Monday, March 18, 2019

Best Planners for University Students

Hi friends, you all must be wondering that why do we have to study math at all? Let’s have a look at few of these, all of these milk, very regular images, but there is one major thing connecting all of them. Can you think of what it’s mathematics for designing such big roller coasters. All the algebra comes from polynomials. for designing such big bridges. You need concepts from geometry like I saw some as an equal lateral triangles and there’s immense mathematics involved when you do a lot of daily life. Things like calculating the time to reach school on time rejecting the amounts after discount and receiving proper change, calculating the amount in your piggy bank and many more that can be really fun and interesting topic if and if you start relating it with your life and

make use of it everyday. Ever wondered that why in kindergarten we start with alphabets and numbers because these are the two most important languages to communicate methods and sharpening the mind healthy to stay focused. Making calculations easy helps in making the right decisions, etc. But why do people feel mad? This difficult subject? One of the major reasons is that students don’t understand math properly. maths and abstract subject, students cannot visualize it properly.

In order to solve any math question. Students need to picture it properly. This lack of visualization is one of the reasons why students are afraid of math, then there is a lack of interest or not taught in an interesting manner.

Let’s see what tips can help.

You to study math in an interesting way so that you can enjoy the subject and learn it for life.

The first tip is try to understand everything logically instead of marking it.

As I said before, math is an abstract subject, you need to visualize it properly to understand it. Hence, you should never make up anything whether it may be mad or not. Try to understand the concept totally related to real life and then try to also apply them in real life by solving questions. also read and understand what exactly you need. Don’t rush yourself in finding the answer has read the question at least two to three times before proceeding.

Why studying pyramids understand the statement of the theorem first, extract what is given and what needs to be proved.

Then understand all the steps that need to be followed and also all the reasons in few cases where there is construction crack the logic for the construction to

master all the key concepts in the chapter and this will really help you to score the maximum maximum your exams the next will be interrelate. All the topics that you studied now on the topics that you study in math are somewhere related to each other. All the basic theorems and concepts remain the same and mathematically entire map is based on these concepts only and many of the basics of triangles are also used internal metric to try to find these interrelations. This will help you to understand the concepts in a way better manner.

Try to understand math in your language. Every student has a different approach to understand mathematics. find your own way to approach man that eventually you will understand.



In a better way, like for example, in linear equations, there are variety of word problems you are you need to understand how to convert these English statements in mathematical equations. For this, you can make a mathematical dictionary which can be helpful for you to go through. The fourth one will be studying groups and play math based games. There might be topics that you understand better and few different topics that your friend me understand better help each other in studying topics that you guys are good at. When you study in groups. You will develop a habit of self learning and if you get stuck somewhere and need help, then you can take the help of E learning videos which are available online. You can watch our variety of videos based on concepts, problem solving, common math mistakes, math, puzzles, etc. And when it comes to math puzzles, try to understand the logic behind the puzzle.

This can help you to become a master in math buzzes, and these also acts and exercise to your brain.

You can try to make some boat games by your own which can be based on math or you can modify some of your normal board games with some mathematical twist. Maintain a separate book and formula list. Well this is a very common thing, maintain a separate book format it would be easier for you to find where you have left while studying math the general formula you feel are important, jot them down and make a chart this will be really helpful and useful for you to go through them all at once during any test or exam. Well here we have come up with the chart for Maharashtra State Board and CBS to buy please click on the card above

number six. Each problem has one solution but they can be

many ways to reach that solution solve every problem in such a way that you are completely thorough with it and understand it and every manner so that if the same question is presented in any other twisted way still be able to answer it. Now, what are the most important steps to reach? Where answer is understanding the question properly? The answer is always hidden somewhere in the question, please read through your questions earlier, you understand it perfectly don’t get pairing with the length of the question when before reading it well, the second last tip is practice as much as you can and soul as many different type of problems you can map is not a theoretical subject. So practicing math is really very important. And the last one is review all your errors if you get stuck anywhere or realize that you have made a mistake take some time to understand that why you made that mistake. Review your errors and make sure that

Do not repeat them. Also understand your doubts This will help you in understanding math in a better way.

I hope this video was helpful and will make math a little easier to study. If you guys have any doubt or any more such amazing tips do common below this video. Do like this Article and hit the bell icon and never miss another update from that state. And don’t forget to subscribe to our website. Thank you. Good morning everyone. So today I have something very fun that I’m looking forward to filminit is time to finally invest in a new diary for 2019 I get such a kick out of doing these things. So I’m going to take you shopping with me to find the perfect diary or planner and probably pick up a few extra organizational items. And I’m also thinking of maybe getting a few little goodies for you guys and doing a little giveaway I might do it on Instagram. So stay tuned throughout this video and I’ll let you know more details. But did you notice something different about me? Maybe, maybe not. I got new glasses finally. So if you didn’t know I actually lost my favorite pink pair of frames on the airplane. When I was coming down to Melbourne from Sydney. There was the one thing that I misplaced as I was packing up my entire life so I think I did pretty well but glasses usa.com have come to my rescue. I said me so.

many pairs of glasses I just have to show you this I have glasses drawer right now I’m very excited so as you probably know we’re currently in an Airbnb just for a few more weeks but I had to clean out one of these jewels, my glasses because they sent me six pitches. So I actually think they Sonny’s one of my favorites the ones I’m wearing and also these pink ones Oh and if anyone’s Hilary Duff and she actually did a collaboration with us for glasses usa.com is I have to have her different designs I think there’s over at to choose from there there little bit more expensive than these ones. So I often spend way too much on my glasses. I was really surprised how cheap they are though. So there’s free basic prescription lenses included and frames and lenses started like 30 bucks which is amazing because I used to spend so much on my glasses so I really appreciate being able to save right now and you’re probably thinking okay but clearly you don’t like all six I can’t all fit really nicely. I kid you not. I love I had this little virtual mirror where you can upload a photo of yourself or you can check

out the glasses and the frames on another person’s face. It has a similar shape to yours and you can actually see if they’re going to sit you or not. So they sent me six pairs. I promise you all six look really good and I’m so happy with them. Also, I thought we do a fun little vote between all of my favorite peers. I want to know which ones you prefer the most. We’ve got option one,

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option two. I think these are so cool. I’ve never had clear white plastic frames or option three the pink ones these are very similar to the ones that I had that were my original favorite color which one is your favor guys so if you like my new look, let me know down below but now it’s time to get serious with this video because we’re about to replace my new baby My all baby Why did I say new is not new is a year old and he seemed to be out of date. So I’ve got some pretty strict criteria for what makes for the perfect diary. Yes, I’m pretty hard to place Yeah, but let’s head to one of my favorite stationery stores.

And hopefully I can find the right one for 2019. And look number four. Let’s head out the door.

I’m arriving today I losing my bubbles.

I think I was browsing through the diaries for over half an hour, but I’m really happy with my purchases. So that was a successful little shopping spree, the lady kkk was so helpful and friendly, I picked up a few things that I think are going to make 2019 so much more organized and I’m really excited to show you what I bought and I also picked up a few little prizes for you guys as well so stay tuned for that I’m back and I have to goody bags or one is for me and one is for you. Or it could be yours if you win my little giveaway.

So I’m going to run it on Instagram, I’ve decided. So if you’re not following me at study with Jess, go and follow me now. And I will have all the details for how you can enter to win some very cool little goodies on my Instagram account. So just make sure to be active and checking out my latest post an Instagram story because details will be there. But let me show you what I picked up. All right, let’s start with the diary. Now. Can I just say last year I wanted this exact diary. And I didn’t have it in stock anymore because they only had the weekly layout and not the daily. So let me explain why I chose the stars specifically because I have wanted this one for ages. Right. So the first race that I chose this story is that it has a day per page says plenty of room tried everything down and it has the timestamp in it as well starts at 7am but there’s actually room to write for six or 5am and it finishes at nine but you can also write a little bit later than that and there is a note section as well.

As a line for birthdays now I always need extra room for my reminders my to do’s birthdays when people are traveling where Adam and I travel a lot for work. So I like to keep track of that. And the last year I had this one here, it actually didn’t have any timestamps, so I would write things down, and then I have another appointment that’s a little bit earlier and I’d have to cross it out or raise it and rewrite it because I just didn’t have time to go through 365 pages and number them from 7am to 9pm. It’s just really, really inconvenient for me, whereas this one’s going to save me a lot of time and I think it’s going to be easier to keep tidy and organized. Okay, this is really cool. I’m actually discovering it in more detail as I’m sharing it with all of you, but it has a note section. It has a page for listing website and notes about those sites, books, so section track down titles and authors. If you get book recommendations, you can store them their restaurants and bars, there is a section for riding down and tracking your expenses.

