Wednesday, 10 April 2019

Teens need adequate sleep for health and fitness

It’s always wonderful when winter ends and spring finally appears…unless you have hay fever.

Hay fever, or seasonal allergies, is very common — and can be really uncomfortable. While it’s not always easy to tell a cold from allergies, it’s more likely to be allergies if there’s no fever, if eyes are itchy, if there’s lots of sneezing…and if it lasts longer than a few days.

The good news is that there are some simple things that you can do to make your child — and anyone else in the house that has hay fever — feel better.

    Close the windows. After a long winter it’s tempting to open them, but don’t — because that lovely fresh air brings pollen in with it. If you have an air conditioner, run it.
    Wash up and change when you get home. Speaking of bringing pollen in, you also do a good job of that when you come inside. The allergy sufferer should definitely change clothes and wash his hands and face when he comes in, but it’s not a bad idea for everyone to do the same, as you all could be pollen-carriers. Try to keep your house as pollen-free as possible. The room where this is particularly important is the bedroom, as that’s where your child spends the most time. If possible, try to keep your child out of his bedroom during the day (move the fun toys somewhere else) and have him bathe before bed.
    Be thoughtful about outside time. As a pediatrician, I absolutely want my patients to be outside; I want them to be active, and to get the sunshine that helps their bodies make vitamin D. But if you have an allergy sufferer, you need to think before you send your child outside. Dry and windy days are the worst, and places with lots of plantings are tough. Many weather sites and apps have local pollen counts; check them as you make your outdoor plans. But since you can’t keep your child in a bubble until allergy season is over, you may need to use medication. When you do…
    Use medication the right way — and talk to your doctor if it’s not working. When it comes to taking a medication to relieve symptoms, like the itchy eyes or sneezing of allergies, we tend to think that we should take it when we have the symptoms, and not take it when we don’t. But it turns out that allergy medications work best when you take them consistently — and can take a while to kick in. So while it’s understandable that you would want to hold off on medications until things get bad, and skip them on good days, your child will actually do better if you get them started at the first sniffle — and continue until allergy season is over (check with your doctor as to when you should stop).The medications we most commonly use for allergies include antihistamines taken by mouth, nasal sprays to help stuffiness and sneezing, and eye drops to help itchy eyes. These days, most of these medications are available without a prescription, so it may not occur to families to call their doctor when allergy season hits; they just head to the pharmacy. If what you buy is working, great. But if not, give your doctor a call — because sometimes changing to a different medication or dose, or using it a bit differently, can make all the difference. Your doctor can also be sure that there isn’t something else besides allergies going on.

If you follow the above suggestions, chances are your allergy-sufferer will feel better — and when kids feel better, parents do too. Enjoy the spring! Having a baby when you’re “older” can have some advantages—women may feel more secure with themselves, their relationships, or their careers. However, expectant moms 35 and older—and their babies—do face some increased pregnancy-related health risks.

Probably the most dreaded is a stillbirth.

Most often, the factor responsible for stillbirth occurs before labor. Some of the reasons a baby might die before birth include problems with the placenta, and women over 35 face increased risk for these complications. That’s why it isn’t unusual for doctors to recommend inducing labor a little early, usually about a week before the due date. For younger women, we often wait at least a week past the due date before helping labor along if it hasn’t started on its own. While there has been no conclusive proof that inducing labor prevents stillbirth, we worry so much about this potential loss that we want to do what we reasonably can to prevent it. And one of those things is not waiting too long for labor to start on its own.

So why is inducing labor a big deal? One concern is that it may increase the chance that the delivery will end up as a cesarean. However, a British study recently published in the New England Journal of Medicine showed, surprisingly (at least to me), that there was no difference in cesarean delivery rates when women over 35 who were having their first baby were induced in the week leading up to delivery.

