Friday, 15 February 2019

Fainting: Frightening, but seldom serious

There’s a certain response I have come to expect whenever I share with someone that I suffer from chronic pain. “You should try acupuncture or yoga,” the person will say, often without asking me first if I have actually tried either.

I have learned to take such suggestions with a grain of salt, seeing them for what they are: a well-meaning, if usually uninformed, attempt to help me get better. But it’s hard not to feel slighted by these responses, even if the underlying intentions are sincere. When the hair-trigger reaction to me sharing my medical issues is usually to automatically recommend some supplement, diet, or exercise regimen I should try, I begin to feel my pain is being undermined by an assumption that I haven’t worked hard enough to defeat it.

For the record, I have tried acupuncture… many times. In fact, I am fortunate that my health insurance completely covers up to 20 visits to the acupuncturist per year, a benefit of which I take full advantage. My insurance also covers chiropractic and osteopathic care, and I make sure to max out my annual allotted visits. Many are not so lucky, as these services are often not covered by insurance and can be too cost-prohibitive to pay for out of pocket. Chances are if a treatment option exists and if I can afford it, then yes, I’ve tried that too.

There is a myth that when people have persistent medical conditions, that it’s the result of having an unhealthy lifestyle. As for me, I am a nonsmoking vegetarian who eschews caffeine and sugary soft drinks in favor of filtered water and fresh fruit. I barely drink alcohol and stay out of the high afternoon sun. I always wear my seatbelt. Before pain became a daily reality for me, I was an avid hiker and swimmer who enjoyed cross-country skiing, rock climbing, rollerblading, dancing, and riding my bike for miles. And not only did I go to yoga class on a weekly basis, but I was a star pupil, famed for pretzeling my body into positions even the instructor couldn’t accurately imitate. Nowadays though, my physicians have advised me against practicing yoga, as it often causes more bodily damage because I have connective tissue disease (and in fact, yoga may be one of the culprits that incited my chronic pain).

Disease doesn’t always follow a necessarily linear or logical path, or at least one that is plainly detectable. In my case, chronic pain became the fallout of an accumulation of issues that began even before birth: a club foot defect that required several surgeries in infancy, and left me with a stunted left leg that led to structural malalignment in my body that — combined with connective tissue disorder — set the stage for premature deterioration in my body. But worse than the way my body was punishing me for something I couldn’t control, is having to deal with society’s constant questioning of the validity of that pain.

Anyone who suffers from chronic debilitating illness for any length of time can attest to the lengths they have gone to quell it. In my chronic pain support group we share long lists of medications and procedures (ranging from things like injections to major surgeries) we have tried. We have often sought consultations from countless health care providers that run the gamut from traditional to holistic in our desperate search for solutions. We compare notes on diets we have undergone, from gluten-free to vegan to the carnivorous “paleo” diet. We offer opinions on what supplements and herbal formulas are legitimate and what amounts to snake oil. Overall, most of us have stitched together a network of treatment protocols, prescription drugs, and caring providers that help us manage the pain as best we can and in some cases, even restore some of our functionality. However, none of us has found a miracle cure, something that reverts us to our former healthier and pain-free selves — that is, for those of us who ever had such selves in the first place.

While I think there is value in proposing solutions, I would advise that those with chronic pain sufferers in their lives resist the urge to make recommendations. Rather, take the time to listen and empathize. That alone might be more healing than any drug or diet. A standard approach for treating aggressive prostate cancer is to give therapies that block testosterone, a tumor-stimulating hormone. Should initial hormonal therapies fail, doctors can switch to other drugs that suppress testosterone in different ways. One of them, a drug called abiraterone, has been shown to significantly extend lifespans in men who have become resistant to other hormonal treatments.

But in June, two major studies reported simultaneously that abiraterone also prolongs life in men with aggressive prostate cancer that’s been newly diagnosed. One of the studies, a phase 3 clinical trial called LATITUDE, enrolled 1,199 men with metastatic prostate cancer, or cancer that had spread to other sites in the body. The other one, called STAMPEDE, enrolled 1,917 men, half with metastatic prostate cancer and the other half with cancer that was still confined to the prostate gland. Both studies split the men in two groups: one was treated with a combination of traditional first-line hormonal therapy plus abiraterone, and another group was treated with first-line hormonal therapy by itself.