But I did buy something else to use instead of this area of my diary to track my spending. I will share that with you soon. And then when I was in the store I asked the lady if they have any loose leaf shades of stickers to just mark any important things in your diary and she turned to the back of this diary and says to me, um, it already comes with them. How awesome is that? So I’m just really excited to start using my new diary and I think it actually starts for December so I could get cracking right away. It does Wow. The little things that get me excited. Alright, so you know how I said I bought something instead of using the diary section to track my expenses. This is it so it says everyday is a fresh start and it is a photo of organizing all of your receipts and spending so the lady in the store recommended this to me because she uses the same and ha every accountant is going to love me in 2019 and I’m definitely

going to be a lot more on top of my spending and more savvy with how I spend my money. So it comes with different stickers, you can organize all of these following photos according to the months of the year. I think that’s how I’m going to do it rather than different categories. And you just write down the date, the amount of money you spent text involved and the details for items that receipt and you’ve got their seat in the back right so last thing I bought for myself is a wall calendar and actually have this one for 2018. I thought it came in handy so much I want one for next year as well. It does have some beautiful quotes for each month. As you can see on the back that’s little way out there. And I just think I prefer to have a monthly calendar above my desk. Rather than using the monthly spread in my diary, I’ll probably use that monthly spread as well. But I think this is easier just to map out everything and it helps you to feel less overwhelmed especially when you have a really busy month because you can break it all down and say that even though there’s a lot going on, it’s probably early according to specific weeks or days and little chunks throughout the month. It’s not usually a really flat out month although December has been pretty busy for me. So I do think I’m going to use this a lot and I can’t wait to hang it up in Adam and my new apartment. So what little goodies did I pick up for the giveaway. I’ve got two things in here. First thing is the 2019 at daily view diary, which I picked up for myself as well in the past or pink. I just really liked the land and format of the story. I think it’s going to help you stay more organized and there’s plenty of room to write everything down. And then to help you write everything down. I also picked up these really really cute pens says one with ladybirds, one with cats, rainbows and hearts and one with cherries. And I thought that was just a really cute little giveaway to kick start your 2019 So again, just follow me on Instagram and you can check out the details for how to enter their at study with just and also I will leave a link down below of all the glasses that I showed you earlier in this video, including the ones I’m wearing now. Thanks to glasses. usa.com. So do check.

them out. And don’t forget to tune in next week for another video. Just turn on your notifications and I’ll see you very soon.
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How to Answer Exam Questions Correctly

Major Mistakes Students Making During Graduation | So main idea behind the scenes with a good education industry or job or money actually industry I just after I asked the man to get those game for can overcome Welcome to gv training from two to 10 into monitored for part is for traders go home on the wall graphics animation can the mobile security can turn off our data center candor home or routing switching and the more he did he did he say well filmmaking cannot be have number of workshops for all the Courses with the mama Jama a joke a password tennis PJ or didn’t get it has to be some experience target a job to deliver content to related to the industry scenario based training so in the schema camera he can afford it education sector and the guy doesn’t even talk about it produce content that the end to end up address later borrow a big part of who I am as he can and now I’m done with my for your graduation up investing which accounts mocha the company is absolutely right in the senior

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See: How to Study for Exams in Less Time 2019

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Monday, March 11, 2019

Teens who use flavored e-cigarettes more likely to start smoking

Are you taking care of someone who seems to be against you? This can be the experience of taking care of a family member with post-traumatic stress disorder — PTSD — and it can take a huge toll on everyone involved. At the same time, caring for a person with PTSD can be an act of love and courage.
What causes PTSD?

PTSD can develop when people experience massively stressful events that involve childhood physical or sexual abuse, being sexually assaulted, or narrowly escaping getting killed or severely injured, whether from accidents or violence or military combat. PTSD can also be caused by witnessing these kinds of things, by them happening to a close friend or relative, or by learning about them in the course of one’s work, such as being a first responder or a social worker helping victims of abuse.
What are the effects of PTSD?

Whether caused by experiences during military service, abuse as a child, being the victim of assault as an adult, or as a side effect of jobs that deal with trauma, the effects can be lifelong. It’s a medical problem, not a weakness. Adrenaline levels stay elevated, causing anxiety, irritability, and hypervigilance (being on guard even in safe places). People with PTSD may become snappy and even physically aggressive. Little, everyday sounds may make the person jump. The ability to feel positive emotions like love and happiness is diminished, and people with PTSD may drink or use drugs to avoid painful feelings and memories. People with severe PTSD may isolate themselves, lashing out and showing little affection toward people they care about, and who care for them. Conflict with family members and coworkers is common.
Caring for a person with PTSD

It can be hard for caregivers not to take it personally. They feel that their loved one doesn’t love them anymore (and indeed it’s difficult for some people with PTSD to feel and express love). The fun is gone, and in romantic relationships so is the intimacy. The family member with PTSD may not be comfortable going out in public or being touched. Caregivers can feel lonely and abandoned, and divorce is common in relationships where a partner has PTSD.

Watchwords for caregivers are self-care, limits, and realistic expectations. It’s a balance: you want to help your loved one but you can’t do that if you’re impaired yourself. So, self-care is important. Figure out what you need to have a happy and healthy life and make an effort to keep those things in your life. Eat right, get exercise, take time off from caregiving, see friends. When you’re healthier, you’ll be better able to help your family member to be healthier.

Set limits. You want to offer gentle support, but not tolerate things that are out of bounds for you in any other relationship, such as abusive language or actions, or heavy substance abuse. Couples therapy can be tremendously helpful when one member of the couple has PTSD.

Expectations need to be realistic. Just as other medical disabilities can limit the activities of people who have them, you may need to adjust your expectations about your loved one’s engagement in “regular” family things like going on outings, to restaurants, to parties, to your kids’ games. You may need to take more of a lead in the relationship than you used to or expected to, such as in managing finances, making plans, and getting things done.
The good news? There are effective treatments for PTSD

The good news is that we live in a time when effective PTSD treatment exists. PTSD is best treated through cognitive behavioral therapies, particularly exposure therapy and cognitive processing therapy. These are specialty treatments and not all mental health clinicians are trained in them. A loved one with PTSD may be reluctant to seek treatment, and gentle encouragement can be helpful. You can find therapist referrals at the International Society for Traumatic Stress Studies and the Association for Behavioral and Cognitive Therapies.

PTSD symptoms may not completely go away, but they can be reduced. Just like turning down a volume knob, constantly high levels of anxiety or irritability can be lowered, and the power of memories and reminders of trauma can be reduced. Just like in the rest of your body, advancing years can take a toll on your brain function. Much of this slowing down is predictable and can be chalked up to normal aging. However, when thinking skills become increasingly fuzzy and forgetfulness gets to be a way of life, an early form of dementia known as mild cognitive impairment may be setting in.

Often, the first reaction is to attribute these changes to the beginning of Alzheimer’s disease. But blood flow problems may be to blame, as well. “An estimated one-third of all cases of dementia, including those identified as Alzheimer’s, can be attributed to vascular factors,” says Dr. Albert Hofman, chair of the department of epidemiology at the Harvard T.H. Chan School of Public Health.
Heart health and brain health are connected

Vascular — blood vessel — problems include atherosclerosis (the buildup of fatty plaque in the arteries) and arteriosclerosis (the stiffening of arteries with age). Both are well-known contributors to heart disease. These same processes can also damage brain function by interfering with the steady supply of oxygen-rich blood that nourishes brain cells.

In the case of a stroke, sometimes called a “brain attack,” large swaths of brain tissue die when a blood clot in a major brain artery abruptly halts the flow of blood. In addition to suffering immediate damage from a stroke, roughly one in three stroke survivors will eventually develop dementia.

More subtle injuries are caused by tiny blockages in the small vessels deep within the brain. These silent strokes are 10 to 20 times more common than overt strokes. The microscopic damage they leave behind also raises the risk that dementia will emerge at a later date.

Having blood vessels compromised by plaque buildup can also pave the way for Alzheimer’s. The accumulation of deposits of a protein known as beta-amyloid — the hallmark of the disease — is a direct consequence of what doctors call hypoperfusion. This means the brain is not getting a sufficient supply of blood over the long term. Because of these overlaps, says Dr. Hofman, it doesn’t make sense to draw sharp distinctions between Alzheimer’s and vascular dementia.
Protect your heart and your brain

As with heart health, a key step in maintaining your cognitive abilities is to reduce your major cardiovascular risks. This includes getting regular physical activity, quitting smoking, managing blood sugar and blood cholesterol levels, eating a healthy diet, and maintaining a healthy weight.

