our brains, and most moderate drinkers like the way it makes them feel — happier, less stressed, more sociable. Science has verified alcohol’s feel-good effect; PET scans have shown that alcohol releases endorphins (the “pleasure hormones”) which bind to opiate receptors in the brain. Although excessive drinking is linked to an increased risk of dementia, decades of observational studies have indicated that moderate drinking — defined as no more than one drink a day for women and two for men — has few ill effects. (A drink equals 1.5 ounces of 80-proof spirits, 5 ounces of wine, or 12 ounces of beer.) However, a recent British study seems to have bad news for moderate drinkers, indicating that even moderate drinking is associated with shrinkage in areas of the brain involved in cognition and learning.
What the study said

A team of researchers from University of Oxford looked at data from 424 men and 103 women who are participating in the 10,000-person Whitehall Study, an ongoing investigation of the relationship of lifestyle and health among British civil servants. At the beginning of the study in 1985, all of the participants were healthy and none were dependent on alcohol. Over the next 30 years, the participants answered detailed questions about their alcohol intake and took tests to measure memory, reasoning, and verbal skills. They underwent brain imaging with MRI at the end of the study.

When the team analyzed the questionnaires, the cognitive test scores, and the MRI scans, they found that the amount of shrinkage in the hippocampus — the brain area associated with memory and reasoning — was related to the amount people drank. Those who had the equivalent of four or more drinks a day had almost six times the risk of hippocampal shrinkage as did nondrinkers, while moderate drinkers had three times the risk. However, the only link between drinking and cognitive performance was that heavy drinkers had a more rapid decline in the ability to name as many words beginning with a specific letter as possible within a minute.
What does this mean?

The study results don’t come as news to Dr. Kenneth J. Mukamal, associate professor of medicine at Harvard Medical School. Dr. Mukamal and his colleagues reported similar findings in 2001. His team studied 3,376 men and women who were enrolled in the Cardiovascular Heart Study and who had also undergone MRI scans and had reported their alcohol consumption. The Harvard researchers also found that brain volume shrank in proportion to alcohol consumed, and that atrophy (shrinkage) was greater even in light and moderate drinkers than in teetotalers.

Yet the meaning of the MRI scans is still far from clear, Dr. Mukamal says. “There’s a great deal of doubt about whether the atrophy seen on MRI is due to loss of brain cells or to fluid shifts within the brain.” He explains that this type of atrophy shows major improvements within weeks when alcoholics stop drinking, which wouldn’t be the case if it were caused by brain cell death. “The study offers little indication of whether moderate drinking is truly good, bad, or indifferent for long-term brain health,” he says. Despite being a less common cause of low back pain, sciatica is still something I regularly see as a general internist. Primary care doctors can and should manage sciatica, because for most individuals the body can fix the problem. My job is to help manage the pain while the body does its job. When a person’s symptoms don’t improve, I discuss the role of surgery or an injection to speed things up.
What is sciatica?

Sciatica refers to pain caused by the sciatic nerve that carries messages from the brain down the spinal cord to the legs. The pain of sciatica typically radiates down one side from the lower back into the leg, often below the knee. The most common cause is a bulging (“herniated”) disc in the lower back. Discs are tire-like structures that sit between the bones of the spine. If the outer rim of the disc tears, usually due to routine pressure on the lower back, the jelly-like inner material can come out and pinch or inflame the nearby nerve. Sciatica is most common in people 30 to 50.
How do you know if it is sciatica?

The key to diagnosing sciatica is a thorough history and a focused exam. Unfortunately, many patients expect an x-ray or MRI, and doctors, often facing time constraints, order one even though we know imaging tests don’t really help us treat early sciatica any better. The symptoms of sciatica are often worse with sitting or coughing, and may be accompanied by numbness or tingling in the leg. A physical exam can confirm that the sciatic nerve is involved, and I look for weakness or diminished reflexes in the legs that suggest that someone needs early referral to a specialist. (This doesn’t happen often.) With this information, I can make an initial diagnosis and start treatment.
Treating pain… and managing expectations

Many people think (understandably) that the worse the pain, the more likely something bad is going on. However, this isn’t true for sciatica. The body can reabsorb the disc material that is causing symptoms, even for those with severe pain. So, treatment focuses on controlling pain and keeping people as active as possible. If the pain is excruciating, lying down for short periods can help, but prolonged bed rest does not. So once the pain diminishes, I tell patients to get up and start walking short distances. Since sitting increases pressure on the discs in the lower back, I recommend avoiding prolonged sitting or driving. Many people try treatments like physical therapy, massage, acupuncture, and chiropractic manipulation, but evidence suggests that while these approaches may help typical low back pain, they are less helpful for sciatica. Over-the-counter pain medicines like ibuprofen and naproxen can help. When they don’t I may recommend short-term use of stronger, prescription pain medicines.