According to Neil Shah, M.D., an obstetrician and an expert in interventions that improve the safety, affordability, and experience of patient care, “The motivation for inducing labor is that women over 35 may be at slightly higher risk of stillbirth compared to younger women. Nonetheless, the NEJM study was not designed to measure the benefit of preventing stillbirth, it was only designed to measure the potential harm of an avoidable cesarean. Ultimately, no difference in cesarean rates were seen (and no difference in still births were seen either). A pregnant woman can’t conclude much from this. In the United States, a larger study is currently underway that might better measure the tradeoffs of inducing labor. By enrolling more patients, they may be able to better parse important differences among pregnant women, since all women above age 35 cannot be painted with the same broad brush.”

One thing the study did not address was the favorability of the cervix – how dilated, softened, or thinned out it was. This “cervical ripeness” can influence how long a woman is in labor during an induction – the “riper” the cervix, the shorter the labor. For many of my patients, the amount of time spent in the hospital influences their decision to choose induction over waiting for natural labor. A long induction can mean being stuck in the hospital for days, which is time that would normally be spent at home. Since having a baby is not a completely medical event, many women want to avoid a long hospitalization and much prefer nature to take its course.

I polled a few of the obstetricians in my department to see if the study would influence their counseling. Dr. Toni Golen, M.D., Director of Labor and Delivery at Beth Israel Deaconess Medical Center, said, “For my patients, knowing the likelihood of cesarean delivery compared to the risk of stillbirth when undergoing induction is important. The best advice I can offer patients in this area should take into account their cervical exam when the induction begins.”

It is important for women and their doctors to talk about their own personal risks, as well as their preferences and options, since induced labor and spontaneous labor are not equivalent birth experiences. Breast cancer is the most commonly diagnosed cancer among women in the United States, and thyroid disorders affect millions of American women. Many breast cancers are sensitive to hormones like estrogen, and according to researchers, thyroid hormone has estrogen-like effects at high levels. So, for years, scientists have wondered whether having too much thyroid hormone might promote the development of breast cancer. A new study suggests the answer could be “yes.”
It’s all about the thyroid

The thyroid is a butterfly-shaped gland at the base of the neck that produces thyroid hormone. Thyroid hormone affects almost every cell in the body and has many crucial functions, like controlling metabolism, heart rate, and body temperature.

Some people have hyperthyroidism, or an overactive thyroid, in which the thyroid gland produces too much thyroid hormone. This can cause weight loss, thinning hair, sweating, anxiety, and a rapid heartbeat. Women are five to 10 times more likely than men to develop an overactive thyroid.

Hypothyroidism, or an underactive thyroid develops when the thyroid gland does not produce enough thyroid hormone. Symptoms of an underactive thyroid include weight gain, fatigue, constipation, depression, dry hair, and a slow heart rate. Like hyperthyroidism, it’s also more common in women than in men.

In an effort to determine whether having an overactive or underactive thyroid affects a woman’s risk of breast cancer, researchers looked at a large group of women in Denmark diagnosed with thyroid disease between 1978 and 2013. More than 60,000 of the study participants had an underactive thyroid, and more than 80,000 had an overactive thyroid. They followed the patients for five to seven years and found that those with an overactive thyroid had a slightly increased risk of breast cancer — an 11% higher risk, to be specific. However, women with an underactive thyroid had a 6% drop in their breast cancer risk.
Putting the study results into perspective

While this study might lead some to conclude that having excess thyroid hormone promotes the development of breast cancer, experts caution that this study does not prove cause and effect. While there may be an association, it is not clear that an overactive thyroid actually causes breast cancer to develop.

Some critics wonder whether women at risk for hyperthyroidism may also be at risk for breast cancer, or whether the treatment for hyperthyroidism may be to blame for increased cancer risk. Another theory is that women with an overactive thyroid see their doctors more often and therefore are more likely to get screened for other problems like breast cancer.

The effect of thyroid hormone on breast cancer risk clearly requires further study. In the meantime, women with an overactive thyroid should stay in close communication with their doctors and follow routine breast cancer screening recommendations. We have all heard it. Perhaps some of us have even said it. Phrases like “No willpower” and “Can’t push away from the table” are frequently used to disparage an overweight or obese person’s perceived lack of “motivation” to control his or her eating habits. But, is this really the primary reason why weight gain occurs?