Of particular importance is keeping high blood pressure in check, especially in middle age. High blood pressure is the leading cause of stroke. It is also thought to stimulate the growth of micro-injuries in the white matter of the brain. The presence of these lesions can slow thinking and hasten the loss of cognitive function that accompanies Alzheimer’s. When I talk to teens in my practice about cigarettes, what I hear from lots of them is that the smell is what keeps them from smoking. They don’t want to smell like cigarette smoke, and they don’t want that taste in their mouth, either.

But what if the smell, and the taste, were good? What if they tasted like bubble gum, or chocolate?

In a study published in the journal Pediatrics, researchers looked at data from the 2014 National Youth Tobacco Survey. They found that among teens that had never smoked cigarettes, 58% of those who had used flavored e-cigarettes planned to start.

That number was 20% for teens who had never used e-cigarettes. It was 47% among those who had used non-flavored cigarettes, which is a high number too. Clearly, teens that use e-cigarettes are more likely to start smoking.

But when the e-cigarettes were flavored, the teens were less likely to think of tobacco as dangerous.

E-cigarettes and tobacco are different, of course. E-cigarettes do not have many of the carcinogens that cigarettes do, and could be useful for smokers who are trying to quit. But for teens that have never smoked, it’s a different story. The “vapor” of e-cigarettes doesn’t have to contain nicotine, but it can (it does contain chemicals such as formaldehyde that could have long-term health consequences) — and nicotine is addictive. Using e-cigarettes is physically close enough to smoking cigarettes that moving from smoking one to smoking the other could easily happen.

The use of e-cigarettes among youth has grown tremendously over the past few years — and e-cigarettes are being marketed to them. We don’t know what the consequences of this will be. It could be that we will end up with more smokers — or that we’ll end up with fewer if teens decide to stick with e-cigarettes, especially if they choose to stick with the nicotine-free kind. But we can’t just sit back and wait to see what happens.

Recently the Food and Drug Administration extended its tobacco regulations to include e-cigarettes and other nicotine delivery systems, which among other things, requires that there be warning labels and that you have to be at least 18 years old to buy them. This is a good start, and will help us look more carefully at how e-cigarettes are being marketed, too.

We need to do more research to understand the short-term and long-term effects of e-cigarettes on our youth. We need more information in order to make the best policy and parenting decisions.

All of us who are raising or interacting with teens need to talk with them more about e-cigarettes. We need to understand how teens think about them, and why they might choose to use them; when it comes to teens, listening is really important. And along with listening, we need to help teens understand the risks involved. We can’t let them get distracted or seduced by marketing and flavoring; we need to help them make the best choices for their health.
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Friday, March 8, 2019

Parents: How smart are you about antibiotics?

One of the more typical reasons for a trip to the emergency department on Thanksgiving Day (and most days, frankly) is accidental cuts to the hands. Be careful cutting up that turkey! Always use a carving fork, and although the household might be busy, try to avoid distractions when working with knives. Thankfully most such injuries can be repaired in the ED, but occasionally are bad enough to warrant being seen by a hand surgeon. For simple cuts to the hand, we generally place non-absorbable stitches that need to be removed in about 10 days. Most of the time, antibiotics are not needed — just a really good washout and cleaning prior to stitching.

Everyone “knows” about the dangers of cooking turkey, yet somehow nationwide, each year, the rate of residential fires more than doubles during this time frame. Never leave the house with the oven on, and check on the turkey frequently. If you choose to deep-fry a turkey, always do this outside, and always make sure the turkey has thawed first. Placing a frozen turkey into a deep fryer can cause explosions of hot oil, which can lead to third-degree burns and other serious injuries. If you’re frying a turkey, always wear good footwear, practice fire safety, and monitor children in the area.

Most birds carry bacteria, and the turkey is no exception. The most common pathogen is Salmonella. If cooked properly, this poses no harm. Under-cooked, the bacteria can cause diarrhea, vomiting, fever, and general illness that ranges from uncomfortable to life-threatening. The recommended temperature for a cooked turkey is at least 165° F, and should be checked by thermometer. Did you know that if you have any questions about cooking your turkey, you can call the Butterball hotline? Even on Thanksgiving Day! (800-BUTTERBALL/800-288-8372)

Delicious holiday foods are usually well seasoned …with salt. For most adults this does little more than make you thirsty, but for people with congestive heart failure or chronic edema (water retention), extra salt can place increased stress on the body. If you have these conditions, please be careful with what and how much you eat. Inevitably, we will see a few patients with episodes of worsening heart failure in the emergency department … usually the day after a holiday.

Last but not least, be careful about driving. It’s all too common to see drunk drivers during Thanksgiving time. It is historically the most dangerous time of the year for car accidents and subsequent fatalities. Monitor how much you drink, and remember that even if you are sober, unfortunately not everyone else out there is. Be extra attentive. Drive safe! When we think of anxiety disorders, we generally think of them as uncomfortable emotional responses to threat. These responses may include symptoms such as palpitations, shortness of breath, sweating, trembling, or absolute paralysis. While there is nothing inherently wrong in thinking about anxiety this way, a recent study pointed out that there is an entirely different way of thinking about anxiety that may be even more helpful. According to psychologist Kalina Christoff and her colleagues, anxiety may be more appropriately thought of as “mind-wandering gone awry.”
The advantages of mind-wandering

In your brain, there are circuits that promote mind-wandering and they are not all bad. In fact, these very circuits help you maintain a sense of self, understand what others are thinking more accurately, become more creative, and even predict the future. Without your mind-wandering circuits, your brain’s ability to focus would become depleted, and you would be disconnected from yourself and others too.

In addition to the natural and frequent tendency for your mind to stray, it also has automatic constraints too, to ensure that it does not stray too far. When daydreaming during a boring lecture, for example, your brain may jerk you back into reality.
When mind-wandering goes awry

One of the things that a wandering mind is in search of is meaning. By connecting the past, present, and future, it helps you compose a narrative to connect the dots in your life. This narrative is constantly being updated. But sometimes, the wandering mind can encounter threats. Rather than proverbially “whistling in the dark,” the brain can overreact to these threats.

In the brain of an individual with generalized anxiety disorder, for example, the anxiety processor (the amygdala) is disrupted. Although it has strong connections to the “inner eye” (attention), it lacks a connection to the brain circuits that signal how important or significant a threat is. Without the ability to assess the significance of threats, they can all feel the same.

As a result, the “inner eye” gets fixated on negative thoughts. This fixation is a way of constraining the mind too, but it is not actually helpful. Anxious people focus more on external threats in an exaggerated way. They become glued to the threats. Anything from being teased to being ticked off feels much more troubling than it would to someone without an anxiety disorder. And it’s not just conscious threats that grab your attention. It’s subliminal threats too! Threats, of which you are completely unaware, capture your brain’s attention. A mind, once free to wander, is desperately forced to stop in its tracks in what can be construed as a catastrophic confusion of constraints.
Let your mind wander away from perceived threats

When your brain has automatically grabbed your wandering mind, and fixed your attention on threat, rather than getting a proverbial “grip” on reality, you actually have to loosen your grip on your threat-focused reality — allow your mind to wander! As Christoff and colleagues put it, you de-automatize your constraints.

Because your brain’s inner eye has its resources fixed on the threat, it gets progressively exhausted too. You can’t really summon it to help you suppress the anxiety, or get your mind off of it. Instead, you have to reactivate your mind-wandering circuits to give your attention a break.

Practically speaking, there are a few ways to do this. First, identify the negative spiral that has occurred like a pothole into which you have fallen on a mind-wandering journey. Simply name the feeling you are feeling and recognize that you need a mental reset. Rather than deliberately trying to suppress the feeling, accept that your mind is wandering, and that the fixation on threat is not the constraint solution you are looking for.

To counter this constraint, up the ante on the mind wandering — wander even more. If you’re at work, you could keep a knitting kit and start using it just when anxiety strikes, or if at home, you could go out and do some gardening. Meditation is also an effective way to get out of the fixed threat hole.

So when you’re next feeling anxious or wired, try allowing your mind to do what it naturally does — wander! You can bring it back to task gently, without fearing that you have lost your way. Or you can expect that it is wired to switch between wandering and focused states, and it will eventually come back on its own. The more you mindfully interact with this switch, the more adept your brain will become at initiating it. A pair of recent studies provides useful information to men facing challenging decisions about what to do after being diagnosed with early prostate cancer. Researchers tracked men for 10 years and found that virtually none died of the illness, even if they decided against treating it.

Early prostate tumors confined to the prostate gland often grow slowly and may not need immediate treatment. Instead, these tumors can be monitored and treated only if they begin to progress.

In one of the studies, British researchers randomly assigned 1,643 men with early prostate cancer into three groups: one group had surgery to remove the prostate, another had radiation treatment, and a third had “active monitoring,” meaning that doctors tried to predict if the cancer was spreading by measuring their prostate-specific antigen (PSA) levels every few months. Treatment could start if PSA levels jumped by 50% or more over the course of a year. It’s important to note that active monitoring differs from “active surveillance” for early prostate cancer, which relies on routine biopsies as well as PSA measurements to monitor for spreading cancer.