The good news is that for most (roughly three out of four) people, symptoms improve over a few weeks. Rarely, I’ll find weakness on exam, such as a foot drop, and refer for immediate surgical evaluation. For those not improving after six weeks, surgery is an option. We know surgery can speed up recovery, but by six to 12 months people who have surgery are usually doing about as well as those who decide to just give the body more time to heal on its own. Surgery involves removing the disc material that is affecting the nerve. It is generally a very safe procedure, and while complications are rare, they can happen. What’s more, 5% to 10% of people who have surgery will not be helped by it, or may have worse pain afterwards.

Patients often ask about spinal injections — where steroid medicine is injected into the affected area. It is worth considering for those with uncontrolled pain or for those with persistent, bothersome symptoms who want to avoid surgery. Injections can provide short-term relief. Like any procedure, it has uncommon risks including more pain, and it doesn’t seem to decrease the need for future surgery.
Staying patient-focused… and “hurt” doesn’t always mean “harm”

For most patients with sciatica, it’s worth seeing your primary care doctor. Patients who come in are often scared. Typically, it is pain the likes of which they may have never had. They want relief and, rightly, they want it now. That is the appeal of surgery and injections, but I also know that most will get better with time and can avoid even the uncommon risks of these procedures. When I see a patient in my office I can assess and identify the few who need immediate referral to a specialist. But for most, I try to reassure that hurt doesn’t mean harm, and that my treatments are geared to managing pain and keeping them active while the body fixes itself. For those not improving, I will get an MRI prior to referring for surgery or an injection, if the patient decides that speeding up recovery is right for them. For those who feel that they can manage the pain, I can reassure them that they can delay surgery for up to six months without risking long-term problems down the road. Allergies to penicillin are the most commonly reported medication allergy. This can be a real problem; if you are allergic to penicillin, it’s not just penicillin you can’t take. You can’t take amoxicillin and other antibiotics that are extremely similar, and it’s iffy whether or not you can take cephalosporins (such as cephalexin or cefdinir), a whole other really useful and commonly used class of antibiotics.

See, that’s the thing: with most common infections such as ear infections, strep throat, or skin infections, if we can’t give you penicillin we end up with limited choices. Some of those choices don’t work as well — and some of them are stronger than we’d like, with more side effects.

Now, this would be just an unavoidable reality of life for penicillin-allergic people, if it weren’t for the simple fact that a lot of them aren’t allergic to penicillin at all.

How does this happen? Well, the diagnosis of drug allergy is generally what we call a “clinical diagnosis,” based on signs and symptoms rather than an actual test. Drug allergies can cause lots of different symptoms, such as rash, vomiting, and diarrhea. When a patient who is on a medication develops one of these symptoms, doctors very often end up diagnosing an allergy to be on the safe side. After all, drug allergies can be life-threatening, and reactions after the first one are often more serious.

But there are pitfalls to this. First of all, sometimes doctors make the diagnosis based purely on patient or parent report, without seeing the rash or examining the patient. For example: a parent says the child had a rash, so the antibiotic is stopped and an allergy is diagnosed — but it turns out that the rash was just a diaper rash, not an actual allergy. A second, more common and more problematic pitfall is that, because the symptoms of a drug allergy can be easily confused with symptoms of a virus or other condition, often a drug allergy is diagnosed when the symptoms were caused by something else entirely. This can be especially true when a child takes amoxicillin for an ear infection, as ear infections commonly occur when a child has a cold caused by a virus — and those viruses can cause rashes and many other symptoms. Viruses commonly cause even hives, which we usually think of as being caused by an allergy.

All of this means that there are lots of people out there who think they have an allergy who actually don’t.

In a study recently published in the journal Pediatrics, researchers tested 100 children whose parents said they were allergic to penicillin based on what the researchers called “low-risk” symptoms. These low-risk symptoms included rash, itching, vomiting, diarrhea, runny nose, and cough. They also included children whose parents said they were allergic because of a family history of allergy. You know what they found when they did tests on the children? None of them actually had an allergy to penicillin.

This doesn’t mean that anyone should start ignoring a diagnosed allergy to penicillin. It’s especially important not to ignore it if someone has what the researchers call “high-risk” symptoms, such as wheezing or any other kind of trouble breathing, swelling of the face or other parts of the body, fainting, a drop in blood pressure, or other symptoms of a serious allergic reaction.

