Saturday, February 16, 2019

How to Score Good Grades in your school

Bakery business is one the lucrative businesses all around the world today. With a nation’s population increasing by millions, it shows that people will continually eat and it will be your business to provide the needed meal. Bread is one of the choice fast foods of people across the globe and in Nigeria, its demand is never in short supply. In Nigeria, for example, the amount of people who consume bread on a daily basis proves that the bakery industry is a profitable industry. In this article, you will have the knowledge needed to start up and maintain a profitable bakery business.
High Demand For Bakery Product

Bread as an example of bakery products is a good source of carbohydrates, proteins, and vitamins. Because it has such high nutritional value, it is widely consumed by almost everyone on this planet. For a very long time consumption of bread has been a necessity for human diets and as continuously yielded an increase in consumption over the years. This proves that the market is wide open for anyone to venture into as one can invest in opening a modern bakery to provide the highest in demand bread for consumers.

Nigeria with a large population consumes a lot of bread with locally made meals such as bean cakes, pap, beans etc. Another fraction of the population may require catering services for parties and wedding to provide snacks and pastries etc. However before you launch into the business, there are some few things you must note
Find Mentors Before You Commence Bakery Business

Search for mentors before you start your bakery business as mentors will easily provide you with solutions to difficulties in the business, provide ideas, tips and information necessary to having a successful bakery business. These mentors will serve as a guide to instruct you on among other things the necessary equipment needed, how to get your license, strategies and branding ideas to selling your bread, etc.


The bakery as a highly lucrative business

Nigerian loves baked foods such as the regular “puff puff”, Agege bread, small chops and so on. With all these, there’s is still a huge market to attract as baking has no limitations in terms of age, religion etc. If you can create a creative branding strategy you will definitely find it profitable by the end of the month.

With the huge population in Nigeria, it’s very easy to say every baker is a millionaire if they get to sell to about one million people in the open market in a day. But baking doesn’t grow in such large fashion in a day but requires adequate time in branding and improving on providing crocrowd-pleasing delicious meals at an affordable price and quick accessibility in order to increase sales.

See: How to Start A Successful Farming Business in Nigeria

If you have an intention of baking or you have started your baking business, here are the ways to make it profitable:
Market Survey

Do a proper survey or research to inquire about the demand presently in the market regarding baking products which other bakeries do not offer. In this survey, you can also find out if there is a customer relationship between the producer and the consumer. In this survey y,ou can state what the customer’s demands are and position your business in such a way that meet such demands.
Source for Start-up Capital

Whatever you discover from the demands in the market will affect the budget of your start-up capital and this could be more than your initial budget.
Source for Start-up Capital

The high demand which you have discovered in the market for a particular product will affect the amount of start-up capital you need to start the business.

Furthermore, your start-up capital will determine the materials you would need, the equipment you should buy, your business size, etc. All these would be drawn up into the estimated amount of what to you need to get your business up and running.
Have a Business Plan

The business plan enables you to draw out strategies to be used in the business such analyzing your start-up capital which has been estimated from your feasibility reports, where you want to get your capital from – this could be a loan, from your savings or assistance from family and friends.

This business plan will show marketing and branding strategies to be used to promote your brand, number of staff you need, equipment etc. It is important to start a business with a proper business plan.
Buy Necessary Bakery Equipment

Purchasing the right and necessary equipment is very important. Buying the right equipment depends on the level at which you want to startup the business such as the size of the bakery, capital and so on. Here is the list of equipment needed for a bakery business: mixers, dough molder, large tables, bread pans, display shelves, water proof wrapping sheets, oven, bread slicer, van for delivery and so on.

Proper installation and maintenance should be given to the skilled technicians to monitor and control.
Baking Materials

The major materials needed for baking are baking flour, baking soda, butter flavors, water and so on.
Get Approval from Government and Regulatory Bodies

If the law requires any form of payment to a regulatory body, kindly comply and pay every necessary dues and get your government approval and license, in order to carry out your business smoothly.
Get a Good Location

Find a good location that will promote sales. Location close to the buyers will improve sales on a regular basis which will mean constant production that will keep you in business. Without demand, there would be no business therefore get a place with enough traffic to keep yourself ib business.
Safety of Lives and Property

Nigerians have no regards about this matter, they rely more on spiritual matters when asked to get insurance. It is important to note that safety of lives and property is as important as the sales you want to make. Therefore, fix every necessary gadget or appliance for preventing major disaster to your establishment.
Recruit the Best Staff

After your business plan, your staff are also important, therefore, make sure you recruit the best hands with relevant experiences on the job. The recruited staff should not be bakers only but also individuals who understand marketing and distribution in order to promote sales.