After 10 years, only 1% of the men had died of prostate cancer, regardless of which group they were assigned to. But tumors did spread, or metastasize, more frequently in the active monitoring group. According to the results, the cancer progressed in one in five men being monitored, compared to less than one in 10 men who received surgery or radiation. Some of the men in the monitoring group had what’s known as “intermediate-risk” prostate cancer that has a higher grade and progresses more often than low-risk prostate cancer. Laurence Klotz, a professor at the Sunnybrook Health Sciences Centre, in Toronto, Canada, who was not involved in the study, says it’s likely that most of the men who progressed on active monitoring were in the intermediate-risk category, although the authors did not report this. As time went on, more and more of the monitored men wound up being treated.

In an accompanying study with the same group of men, those treated with surgery reported more long-term problems with sexual performance and urinary continence. Conversely, the radiation-treated men reported more bowel problems, while the urinary and sexual side effects from radiation treatment typically resolved within six months. Both the monitored and treated men reported the same amount of anxiety and depression.

Taken together, the studies bolster a growing consensus that men with organ-confined prostate cancer can safely avoid treatment for some period of time. The results show that one case of metastatic cancer was prevented for every 27 men treated with surgery and every 33 men treated with radiation. “These studies again confirm the lack of evidence that treatment interventions for so-called early prostate cancer lead to any meaningful benefits in survival,” said 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. “Additional analyses will be required to see if we can identify those men in each group who did develop metastases and then design treatment programs to see if we can modify that risk.” I come from a long line of skilled soup makers. In the late 1800s, my great-grandmother Enrichetta Cavagnolo, newly arrived from northern Italy, was a soup chef at Delmonico’s in New York City. Enrichetta’s daughter and granddaughters (my grandmother, mother, and aunts) were talented soup makers as well, to the delight of our well-fed family.

But the soup-making gene seemed to skip me. I was never interested in boiling bones for broth, chopping mounds of vegetables, and stirring soup — with love — for hours. It was too much fuss, I thought — until I learned the shortcut.
Fast and healthy

Turns out, making a delicious batch of soup doesn’t require homemade bone broth or all-day simmering. Just boil your favorite vegetables and spices in some water and low-sodium (store-bought) soup stock. There’s no right or wrong combo of ingredients; it’s whatever appeals to you. Want a small batch? Use two cups of liquid. Want a big batch? Use four. Add more liquid to make it soupier, or less liquid to make a stew. Boil, add the ingredients, and you’re in business in about 20-30 minutes.

It’s also easy to go a step further, and make soup a complete meal. “Add protein such as lentils or beans, fish, extra-lean beef, turkey, or chicken,” says registered dietitian Kathy McManus, director of the Department of Nutrition at Harvard-affiliated Brigham and Women’s Hospital. She recommends increasing the nutrient power and fiber by adding as many vegetables as possible, such as peppers, asparagus, broccoli, spinach, onions, and carrots.
Too busy? Beware

Knowing the shortcut is important in an age when soup tops the list of culturally cool comfort food. It’s featured in trendy soup “bars,” tiny take-out windows, and all varieties of grocery stores. While it’s tempting to skip the stove and buy prepared soups, you should note that they often contain preservatives and other unhealthy ingredients. In particular, be on the lookout for these:

    Saturated fat. Any soup with a cream base, such as cream of tomato, is made with cream and butter, which contain unhealthy saturated fat. Too much saturated fat in your diet may drive up your cholesterol and lead to blockages in arteries.
    Sodium. Canned soups often contain high amounts of sodium. Too much sodium in your diet can lead to high blood pressure, heart attack, stroke, and heart failure. Federal guidelines limit sodium intake to 2,300 mg per day for most people.
    Sugar. Added sugar is found in chilled fruit soups and even some vegetable soups. The American Heart Association recommends limiting added sugars to no more than 24 grams per day for women and 36 grams for men.
    Calories. Soups are generally lower in calories than other entrée choices, but that changes when you top soup with cheese, sour cream, or croutons, or pair it with a piece of bread.

Keep it healthy

McManus recommends avoiding prepared soups for the most part. “They’re okay in a pinch and on occasion, as long as you set limits. Aim for less than 500 calories, 600 mg of sodium, 5 grams of saturated fat, and 5 grams of added sugar in a bowl of soup,” she says, “and cut that in half for a cup of soup.”

It’ll take some detective work to stick to those limits and find healthier prepared soups. Look at the nutrition information on a restaurant’s menu or website, or on a product’s Nutrition Facts label. If it’s too much work to hunt down healthy soups, then consider making the soup from scratch, like I do now. You’ll find some healthy soup recipes to get you started here. You can control the ingredients, and you can give it your own special flair. And trust me, it doesn’t take a soup-making pedigree to be good at it.
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Let’s recognize caregivers and make it easier for all of us to do the right thing

Recently I saw a young woman in my clinic for her annual exam. As usual, I asked her if she would like to be tested for sexually transmitted infections, and then we reviewed the “menu” of options: we could collect a swab of her cervix for chlamydia, gonorrhea, and trichomonas, and a PAP smear for human papillomavirus. We could collect blood for HIV, hepatitis C, syphilis, and herpes. We discussed the pros and cons and details of testing — not everyone wants every test. But she cheerfully consented to all of it, and when the results came back positive for chlamydia, she was shocked.

“But I had no symptoms!” she exclaimed.

Like most primary care providers, I am a huge fan of screening for STIs and believe every patient should be asked at every annual exam if they would like to be tested, even if they feel fine. Why? Because most people don’t even know that they are infected.
How many people actually have a sexually transmitted infection?

The Centers for Disease Control and Prevention (CDC) recently published its summary of reportable sexually transmitted infections in the United States over the past year, and it is not good. Rates of every reportable STI, which includes chlamydia, gonorrhea, and syphilis, have all increased significantly; all told, we are seeing a 20-year record high in the number of these cases.* What’s extra concerning is that it is the third year in a row that these rates have increased.

Chlamydia is king, with over 1.5 million cases in 2015, a 6% increase from 2014. Gonorrhea follows with 400,000 cases, a 13% increase. These infections can result in pelvic inflammatory disease, which is a major cause of infertility, ectopic pregnancy, and chronic pelvic pain. A pregnant woman with chlamydia can pass it to her baby; the baby can then develop serious eye and lung infections. The people at highest risk were young people between the ages of 15 and 24; they accounted for over two-thirds of the cases of chlamydia. This is why the CDC has been recommending that every sexually active woman under age 25 be screened.

There were 24,000 cases of syphilis, which may the most harmful of the three, and this was a whopping 19% increase. Gay and bisexual men remain at highest risk for syphilis and gonorrhea, though there were also significant increases in syphilis among women, as well as in congenital syphilis, which is spread from infected mothers to their newborns. Untreated syphilis can lead to blindness, paralysis, and dementia in adults, and seizures or stillbirth in babies. The CDC recommends that every pregnant woman be tested for syphilis, and sexually active gay and bisexual men should be tested for syphilis annually.
Barriers to preventing the spread of STIs

If someone doesn’t know that they are infected, they can’t get treated. If they don’t get treated, they may have sex with many partners, or without a condom, and spread the infection. So, screening tests like the ones we offer at the annual exam are important for the prevention of new infections.

Many people can’t access clinics like mine. They may be young people worried about what their parents may think. They may be uninsured, under-insured, or undocumented. That’s where the “safety net” comes in. These are the free or lower-cost clinics that focus on STI diagnosis, treatment, and prevention. But since 2003, there has been a slow and steady decrease in funding for these safety-net clinics, and we are paying a serious price for that now.

CDC officials blame the surge in STIs on these budget cuts: they point out that over 40% of health departments have reduced their clinic hours and tracking of patients, and at least 20 STI clinics flat-out closed in the past few years due to lack of funds.

Dr. Jonathan Mermin, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, points out that, “STI prevention resources across the nation are stretched thin, and we’re beginning to see people slip through the public health safety net.”

Combine this decrease in public health clinics with the rise in popularity of dating apps like Tinder and Grindr, and ongoing inconsistent condom use, and we have a huge problem.
Keys to preventing STIs

Chlamydia, gonorrhea, and syphilis can be prevented with condoms, and cured with antibiotics. And all can present with minimal symptoms, or none at all.

Sexual education programs that include instruction about condom use have been shown to help youth to delay first sex and use condoms when they do have sex. But, only 35% of U.S. high school students are taught how to correctly use a condom in their health classes. So it’s not surprising that among teens, only about a third of males and nearly half of females reported that they or their partner did not use a condom the last time they had sex.