After 30 to 40 months of follow-up, both studies showed similar results: the combined treatment that included abiraterone reduced the risk of death by nearly 40%. Abiraterone treatment also prolonged the time it took for the cancers to worsen by 14 to 15 months, delayed the need for chemotherapy, slowed the increase in blood levels of prostate-specific antigen (or PSA, which is released by prostate tumors), and lessened pain.

Abiraterone does have side effects, such as high blood pressure and a drop in blood levels of potassium that can trigger heart problems. But those effects can be minimized with prednisone, a powerful anti-inflammatory agent. So the Food and Drug Administration requires that abiraterone and prednisone be given together.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, say the evidence helps to challenge conventional wisdom that abiraterone can’t suppress testosterone to levels below those achieved with first-line hormonal treatments. “But additional research is needed to identify the patients who might benefit most from abiraterone,” he said. “Aggressive prostate cancer often strikes elderly men with additional health problems, and for some, adding abiraterone might be too burdensome. But based on the results of these studies, it’s likely that abiraterone will be prescribed to newly diagnosed men with aggressive prostate cancer more often.” One minute you’re feeling a bit woozy; the next thing you know, you’re flat on your back wondering what happened. No matter what you call it — swooning, passing out, or fainting —the experience is surprisingly common. About a third of people say they’ve fainted at least once.

Although often harmless, fainting can cause injuries and sometimes signals a problem with the heart or circulatory system.

“Witnessing a faint can be scary, because it can look like the person has died,” says Harvard professor Dr. Lewis A. Lipsitz, director of the Division of Gerontology at Beth Israel Deaconess Medical Center and the Institute for Aging Research at Hebrew SeniorLife in Boston. If it’s really a faint, the person will regain consciousness quickly; if not, call 911. Here’s the lowdown on the most common reasons people pass out.
The “common faint” (vasovagal syncope)

These faints are caused by excessive stimulation of the vagus nerve, the part of the nervous system that regulates blood pressure and heart rate. In response to some trigger, the blood vessels in your legs relax and the heart rate slows, making it difficult for blood to return to the heart. Blood pressure drops, and down you go.

Sometimes, the trigger for vasovagal syncope is a strong emotion, such as a response to bad news, the sight of blood, or a feeling of panic or claustrophobia. This type of faint can also occur when you have a bad coughing spell or strain to have a bowel movement, or even if you’ve been standing for a long time. Vasovagal syncope tends to be more common in people under 35. With age, the nervous system doesn’t react as quickly, so these types of faints occur less frequently.
Low blood pressure when standing upright (orthostatic hypotension)

The classic example is a 70-something person who’s been ill (and therefore not eating or drinking normally) and who faints right after getting out of bed in the morning. Older people are more prone to abnormalities in blood pressure regulation because of age, medications, or disease, explains Dr. Lipsitz.

With age, blood vessels tend to stiffen, and the body’s system for monitoring blood pressure becomes less sensitive. Older people are more likely to take drugs that can worsen orthostatic hypotension, such as beta blockers (which reduce the heart rate) and alpha blockers (which can reduce blood pressure; they’re used in men to treat an enlarged prostate). Older folks are more prone to dehydration, as the sense of thirst diminishes over the years. Also, diseases such as diabetes, cancer, and Parkinson’s (all of which are more common with age) may cause orthostatic hypotension.
Abnormal heart rate

If your heart rate is very fast, your blood pressure may fall, and fainting may follow. A number of different heart conditions — from problems with the heart’s electrical system to defective valves — can trigger palpitations, a feeling that your heart is fluttering, racing, or missing a beat. Conversely, a very slow heart rate can also cause you to faint. This condition is usually caused by electrical abnormalities in the heart or heart damage from a heart attack or other disease. Thyroid problems and certain medications can also lead to an abnormally slow or fast heart rate.
Finding the underlying cause

If a young, healthy person faints after an obvious vasovagal trigger, there’s not always a need to see a doctor. But if you faint for the first time after age 40, see a doctor to explore all the potential causes. He or she should check your blood pressure (both sitting and standing, if orthostatic hypotension is suspected) and do an electrocardiogram (ECG), a test that checks for electrical problems with the heart.

If you have any type of heart disease — including a previous heart attack, a rhythm disorder such as atrial fibrillation, a narrow or leaking heart valve, or heart failure — fainting may foretell a more serious problem and may require more extensive testing, says Dr. Lipsitz.

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