It is a simple nutritional principle that if calories consumed exceed calories expended, weight gain will result. Therefore, most weight reduction programs focus on cutting calories. Many people view failure to adhere to these regimens as a lack of motivation, dedication, or mental toughness. However, there is now increasing evidence that the “lack of willpower” may be explained by chemical and hormonal changes resulting from sleep deficiency.

There are more and more data that support a link between obesity and insufficient sleep. The growth of this country’s obesity epidemic over the past 40 years correlates with a progressive decline in the amount of sleep reported by the average adult. In large population-based studies, obesity has been found to be related to reduced amounts of sleep. But if this association is true, how might sleep deficiency be related to weight gain?

A recent experimental study published in the journal Sleep provides some clues. Sleep restriction to 4.5 hours per night was compared with normal sleep duration for 4 nights each in a group of young, healthy adults. When measured at the end of 4 days, the ratio of 2 hormones responsible for hunger levels, ghrelin (which increases appetite) and leptin (which reduces appetite) was altered to favor greater appetite. Other studies have observed the same thing. However, this study measured something the others hadn’t: snack consumption, particularly items with greater fat and protein content, was higher after sleep restriction — and, strikingly, the participants’ levels of endocannabinoids increased corresponding to the time of greater snack consumption. Endocannabinoids are chemicals that kindle appetite (like ghrelin), but more importantly, also stimulate reward centers in the brain. Thus, this finding suggests that sleep restriction may make the act of eating more satisfying. Could it be that insufficient sleep contributes to weight gain by stimulating the brain to make eating more pleasurable? If so, the “lack of willpower” may not be due to personal weakness, but rather a result of an addictive chemical imbalance resulting from sleep loss.

No doubt that this exciting finding requires further investigation. However, it already provides additional evidence that sufficient sleep is important for optimal health, and in particular, for combating obesity. It also suggests that greater efforts need to be made on the part of public health officials, individual clinicians, and the general public to get the 7 hours or more of nightly sleep recommended by the American Academy of Sleep Medicine. In 2012, the Consumer Products Safety Commission (CPSC) issued a report warning about high levels of inorganic arsenic in rice and rice products. Rice plants are particularly good at absorbing arsenic from the soil, in particular because they grow in a lot of water. Inorganic arsenic is a common ingredient in pesticides and other products used in farming, and can linger in the soil for a long time after it is used. It can be poisonous. In high doses it is lethal, but even small amounts can damage the brain, nerves, blood vessels, or skin — and increase the risk of birth defects and cancer. The CPSC report said that babies who eat two servings of rice cereal a day could double their lifetime cancer risk.

The FDA has been studying this problem, and has decided to propose a new upper limit, or “action level,” for inorganic arsenic in infant rice cereal of 100 parts per billion (ppb), consistent with levels recently set by the European Commission.

It’s not just the cancer risk that worries the FDA. They are also concerned about studies that show babies exposed to inorganic arsenic, including exposures before they are born, have a higher risk of learning problems.

The infant and toddler rice cereals tested by the FDA had an average arsenic content of 103 ppb. Because that number is an average, it means that some of the cereals were lower — and some were higher. Brown rice has more arsenic than white because arsenic accumulates in the “germ” that is removed from brown rice to make white rice — so cereals and other products made from brown rice are particularly likely to be high in arsenic.

It’s not that we need to cut all rice and rice products out of our diet (although the CPSC report did suggest that children not drink rice milk). But we do need to think a bit differently about rice than we did before, especially with young children and pregnant women.

Here is what the FDA and the American Academy of Pediatrics (AAP) suggest:

    While iron-fortified cereals are still a recommended first food for babies at around 6 months of age (babies only need breast milk or formula until 4 to 6 months), rice cereal isn’t the only choice and doesn’t need to be the first choice. Oat, barley, and mixed-grain cereals can provide iron too.
    It’s a good idea for toddlers to eat varied grains as well, not just rice — and for parents to be mindful of the rice (or rice syrup) toddlers may consume in “puffs” and other snacks marketed for them.
    Pregnant women should be sure to vary their diet and eat other grains besides just rice.
    To decrease the amount of arsenic in rice, cook it as you would cook pasta: cook rice in 6-10 parts of water to one part rice, and drain off the excess water. You may reduce some of the nutrient content, but cooking it this way can also decrease the arsenic content by 40% to 60%.