What can we do about this? Obviously, we need to better fund our public health clinics. Anyone who is or has been sexually active needs to go get tested. We need to push for comprehensive sexual education in schools. Parents should talk openly with their kids about sex and STIs, and ensure that they have access to confidential medical care. We need to promote safe, protected sex through consistent condom use for everyone. These interventions are all cheaper and better than ongoing rampant infection.

*What about other STIs, like herpes and trichomonas? These were not included in the report, as they are not reportable in the same way. However, the CDC estimates that there are 20 million new STI cases yearly, costing the U.S. health care system approximately $16 billion. News last week about celecoxib shows how challenging it can be to understand the risks and benefits of newly developed drugs. This is particularly true when the findings of one study contradict those of past studies. And that’s exactly what has happened with celecoxib.
Anti-inflammatory medications: pros and cons

The FDA approved celecoxib (Celebrex) in 1999. This anti-inflammatory medication can be a highly effective treatment for arthritis and other painful conditions. It was developed with the hope that it would be at least as effective as other anti-inflammatory medications (such as ibuprofen or naproxen) but cause less stomach irritation. Developing a safer anti-inflammatory medication is a worthy goal, since stomach irritation can not only cause annoying pain or nausea, but it can also lead to ulcers, bleeding, or perforation. These medications can also increase blood pressure and cause kidney problems.

Celecoxib is known as a COX-2 inhibitor — that’s because it targets an enzyme (COX-2) involved in inflammation. Ibuprofen and naproxen (and many other anti-inflammatories) target COX-1 and COX-2. They’re called “non-selective” anti-inflammatory drugs. Because of where these enzymes are found in the body, the COX-2 selective medications seemed capable of dampening down inflammation while going easier on the stomach.

And that was true. Celecoxib — and other COX-2 inhibitors, such as rofecoxib (Vioxx) — did cause less stomach trouble. But soon after its approval, studies suggested other concerns: an increased risk of heart attack and stroke. Rofecoxib was removed from the market in 2004. And while the FDA allowed celecoxib to remain on the market, it required the manufacturer to issue additional warnings to patients. It also required additional study. And that’s why celecoxib is back in the news this week. The results of the PRECISION (Prospective Randomized Evaluation of Celecoxib Integrated Safety versus Ibuprofen or Naproxen) trial were released. And the news is good for celecoxib.
Results suggests lower cardiovascular disease risk — and fewer side effects — than expected

The PRECISION trial is a carefully designed and powerful study that analyzed the impact of celecoxib on cardiovascular disease. The study spanned 926 medical centers in 13 countries and enrolled more than 24,000 patients with two of the most common types of arthritis (osteoarthritis and rheumatoid arthritis). Each study subject had a higher than average risk for cardiovascular disease due to a history of high blood pressure or high cholesterol.

Study subjects were divided into three groups who took anti-inflammatory medications every day: one group took celecoxib, one group took ibuprofen, and the last group took naproxen.

Study subjects taking celecoxib in moderate doses were

    no more likely than those taking ibuprofen or naproxen to have a fatal or non-fatal heart attack or stroke
    less likely than those taking ibuprofen or naproxen to have significant gastrointestinal problems, such as serious bleeding
    less likely than those taking ibuprofen to have kidney problems or hospital admission for high blood pressure.

What does this mean for you?

It’s rare that a single study provides a definitive answer or changes practice overnight. But this was a large, well-designed, and expensive study that is unlikely to be repeated any time soon. And, another study of lower-risk people came to a similar conclusion just last year.

Still, questions may yet come up regarding:

    The lack of a placebo group. As suggested by some prior research, it is possible that all three of the drugs used in this study increase the risk of cardiovascular problems; without a control group, it’s impossible to say.
    Dosing. Study subjects were allowed to take up to 400 mg/day of celecoxib if they had rheumatoid arthritis but only 200 mg/day if they had osteoarthritis. In real life doctors may prescribe a wider range of doses.
    Reason for treatment. This study only included people with rheumatoid arthritis or osteoarthritis. The results might be different if people with other conditions had been included.
    Other medical problems. The risks and benefits of celecoxib in people with other medical problems (such as significant kidney disease) are uncertain because this study excluded them.
    Other medical treatments. All patients in this study took a medication to protect the stomach; outside of studies, that’s not always the case.

While these issues are valid, I think this study does provide a significant measure of reassurance regarding the cardiovascular risks of celecoxib. And it may encourage doctors who thought the drug was too risky to prescribe it more often.

This new research shows in a dramatic way why “more research is needed” is not just a tagline at the end of so many medical news stories. And in the case of celecoxib, the result of the additional research is good news indeed. Since 2003, the Movember movement has been raising public awareness of testicular and prostate cancer. The common theme that links cancers of all types is that early detection tends to lead to better outcomes. Because cancer often has no symptoms in its early stages, screening for cancer has been an integral part of primary care routine visits.
I go for an annual physical every year. Do I really need to do self-examinations?

Although routine screening by a health care provider is critical, it does not alleviate the need for self-examinations. In terms of gender-specific cancers, breast cancer is one that receives a great deal of attention due to its prevalence, as one in eight women will develop breast cancer during their lifetime. It is the most commonly diagnosed form of cancer in women, and the second leading cause of cancer death in women. As with any form of cancer, early detection is critical, and the importance of routine breast self-examinations cannot be stressed highly enough. For these reasons, multiple foundations and even the National Football League promote awareness.
What is the deal with men’s health?

Far fewer people know the facts about prostate and testicular cancer. Regarding prostate cancer, about one in seven men will be diagnosed during their lifetime. It most often affects men over the age of 65, and it is the second leading cause of cancer death in men. Although there is no proven way to do self-exams, a digital rectal examination (DRE) performed by a health care provider is a useful screening tool in the detection of prostate cancer. During a DRE, a healthcare provider uses a gloved, lubricated finger inserted into the rectum to feel the prostate gland.

Testicular cancer is fortunately much less common than prostate cancer, as about one in 263 men will be diagnosed during their lifetime. Unlike prostate cancer, testicular cancer is a disease of young and middle-aged men, with about 7% of cases occurring in teens and young boys. Although the number of deaths from testicular cancer is far lower than breast or prostate cancer, it is estimated that about 380 men will die of testicular cancer in the U.S. in 2016. Early detection is critical, and we must stress the importance of routine testicular self-examinations.

Prostate and testicular cancers, especially when not detected early, can lead to difficult treatment, sterility, and potentially a lifetime of hormone replacement therapy. Men tend to be less likely in general to access the health care system, particularly for routine care, which further punctuates the need for awareness. Many men find the thought of a DRE or a testicular examination embarrassing, but such embarrassment can be lifesaving.
 Why is a neurologist so interested in prostate and testicular cancer?

A few years ago, I met a colleague who was similar to me in many ways, a relatively young physician and father of two with no health problems. That is, until he discovered a small nodule on one of his testicles during a self-exam. Follow-up tests confirmed testicular cancer. Fortunately, with early intervention, he was cured after the surgical removal of one of his testicles.

So when I heard about the Movember movement, I felt compelled to do my part to raise awareness.
So here are some of my Movember experiences…

For the past few years, I have grown out a full beard in October, and then shaved it down to a mustache on November 1. For a man who never wears a mustache to suddenly have one is very much an attention grabber. I fondly recall my daughter who is now 4 saying, “Papa, you look like Super Mario with that mustache.” Fortunately, some of the comments I received have been a little more flattering. After sharing the story of Movember with some coworkers, one of the nurses said, “That mustache reminds me of Tom Selleck’s mustache. The only difference is, he is Magnum P.I., which I guess makes you Magnum P.M. (my initials).” During Movember, I begin every patient encounter explaining why I have a mustache, the importance of prostate and testicular cancer awareness, and how early detection can be lifesaving. It has always amazed me how many patients reply with a personal story of their own about a brother, uncle, coworker, etc. who was diagnosed with prostate or testicular cancer.

I fondly recall one such patient, a woman in her 70s, later changing the subject by saying, “Dr. Mathew, do you know that it tickles very much to kiss a man with a mustache?” I replied with a big smile while shrugging my shoulders, “I wouldn’t know (implying that as a heterosexual married man, I have never tried to kiss a man with a mustache),” One of my most rewarding Movember experiences occurred when I had a female patient in the medical field ask me how to perform a testicular exam. I was initially shocked by the question, but then later elated that my mustache served its purpose and then some. Not only did I raise awareness of testicular cancer, but this woman may actually help detect a case, and save someone’s life.