But it does mean that you should talk to your doctor if your child’s diagnosis of allergy was based on a low-risk symptom. It may be that doing further testing, or even trying a dose of penicillin under medical supervision, may make sense to be sure that the allergy, with all of its ramifications, really exists. Headed to the beach or a day out on the lake? Most likely you’ll protect yourself from the sun with sunscreen, a hat, and sunglasses. Maybe you also take along insect repellent. But how good is your water safety knowledge? You can’t tuck it in a beach bag or backpack, but it’s essential to a good day on the water.

According to the Centers for Disease Control and Prevention, between 2005 and 2014 nearly 10 people died each day from unintentional (non-boating related) drownings, and over 300 per year from boating related incidents. And water injuries can do great damage even when they are not fatal. Over half of drowning victims require hospital care beyond the emergency room, and some of them experience brain damage that requires long-term care.
Enjoy the water safely

Drowning is the most common cause of unintentional death in children ages 1 to 4, and the second most common for ages 5 to 9, according to the CDC. But Dr. Josh Kosowsky, attending physician in emergency medicine at Brigham and Women’s Hospital, says these statistics can be avoided with proper supervision. He suggests taking your children to swim only at beaches or pools with lifeguards. Even adults should never swim alone. Think back to those times you had “buddy checks” at camp. “It may have seemed kind of hokey at the time,” he said. “But it works.”

Would you recognize when a person is drowning? Maybe not. Most of us picture drowning as a loud activity with yelling and struggling from the victim, but in reality drowning is quiet, and goes easily unnoticed in a crowded lake or pool. Once someone starts taking on water, their voice box (larynx) begins to spasm, which is part of the reason there isn’t much screaming. The larynx closes to keep water from flowing into the airway, but it also means the lungs can’t take in air. When water does get into the smaller airways they tend to constrict, which is referred to as a bronchospasm. Survivors of a near drowning episode may develop wheezing as a result.

Ideally, all backyard pools should have a secure fence. Storing pool toys away from the pool can deter children from being drawn to the water. And lastly, make sure your children are strong swimmers. Start them early with swim lessons to help them stay safe in the water.

Water safety applies to adults too. Kosowsky points out that the danger isn’t just with operating the vehicle safely. Anyone on a boat who is “under the influence” is at risk for drowning. And of course, be sure there are plenty of life jackets around; federal law requires a life jacket for everyone on board.

Head and neck injuries are always serious and can easily happen around the water. Make sure you only dive into an area where you know the depth. Dr. Kosowsky points out that body surfing in the ocean is an underrated risk because the waves can slam people head-first into the beach, causing serious neck and spinal injuries. My Facebook page is a collection of links to stories about inspirational people. Almost all have a common theme — older people who do extraordinary things. Some of my favorite stories, though, involve those with acute mental prowess. This special group of adults ages 60 to 80, called “super-agers,” have a higher resistance to natural brain aging and thus can keep their gray cells young and vibrant.
The science of super brains

What makes super-agers’ brains so super? A small study published in The Journal of Neuroscience looked at this question. Researchers enrolled 44 adults ages 60 to 80 and found that those who performed well on memory tests had brains with youthful characteristics. Specifically, the cortexes of their brains — the outermost layer of brain cells essential to many thinking abilities — were comparable in size to those of the younger adults in a control group. Scans found that the brain regions associated with the ability to learn and remember new information — which include the hippocampus and medial prefrontal cortex — were larger in super-agers than in normal older adults.

Lead researcher Dr. Bradford Dickerson, associate professor of neurology at Harvard-affiliated Massachusetts General Hospital, said that one of the most surprising findings was that the size of the super-agers’ brains did not fall somewhere between the younger people and the other older adults. “Their brain size was close to equal to that of the younger subjects, which suggests that the brain size was preserved,” he says.
Wouldn’t you like to be a super-ager too?

Are super-agers born or made? Probably a little of both, says Dr. Dickerson. “There may be a genetic component that makes them more resilient to natural aging, but it also may be associated with lifestyle habits,” he says.

So, can you become a super-ager? While you may not be able to transport your brain back to your 20s, it may be possible to maintain and even improve some cognitive function with a combined approach to treatment, says Dr. Dickerson. For example:

    Do regular aerobic exercise. Research has suggested that aerobic exercise can improve cognitive function, even if you begin later in life or have shown signs of mental decline. A study presented at the 2016 annual meeting of the Radiological Society of North America found that older adults (average age 67) with mild cognitive impairment who exercised four times a week over a six-month period (using either a treadmill, a stationary bike, or an elliptical trainer) experienced an increase in brain volume and better executive function.
    Get plenty of sleep. Using MRI scans, a study in NeuroImage looked at the brains of 41 healthy men who were deprived of sleep for one night. The researchers found that compared with those who’d had a regular night’s sleep, they showed a decline in memory and attention. Older adults often have trouble falling asleep or staying asleep, problems that may reflect drug side effects or health conditions. See your doctor if you have sleep issues.
    Lower anxiety with meditation. Chronic levels of anxiety may speed up the conversion to Alzheimer’s disease in people with mild cognitive impairment (MCI). In fact, a 2014 study in The American Journal of Geriatric Psychiatry found that in MCI patients with mild, moderate, or severe anxiety, Alzheimer’s risk increased by 33%, 78%, and 135%, respectively. Mindfulness meditation can help lower anxiety levels, according to findings published online earlier this year by Psychiatry Research. Meditation programs for beginners are offered at many yoga studios and senior centers. You can try a free online guided meditation exercise from Ronald Siegel, an assistant clinical professor of psychology at Harvard Medical School.
Hiding in the shadow of the opioid epidemic is another troubling public health crisis, the precipitous increase in people whose liver is infected with hepatitis C virus (HCV).

It’s likely you have seen the drug company commercials advertising medications to treat hepatitis C. In these commercials, it appears that hepatitis C is only a problem among older Americans. Although baby boomers still represent the largest group infected with hepatitis C virus, these commercials only tell a part of the story.

The hepatitis C virus is transmitted by direct contact with the blood of someone who is infected with the virus. Most people who are infected with the hepatitis C virus do not have any symptoms. Others may have very mild, vague symptoms including fever, fatigue, joint pain, nausea, and vomiting. Although the infection often goes away on its own, more than 75% of people who get the hepatitis C virus will develop a persistent (chronic) infection. Over time, chronic HCV can lead to liver failure and an increased risk of liver cancer.

The good news is effective treatment options are available that cure hepatitis C. You are considered cured when the virus is no longer detected in your bloodstream. But because you may not develop any symptoms until it is much too late to prevent the serious liver complications of chronic hepatitis C, you need to be tested to see if you are at risk of infection.

The prevalence of HCV has been steadily rising over the last three decades since its discovery in 1989. But according to the CDC, more recently there has been a marked increase in the diagnosis of HCV, especially in those under 40. This increase parallels the rise in the misuse of opioids and heroin in this age group.
But there is another problem: HCV infection during pregnancy

About half of these young people who are injecting drugs are women of childbearing age. And although sexual transmission or transmission of HCV from infected household items is rare, it can happen. And women whose partners inject drugs are also at risk for exposure.

A pregnant woman can pass the hepatitis C virus to her baby. It is not exactly clear at what point in pregnancy HCV transmission occurs, but there is some evidence to suggest it is more likely to occur close to the onset of labor or actually during labor and delivery. This is known as vertical transmission. Luckily vertical transmission of HCV is relatively uncommon, with 6 out of 100 babies born to HCV-infected mothers ultimately testing positive for HCV.

That said, in a recent article published in the Annals of Internal Medicine, researchers from the CDC reported that cases of HCV “essentially doubled among reproductive-aged women between 2006 and 2014, from 15,550 to 31,039.” They went on to compare rates of HCV in pregnant women and anticipated new cases in children to actual reported cases of HCV in children. The results suggest that there are likely a lot of children who have the hepatitis C virus but no symptoms. The authors conclude that these results should spur thinking about whether it might be appropriate to screen children for HCV and if so, which children and when?
How do you know if you have hepatitis C?

A screening test that measures antibodies to HCV can only tell whether a person has been exposed to the virus, but it doesn’t tell whether there is active virus in the body now. To diagnosis an active infection, you need another blood test that looks for HCV RNA. This measures “viral load” (how much active virus is present).
Factors that increase a pregnant woman’s risk of passing HCV to her baby

A pregnant woman with evidence of HCV antibodies but no detectable active virus in her body is very unlikely to transmit HCV to her baby. On the other hand, pregnant women with very high viral loads are believed to be at increased risk for vertical transmission of HCV.

Babies born to women who are infected with both HIV and HCV are at increased risk of becoming infected with HCV. Although we don’t know exactly why, it may be that the HIV weakens the immune system so that there is more HCV in the blood.

HCV tends to infect a certain type of blood cell more often in women who contract the virus from injecting drugs. And it turns out that pregnant women with this type of infection are more likely to transmit the virus to their babies.
How to protect moms and babies from the effects of HCV

Although the chances are relatively low, the vertical transmission rate of HCV is significant, as is the liver disease that chronic infection can cause. And in the shadows of the current opioid epidemic, a growing number of reproductive-age women are contracting HCV, making vertical transmission of HCV even more of a concern.

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