To learn more about why the FDA is taking this step, including links to studies and their testing data, check out their “Arsenic in Rice and Rice Products” page — and for tips from the AAP on how to reduce arsenic in your baby’s diet, check out healthychildren Osteoarthritis (OA) affects tens of millions of Americans and is a leading cause of disability and reduced quality of life across the globe. Other than joint replacement surgery, there is no known “cure” for OA, and most treatments focus on relief of symptoms such as pain. Often, the first step is non-medication-based approaches such as physical therapy, exercise, and weight loss. Most patients, however, will eventually use pain relievers such as non-steroidal anti-inflammatory drugs (NSAIDs). Other kinds of medication, such as opioids, have also been tested as treatments for OA, and there is ongoing debate about what treatments are best.
NSAIDs vs. opioids: Was there a clear winner?

A recent study compared oral NSAIDs and oral opioids for relief of osteoarthritis pain. Researchers at Harvard-affiliated Brigham and Women’s Hospital performed a meta-analysis (that is, they combined and summarized the results of numerous published studies). They included clinical trials in which patients with knee osteoarthritis (KOA) were chosen at random to receive treatment that lasted at least 2 months.

The researchers carefully chose which studies to include, and two members of the team independently reviewed each study and extracted the data. They selected studies that used a common, well-validated, and widely-accepted measure of pain (the WOMAC scale, which rates pain on a scale from 0 to 100). Data from over 5,500 patients were included, and the researchers found that, on average, oral NSAID treatment reduced pain by around 18 points on the WOMAC scale. Treatment with less potent oral opioids (such as tramadol) also reduced pain by around 18 points, and potent oral opioids (such as oxycodone) reduced pain by around 19 points on the WOMAC scale. Since, on average, patients started out with pain ratings of around 50-60 out of 100, each of these medications achieved around a 30% reduction in patients’ pain.

In short, each of these medications helped reduce pain, and their effects were about identical. The finding of a roughly 30% reduction in pain is very consistent with studies of many treatments for chronic pain. While we are fairly good at acute pain management, many chronic pain conditions such as OA, low back pain, and others are harder to treat effectively. Many researchers in the field believe that a multidisciplinary team (which includes health care providers with different backgrounds) working together to use a number of different approaches to manage pain offers the most effective way of managing chronic pain. And there is good evidence for the effectiveness of these kinds of treatments. For example, a patient with severe KOA might: be treated with NSAIDs prescribed by her primary care physician; see a physical therapist to work on strengthening and conditioning the leg muscles; receive occasional steroid shots in the knee to alleviate inflammation and pain in the joint; and see a nutritionist to help with diet and weight loss, which relieves pressure on the joint and can significantly reduce knee pain.
Working toward a personalized approach to pain management

This meta-analysis cannot tell us which of these types of medication (if any) should be prescribed for a particular patient. No study can. The person-to-person variation in the effectiveness of any KOA treatment is huge. One patient may get near-total pain relief while another is not helped at all. These findings do give clinicians a benchmark for the “typical” amount of pain relief that might be expected from these medications, and suggest that, since they work about equally well, the choice of which one to use will be influenced by considerations other than effectiveness. Providers and those suffering with chronic pain also need to weigh potential side effects. Treatment (especially long-term treatment) with oral NSAIDs can result in stomach problems like bleeding, ulcer, and stomach upset, as well as high blood pressure and kidney problems. Opioids can have side effects such as constipation, nausea, and drowsiness. As you are also likely aware, opioids are also associated with a risk of serious overdose and addiction.