Then came the difficult part … showing this woman how to perform a testicular exam. My mind quickly scrambled, and after scanning the room, I noticed an Angry Bird toy from a Happy Meal that my daughter did not want. As I picked up the rotund bird, and used it as a teaching prop, she seemed to grasp the concept perfectly. I then put the Angry Bird down, and I could not help but feel that one just flew over the cuckoo’s nes. I walked out of the doctor’s office, overwhelmed and paralyzed. My daughter had just been diagnosed with multiple food allergies from nearly all fruits, numerous vegetables, seafood, nuts, soy, wheat, and more. We headed straight to the grocery store to figure out what she could eat without wasting away from malnutrition, or so I thought.

Two hours later, we were still in the grocery store, reading every label.

You would think I would know what to do. After all, I am a doctor. But that day, I was simply a mom and a caregiver.

My problem was simple in the big scheme of things. Many years later, we figured out what my daughter can and can’t eat, how to go out to dinner, have friends over, and basically return to normal everyday life.

But for many of the more than 40 million caregivers in the USA today, it’s not so easy.
The costs of caregiving: health, time, and money

Fully 32% of family caregivers provide at least 21 hours of care per week with the average of 62.2 hours, according to a June 2015 AARP and National Alliance on Caregiving research report, Caregiving in the U.S. Those who provide caregiving 14 hours per week or for two or more years doubled the risk of developing cardiovascular disease and significantly increased the risk of developing high blood pressure and depression.

And it’s not just the time burden and health risks, but there’s also the expense.

A just-released AARP study, Caregiving and Out-of-Pocket Costs: 2016 Report, concludes that “family caregivers are spending roughly $7,000 in 2016 on caregiving expenses which amounts to, on average, 20% of their total income.” Some groups, including Hispanic/Latino, African American, and those caring for someone with dementia experience higher than average out-of-pocket expenses.

Many caregivers are forced to cut back on their own personal spending, reducing leisure spending or retirement savings, to accommodate caregiving costs.

When I think back to the day our family life changed, I am struck by how little doctors seem to know about the impact of our recommendations to our patients. My problem was minor — just changing grocery shopping habits and recipes.

But think about a new diagnosis of diabetes. It’s not just the recipes and grocery habits, but more trips to the pharmacy, tracking blood sugars, and follow-ups to doctors. According to a Harvard Medical School study, it takes two hours on average for one doctor visit for travel, waiting time, and visit. Even more time is spent if one needs public transportation or to arrange a ride.
Maybe it’s time to contemplate new measures for health care delivery

What if doctors and health systems were measured by how much they reduced the time, money, and the overall burden of care that patients, family, and caregivers need to follow recommended care? What if we told our patients, their families, and their caregivers not only what they “should do,” but “how to” with the least disruption to their everyday lives?

We need to make it easy to do the right thing.

Doctors care about having meaningful time with their patients. So, every time a new guidance or documentation rule is mandated, physicians understandably complain about the new time burden to incorporate the new tasks into the workflow of their practice.

Similarly, every time we give our patients and caregivers new recommendations to follow, we are disrupting the “workflow of their lives.” Is it any wonder that compliance is challenging for our patients? Do we address the daily changes that will be needed in everyday living? The Lasix prescription that means figuring out where all the nearest bathrooms will be when the fluid reduction pill takes effect. Or the cost of dressings, bandages, tape, and time to manage wound care at home? And the anxiety of not knowing if one just broke sterile technique at home? What a steep learning curve we expect from our patients following each visit!
A thank you from health care providers to caregivers

November is National Family Caregivers Month. Kudos to all family and friend caregivers, not only for “care taking” — ensuring your loved one is safe, taking the correct medications at the right time, preventing falls, making the right meals, and helping with bathing — but also for “care giving” – the giving of love, compassion, and care. You are spending your precious hours and your own money to do what you do best: sharing your love to your parent, your spouse, your children, or your friends. You are making a difference to our patients (your loved ones). It’s time we clinicians pay tribute, recognize, and thank you for being a caregiver, and not just a caretaker.
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Tips for making the most of your child’s checkup

It’s that time of year again, when people gather with friends and family to celebrate the holiday season. The festivities often feature wine, champagne, and other alcoholic beverages. But before you raise your glass, make sure you’re aware of just how much alcohol you’re actually consuming — and how it may affect your heart.

For the most part, moderate drinking — defined as one drink per day for women and two drinks per day for men — is considered safe. But there are some caveats.
Defining “one” drink

“We ask people about numbers of drinks, but you have to be careful about what they really mean by that,” says cardiologist Dr. Stephen Wiviott, associate professor of medicine at Harvard Medical School. For some people, “one drink” may be 6 ounces of whiskey, which is actually four drinks, he notes. One standard drink contains roughly 14 grams of pure alcohol, which is found in:

    12 ounces of regular beer (about 5% alcohol)
    5 ounces of wine (about 12% alcohol)
    1.5 ounces of distilled spirits, such as whiskey, rum, and vodka (about 40% alcohol)

Despite popular belief, the evidence that alcohol is good for your heart is fairly weak and based solely on what researchers call observational data. “We observe that people who drink moderately have lower rates of heart disease and death from heart disease, but that doesn’t prove cause and effect,” says Dr. Wiviott. For example, light-to-moderate drinkers tend to be educated and relatively wealthy, and they’re likely to have heart-healthy habits that may explain their lower risk.
Holiday heart

There’s a well-established connection between binge drinking and atrial fibrillation or afib, an irregular heart rhythm that can increase the risk of a stroke. It’s known as holiday heart syndrome because it typically happens around the holidays and on weekends, when some people drink to excess. It’s not exactly clear why binge drinking (defined as consuming about four to five drinks over a two-hour period) triggers afib. But it can happen in people with and without a history of the heart rhythm problem.

A recent study found that even as little as one drink a day may enlarge the heart’s upper left chamber (atrium) and increase the risk of developing afib. Researchers found that every 10 grams of alcohol consumed was linked to a 5% higher risk of developing afib. About 24% (and in some cases, up to 75%) of the higher risk could be traced back to an enlargement of the left atrium. Stretching of the atria — which can also result from longstanding high blood pressure or a genetic problem — seems to make the heart more electrically unstable, Dr. Wiviott explains.
So what should you do?

These new findings don’t change the observation linking moderate drinking to a lower risk of heart attack noted in some studies. But no one should ever start drinking in hopes of avoiding a heart attack, he says. For his patients who do drink alcohol, he suggests no more than one drink a day, even for men. If you have afib and drink alcohol, you should probably have a discussion with your doctor, Dr. Wiviott advises.

The National Institute on Alcohol Abuse and Alcoholism already advises people ages 65 and older to limit themselves to one daily drink. Age-related changes, including a diminished ability to metabolize alcohol, make higher amounts risky regardless of gender. As a headache specialist, the topic of sinus headache is a frequent point of discussion. Many patients deny that they have migraines, believing sinus problems are the cause of their headaches. Some of the more tech-savvy patients believe that they have both migraines and sinus headaches after consulting with “Dr. Google.” The reality of the situation is that 86% or more of patients who suspect that they have sinus headaches in fact have migraines.
Why the confusion between sinus headaches and migraines?

It begins with the many symptoms that both migraines and sinus headaches share, which include pressure in the face, an association with barometric/seasonal weather changes, and autonomic nervous system dysfunction. The autonomic nervous system controls many of the involuntary functions in your body including heart rate, blood pressure, and sweating. In the case of migraines, autonomic dysfunction can cause eye redness, eyelid swelling/drooping, tearing, sinus congestion, and even a runny nose.

Response to treatment can also further drive patients to believe that they have sinus headaches rather than migraines. For example, a patient may have a headache involving a pressure sensation in the face, and calls their primary care physician thinking a sinus infection is causing the symptoms. The primary care physician then prescribes antibiotics and steroids to treat this assumed sinus infection. The patient feels better after taking these medications, and believes that the infection is cured. The reality of the situation is that steroids can be effective for the treatment of sinus issues and migraines. Even without steroids, antibiotics can be perceived as an effective treatment for two reasons. First, the patient truly believes he or she has an infection, so the antibiotic has a powerful placebo effect. The other reason is that with time, the migraine would have gone away anyway.

Unfortunately, this cycle of antibiotics with or without steroids for the treatment of a migraine masquerading as a sinus infection can go on periodically over years and even decades. Taking steroids can cause many problems including weight gain, hair loss, and bone weakness. Inappropriate use of antibiotics can contribute to the rise of antibiotic-resistant bacteria. Conversely, if a sinus headache responds to a migraine-specific treatment like sumatriptan, migraine is more likely the diagnosis than sinus headache.
Here’s why you want to know whether you have migraines and not sinus headaches

An incorrect diagnosis of sinus headaches can also serve to skew a patient’s family history. Migraine is a genetic disorder that is passed down through family members. Patients often deny that any of their family members have migraines, but when asked about sinus headaches, they will often respond, “Actually, my mother had sinus headaches.” When questioned about the mother’s sinus headache behavior, the same patients frequently respond, “She would lay down, and insist that the room be dark and quiet. She would also ask for a bucket to be placed by the head of the bed even though she rarely ever threw up.” Such responses tend to lead the physician and patient to the conclusion that migraines actually do run in the family, as sinus headaches are not typically accompanied by light sensitivity, sound sensitivity, and nausea. The same patients will also return for a follow-up appointment noting, “It turns out that my sister, cousin, and aunt all have migraines, which they thought were due to sinus problems.” In a jocular way, I at times reply, “Discovering family members that suffer from migraines can be both unfortunate and comforting, but such discovery is not as devastating as routinely encountering a family member who regularly causes headaches, which I refer to as ‘mother-in-law syndrome.’”
Three telltale signs it’s a sinus headache and not a migraine

While I was lecturing on distinguishing sinus headache from migraine with some Harvard medical students, they came up with the phrase Mathew’s Sinus Triad to encompass three features that are more suggestive of sinus headache than migraine. These are:

    Thick, infectious looking mucous. A little clear drainage can be seen with a number of conditions, and is not necessarily indicative of a sinus infection.
    Fever. It would be very unusual for migraine to present with fever, but fever is a primary symptom of a sinus infection.
    Imaging. If an imaging study or evaluation with an endoscope looking up the nose shows a sinus problem, then the headaches are likely related to that — unless the headaches continue after the sinus problem is successfully treated.

In conclusion, if you suffer from frequent sinus headaches, there is a good chance that you are actually experiencing migraines. Making the correct diagnosis and formulating an appropriate treatment plan can reduce the frequency and intensity of headaches, as well as avoid unnecessary testing, visits to specialists, and taking medicines that are not actually treating the problem. The yearly check-up: it’s the time when your child gets a total look-over. As a pediatrician, I’m often struck by just how much I need to cover in that appointment. I need to find out about eating, sleeping, exercise, school, behavior, even about peeing and pooping. I need to ask about the dentist, about screen time, about changes in the family’s health or situation. I need to do a full physical examination and check on growth and development. I need to talk about and give immunizations — and make sure parents have the health information they need and want. And of course, I need to address any chronic health problems the child might have, and any concerns the parents have.

In our practice, the longest I have to do this is 30 minutes. Usually I have 15 minutes.

After 25 years of being a pediatrician and doing thousands of check-ups, I’ve learned about what can help parents get the most out of whatever time they have. Here are some tips:

    Think about what you want to talk about before the visit. This sounds really obvious, but too often parents don’t do it. They get caught up in scheduling and getting to the visit, or in the forms they need, and don’t take the time to think about what they want to ask the doctor. Keep a list somewhere (like on your phone, so you don’t leave it at home); jot things down. As you go along, prioritize the concerns: what is most important to cover at the visit? Which leads me to…
    Don’t leave it all for the visit. This happens all the time. Parents store up all their worries— and have a list that is so long and complicated I can’t possibly tackle it all and still do what I need to do medically. While sometimes we schedule a follow-up visit to finish up (more on that below), another alternative is to find ways to get some of your questions answered ahead of the visit.

    Most practices have nurses that can answer common health questions and otherwise help families. You may be able to leave a message for your doctor and have them call you back; this can be particularly helpful when there are concerns, such as behavioral problems or bullying, that might be best discussed without the child present.
    Use portals or other forms of communication. More and more, practices are devising ways for families and doctors to communicate. You can use these to get a question answered or get advice. I’ve also had parents send me written information about their child ahead of a checkup exactly to save time at the visit — and allow us to be more efficient and focused when we are together.
    Consider making an appointment before the checkup. This sounds odd, but it can be really helpful, especially when there is something complicated going on — like asthma acting up, school problems, worries about behavior, or a family crisis. That way, I can fully focus on the problem, instead of having to ask about sleep or poop or daily servings of vegetables. Plus, it gives us a chance to try something — and then at the checkup, see if it helped or not.
    Ask your doctor which health and parenting websites they recommend. There’s a lot of great information out there.

    Have any forms or papers ready — and have your child undressed before the doctor comes in. Little stuff, but it really helps things move smoothly. If you have to fill out something for the visit, get it done. Have the argument with your modest child about the gown before the visit starts. If you have forms you need for school or sports, let the nurse or clinical assistant know; sometimes they can help.
    Work with your doctor to set an agenda for the visit. Too often, we docs come in with our own agenda. Or, parents start in with their first concern — and then time runs out before they get to the second or third. As soon as the doctor comes in, say something along the lines of, “I have three things I want to be sure we talk about today, and I know you have things you need to ask. How can we best make this work?” Planning it out together can make all the difference.
    Be brief whenever you can. I’m not saying you shouldn’t say everything you need or want to say. But if all is going fine in a particular area, say it’s fine rather than giving lots of details. Or if all isn’t going fine, just say it’s not, rather than defending or giving excuses. Save the time for questions and conversations that can help you and your child.
    Let your doctor know if your needs aren’t met. Sometimes we just can’t pull it off in that one visit, but that doesn’t mean that you can’t get all of your needs met. As I said before, sometimes a follow-up visit makes sense. Maybe there is a nurse who can spend some time helping you before you leave or a social worker who can give you a call. Maybe you can get a handout about a topic you are interested in or a recommendation for good online information. Never just leave saying, “Oh well, maybe next year.” That’s not how primary care works; it’s an ongoing relationship. We are here to support you, every step of the way.
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Tuesday, February 26, 2019

Don’t take fatigue lying down

Sure, everyone gets tired sometimes, and often bounces back after a quick rest or a good night’s sleep. However, if bouts of fatigue occur more often and last longer, you shouldn’t ignore them.

“Older adults may chalk up fatigue to aging, but there is no reason you should battle ongoing tiredness,” says Dr. Suzanne Salamon, a geriatric physician with Harvard-affiliated Beth Israel Deaconess Medical Center.

Here are signs that you should take your tiredness seriously:

    inability to do activities you enjoy
    waking up exhausted, even after a good night’s sleep
    not feeling motivated to begin the day
    sudden bouts of exhaustion that go away and then return
    shortness of breath.

This type of fatigue can affect your health in many ways. You may have less energy to exercise. You may have trouble concentrating, staying alert, and remembering things. You may anger easily and become more socially isolated.
It’s worth checking in with your doctor

Fatigue also could signal a medical condition, according to Dr. Salamon, and you should consult your doctor to see if you have any of the following issues.

    Anemia. This occurs when your blood has too few red blood cells or those cells have too little hemoglobin, a protein that transports oxygen through the bloodstream. The result is a drop in energy levels.
    Heart disease. Heart disease can cause the heart to pump blood less efficiently and lead to fluid in the lungs. This can cause shortness of breath and reduce the oxygen supply to the heart and lungs, making you tired.
    Sleep problems. Sleep apnea is characterized by pauses in your breathing, often lasting several seconds, or shallow breathing while you sleep. It is common among older adults and those who are overweight. Another sleep-related issue is an overactive bladder, which forces repeated nighttime bathroom trips. Either of these can disturb your sleep enough to leave you feeling tired during the day.
    Medication. Certain medications can make you feel tired, such as blood pressure drugs, statins, antidepressants, antihistamines, nonsteroidal anti-inflammatory drugs, and cold medications. “People react to medications differently and they often end up taking more as they get older,” says Dr. Salamon. Check with your doctor, especially if you have added a new medication or recently increased your dosage. “Sometimes it helps to take certain medicines, which may cause fatigue, at night rather than in the daytime,” she says.
    Low-grade depression or anxiety. Mental health issues often drain energy levels. “You may suffer from depression or anxiety and not even know it,” says Dr. Salamon.
    Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). This is a complex disorder that causes unexplained extreme fatigue, which can worsen after physical or mental activity and does not improve with rest. Its cause is unknown, but may be linked to one or more underlying issue.

Some simple ways to boost energy levels

For regular, everyday fatigue, try these tips:

    Drink a cup of coffee or tea. A little caffeine can jump-start your day, she says. “You don’t need more than that, but it can offer a mental and physical lift, especially if you have trouble with morning fatigue.”
    Go for a 30-minute walk. “If you can’t get outside, walk around your house in bouts of 10 to 15 minutes, two to three times a day,” says Dr. Salamon.
    Take a nap. A midday nap can help overcome tiredness later in the day. Keep naps to about 20 to 30 minutes, as studies have suggested that napping for 40 minutes or longer can have the opposite effect and leave you feeling groggy rather than refreshed. “Also, don’t nap too late in the day or in the early evening, when it could interfere with your normal sleep schedule,” says Dr. Salamon.
If you Google “coconut oil,” you’ll see a slew of stories touting the alleged health benefits of this solid white fat, which is easy to find in supermarkets these days. But how can something that’s chock-full of saturated fat — a known culprit in raising heart disease risk — be good for you?