Many of us in the field of pain management are hopeful that eventually we will be able to more effectively “personalize” pain treatment on the basis of an individual’s characteristics, and his or her likely responses to a particular treatment. It is worth noting that non-medication treatments such as exercise, weight loss, and improvements in diet generally have few or no side effects, and have benefits that extend beyond relief of knee pain (for example, improvements in heart health). For most people, these treatments should be included as a part of their multidisciplinary pain management program, regardless of the medication options being considered. On average, 44 people in the United States die every day from an overdose of opioid prescription painkillers. These drugs — such as Vicodin, Percocet, codeine, and morphine — reduce the brain’s recognition of pain by binding to certain receptors in the body. With continued use, a person can develop a physical dependence on these drugs, such that withdrawal symptoms occur if the drug is stopped. These drugs can also cause a “high.” Both of these effects contribute to addiction — that is, the loss of control around the use of a drug, even though it causes harm to the person. Addiction to opioid painkillers is the biggest risk factor for heroin addiction.
Treatment options

Treatment for opioid addiction includes detoxification (or “detox”) programs. However, this alone is often not enough; many people will relapse and use again without additional treatment such as counseling and long-term medications. There are three FDA-approved long-term medications for treating opioid addiction:

    Methadone. This is an “agonist” drug that binds to the body’s opioid receptors and activates these receptors as the opioid drug would. It is offered at certified treatment facilities, usually as a liquid medication taken every day.
    Buprenorphine. This is a “partial agonist” drug that binds to the body’s opioid receptors and partly activates them. It is prescribed by trained physicians, most often as a combination pill with antagonist naloxone (Suboxone), and is taken every day.
    Naltrexone (Vivitrol). This is an “antagonist” that binds to the opioid receptors but does not activate them, and thus blocks the action of other opioid drugs. It can be prescribed by any health care provider who is licensed to write prescriptions, and is available as either a daily pill or a monthly injection.

More on naltrexone

When naltrexone is given as a pill every day, many people have a hard time sticking to it and drop out of treatment.

Vivitrol is a long-acting form of naltrexone which is given as an injection once a month. Scientists are also working on similar longer-acting implants. Vivitrol was approved by the FDA for alcohol dependence in 2006 (as it has been shown to reduce alcohol cravings and heavy drinking), and for opioid dependence in 2010.

In one 6-month study, participants were treated with monthly injections along with counseling. Though many participants did drop out of treatment, 36% of those in the injection treatment group succeeded in total abstinence from opioids, as compared with 23% in those treated with a placebo injection.

There have been no studies directly comparing the three long-term treatments with each other. However, it appears that individuals are more likely to stick to treatment and avoid other opioid use with the agonist drugs methadone and buprenorphine. Vivitrol may be more appropriate for individuals who

    have had no success with the agonist treatments
    have a milder addiction and are highly motivated to quit
    prefer to not take agonist treatments, or cannot do so because of legal or job requirements
    have difficulty committing to taking a medication every day
    face an increased risk for relapse, such as right after detoxification or during a time of stress.

Vivitrol side effects

Side effects of Vivitrol may include nausea (temporary), headache, and dizziness. There may be serious reactions at the injection site, especially if not given into the muscle with a specially designed needle, as recommended. Other reported side effects include liver test abnormalities, depression, and an allergic pneumonia.

If someone relapses and starts to use opioid drugs again, they will not experience the same “high” since the antagonist is blocking the receptor from the opioids. However, using very high doses of opioids to try to overcome the blocking effects of Vivitrol may cause overdose and death.

Also, the risk of overdose or death is high in those who stop Vivitrol and then reuse opioid drugs. Individuals may be unaware of their loss of tolerance while on Vivitrol, and misjudge the effects of even a smaller amount of opioids than what was previously used.

It is recommended that those using Vivitrol should always carry some form of medic alert in case of emergencies.
How is Vivitrol given?

There are increasing numbers of clinics and doctors’ offices that offer Vivitrol injection. Patients must be off all opioids for 7-10 days and alcohol for at least 24 hours prior to starting naltrexone, otherwise severe withdrawal symptoms might occur. Giving a short-acting antagonist (oral naltrexone or naloxone) prior to starting the injections to confirm no withdrawal symptoms can shorten the wait time for starting the long-acting injections. Also, trials have been promising using slowly increasing doses of oral naltrexone combined with slowly decreasing doses of buprenorphine to help shorten the wait time to Vivitrol treatment.

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