Coconut does have some unique qualities that enthusiasts cite to explain its alleged health benefits. But the evidence to support those claims is very thin, says Dr. Qi Sun, assistant professor in the Department of Nutrition at the Harvard T.H. Chan School of Public Health.

“If you want to lower your risk of heart disease, coconut oil is not a good choice,” he says. It’s true that coconut oil tends to raise beneficial HDL cholesterol more than other fats do, possibly because coconut oil is rich in lauric acid, a fatty acid that the body processes slightly differently than it does other saturated fats.
Coconut oil’s effect on cholesterol

But there’s no evidence that consuming coconut oil can lower the risk of heart disease, according to an article in the April 2016 Nutrition Reviews. The study, titled “Coconut Oil Consumption and Cardiovascular Risk Factors in Humans,” reviewed findings from 21 studies, most of which examined the effects of coconut oil or coconut products on cholesterol levels. Eight were clinical trials, in which volunteers consumed different types of fats, including coconut oil, butter, and unsaturated vegetable oils (such as olive, sunflower, safflower, and corn oil) for short periods of time. Compared with the unsaturated oils, coconut oil raised total, HDL, and LDL cholesterol levels, although not as much as butter did.

These findings jibe with results from a study by Dr. Sun and colleagues in the Nov. 23, 2016, issue of The BMJ, which examined the links between different types of saturated fatty acids and heart disease. Compared with other saturated fats (like palmitic acid, which is abundant in butter), lauric acid didn’t appear to raise heart risk quite as much. But that’s likely because American diets typically don’t include very much lauric acid, so it’s harder to detect any effect, Dr. Sun notes.
Tropical diets are different

Coconut oil proponents point to studies of indigenous populations in parts of India, Sri Lanka, the Philippines, and Polynesia, whose diets include copious amounts of coconut. But their traditional diets also include more fish, fruits, and vegetables than typical American diets, so this comparison isn’t valid, says Harvard Medical School professor Dr. Bruce Bistrian, who is chief of clinical nutrition at Beth Israel Deaconess Medical Center.

Some of the coconut oil available in stores is labeled “virgin,” meaning that it’s made by pressing the liquid from coconut meat and then separating out the oil. It tastes and smells of coconut, unlike the refined, bleached, and deodorized coconut oil made from the dried coconut meat used in some processed foods and cosmetics. Virgin coconut oil contains small amounts of antioxidant compounds that may help curb inflammation, a harmful process thought to worsen heart disease. But to date, proof of any possible benefit is limited to small studies in rats and mice, says Dr. Bistrian.
Unsaturated fats

In contrast, there’s a wealth of data showing that diets rich in unsaturated fat, especially olive oil, may lower the risk of cardiovascular disease, Dr. Sun points out. The evidence comes not only from many observational studies (like those in the aforementioned BMJ report) but also a landmark clinical trial from Spain, which found that people who ate a Mediterranean-style diet enhanced with extra-virgin olive oil or nuts had a lower risk of heart attack, stroke, and death from heart disease than people who followed a low-fat diet.

Of course, there’s no need to completely avoid coconut oil if you like the flavor. Some bakers use coconut oil instead of butter in baked goods, and coconut milk is a key ingredient in Thai cooking and some Indian curry dishes. Just be sure to consider these foods occasional treats, not everyday fare. High-grade cancer that’s still confined to the prostate is generally treated surgically. But a third of the men who have their cancerous prostates removed will experience a rise in blood levels of prostate-specific antigen (PSA). This is called PSA recurrence. And since detectable PSA could signal the cancer’s return, doctors will often treat it by irradiating the prostate bed, or the area where the gland used to be.

In February, researchers reported that radiation is a more effective treatment for PSA recurrence when given in combination with androgen-deprivation therapy (ADT). ADT interferes with the body’s ability to make or use testosterone, which is the hormone (or androgen) that makes prostate tumors grow more aggressively. It targets rogue cancer cells in the body that escape radiation.
Here’s what the study found

The newly published study randomly assigned 760 men with detectable PSA after surgery to one of two groups. One group got radiation plus ADT and the other group got radiation plus a daily placebo tablet. The study recruited patients between 1998 and 2003, and after an average follow-up of 12 years, 5.8% of men in the combined treatment group had died of prostate cancer, compared to 13.4% in the radiation-only group. Rates of metastatic prostate cancer were also lower among men treated with ADT: 14.5% compared to 23% among the placebo-treated controls.

“The take-home message is that ADT has a major and beneficial impact on the risk of death from prostate cancer when added to radiation for PSA recurrence,” said Ian Thompson, M.D., a professor of oncology at the UT School of Medicine, in San Antonio, Texas, and the author of an editorial accompanying the newly published findings.

Men in this study received a high dose of the ADT drug bicalutamide, which doctors use less frequently for PSA recurrence today, instead favoring other testosterone-suppressing medications that have since been shown to be more effective. Therefore this is an instance of a long-term study reporting results after treatment standards — in this case the selection of a specific ADT regime — have changed.
A new treatment standard

Still, some men have difficulty tolerating ADT, and not all of them should get it, particularly if they’re older and more likely to die of something other than prostate cancer. “I’d reserve ADT for younger men with a long life expectancy ahead of them who were diagnosed initially with high-grade or late-stage disease,” Thompson said. As a primary care physician at Massachusetts General Hospital (MGH), I am profoundly grateful for my 10 years in recovery from opiate addiction. As detailed in my memoir Free Refills, I fell into an all too common trap for physicians, succumbing to stress and ready access to medications, and became utterly and completely addicted to the painkillers Percocet and Vicodin. After an unspeakably stressful visit in my office by the State Police and the DEA, three felony charges, being fingerprinted, two years of probation, 90 days in rehab, and losing my medical license for three years, I finally clawed my way back into the land of the living. I was also able to return, humbled, to a life of caring for patients.

There is one question that I invariably get asked, by my doctors, colleagues, friends, family members, and at lectures and book talks: now that you are in recovery from opiates, what are you going to do when you are in a situation such as an accident or surgery, when you might need to take opiates again? I have blithely answered this question with platitudes about how strong my recovery is these days, and how I will thoughtfully cross that bridge when I come to it. In other words, I punted consideration of this difficult issue into some unknown future time.

Unfortunately, that future is now, and that bridge is awaiting my passage.

Last week I slipped on my top outside step, which was covered in ice, went into free fall, and managed to completely tear my left quadriceps tendon. This required a surgical repair in which doctors drilled three holes into my kneecap and then tethered what was left of my quadriceps muscle to the kneecap. Taking Tylenol or Motrin for this kind of pain is kind of like going after Godzilla with a Nerf gun. I was sent home with a prescription for one of my previous drugs of choice: oxycodone.

My leg was hurting beyond belief. I literally felt as if it were burning off. But, I had spent the last 13 years of my life conditioning myself, almost in a Clockwork Orange kind of way, to be aversive to taking any and all opiates.

What is a person who used to suffer from a substance use disorder (SUD) to do? There are millions of us in this country who may eventually face this choice.

Fortunately, I am not the first person who has confronted this issue. There exist safeguards one can put in place. It is important that all of your doctors know about your history of SUD. It is also helpful if you have a significant other or partner at home who can manage the pills for you, and dole out two of them every four to six hours as directed, to avoid the temptation to take more than prescribed in order to get high. (Old habits die hard.) Finally, the key to all addiction treatment is being open and honest. It is critical to check in with one’s support network about medications, cravings, and fears, and to use all of the recovery tools that are available to you, such as asking for help if you need to, and not trying to control things that can’t be controlled.

In the end, my level of pain was so great that there really wasn’t any choice but to take the oxy. My nerve receptors made the decision for me. I’m sure there are Shaolin monks somewhere who can block out high levels of pain, but that just isn’t me.

I am reassured, and even pleasantly surprised, by several aspects of having taken the oxycodone. First, it worked well for the pain. Second, I did not get high from the pills. I guess that taking two pills is different from taking (or snorting) 10 or 20, as we tend to do when we are addicted. Finally, it was very easy to stop taking them, and I have had absolutely no cravings or dreams about using since stopping.

This is a critical issue. It would be cruel and inhumane to not sufficiently treat any patient’s pain, especially after surgery, and it is important not to discriminate against people with SUDs. There are millions of people in recovery from opiates in the United States alone, and they are as deserving of pain control as anyone else.

Finally, I am grateful beyond belief to have survived my opiate addiction, and to not have become one of those all too common overdose stories we all read about in the newspapers. I am also grateful to my excellent doctors at MGH for fixing my wounded knee, and for providing me adequate pain control. Fortunately, my recovery and my pain control do not seem to have been mutually exclusive.
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