See also: Establishing a Profit-Making Fish Farming Business
How is Bakery Business Profitable?

Bakery business is profitable if you start up with the right capital, inculcate and promote good customer relations, have the right team working with you; that is a team that understands the level of business and so on and so forth.

To venture into the profit side of the business, take note of the following:
Bakery Products Sales and Distribution:

If your product has the right branding and it’s properly packaged with a delicious taste, people will buy it.

Make sure that your products are fresh and attractive fonts or images pleasing to the consumer eyes.

Your distributors can include wholesalers, retailers as they bring your products closer to the consumers
Offer Trainings

You can offer training to a number of persons and charge from as low as 20,000 Naira and if you have 10 students, that’s 200,000 Naira. This student can also help in production of more products after completing the training.
Offer Event Catering Services

This is the most popular avenue used to make money in Nigeria. A lot of event are usually held on weekly basis and most of them require services of bakers to provide them some tasty meals.

For example a wedding cake costs about 50,000 to 500,000 Naira depending on the number of tiers and decoration. This is also similar to small chops which can be priced at 500 Naira per guests. If your production and packaging is top notch you will get referrals and lots of events will be needing more of your services.
Go on TV Shows

You could have the opportunity to host your personal baking show on TV which could bring more sponsorship deals and brand endorsement, creating a total uniqueness to your brand.

To get to this platform, you must be ready to invest all, that is your time, money and so on but at the end it’s definitely profitable.

Be very open to criticism so you can correct mistakes and do not allow anyone tell you it can’t be done, constantly press on to be better on every side. Turn your business into a money making venture.
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How to learn some langauge in collage

Hello, what's happening folks. So today we will cover six critical procedures for enhancing your dimension of self-control. Presently before we get into the bare essential, I would like to take a concise minute to characterize what precisely self-restraint is. Since when I asked you all to inform me regarding your with control on Twitter a few days ago, I found a great deal of solutions extending from inspiration to diversions to wireless dependence, a wide range of things in the middle of, and what every one of these answers are genuine issues. I don't assume that every one of them fit conveniently into the class of self-restraint, where they do fit in the more extensive classification of conduct change. What's more, that is the enormous objective for the majority of us. We need to change our practices to be progressively lined up with our objectives and our long haul wants. Also, with regards to that general mission, to change our practices, I see four fundamental territories that we have to concentrate on. One of which is simply the development discipline, which we're going to handle in this video, yet additionally the working of new propensities which can make that conduct programmed, the customization of our condition which can evacuate barriers and help us oppose enticements by essentially expelling them and obviously, the utilization have however much Brando as could reasonably be expected since it is the initially meet later.

Yet, as you may have speculated, this video is just about that first territory self-restraint. Furthermore, where I need to begin is by asking and noting two inquiries. Number one, what precisely is self-restraint? What's more, number two? How can it contrast from inspiration? Since I think many individuals get these two terms befuddled.

To begin, I need to share a statement from the essayist Samuel Thomas Davies, since it really answers both those inquiries in a truly clean manner. self-control is tied in with inclining toward obstruction making a move regardless of how you feel living by plan, not naturally, however in particular it's acting as per your considerations, not your sentiments. Be that as it may, another way inspiration is your general dimension of want to accomplish something Reza discipline is your capacity to do it paying little respect to how you feel. What's more, for any of you who've ever woken up supposing I don't feel like it, which is every one of you, myself notwithstanding. You can see now how essential self-control is. It's building that benchmark that enables you to act as per your long haul objectives.

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Regardless of how spurred you feel. So, how about we spread six essential techniques for building your self-restraint. Also, we're going to begin with one that doesn't appear to be truly unmistakable or noteworthy at first. Yet, stay with me here, on the grounds that this is an outlook move that I discovered more accommodating than some other personal growth strategy. I've attempted in late memory.

To say it basically, when you're attempting to change your conduct, disregard the objective, you're endeavoring to accomplish the outside result, and rather center around the adjustment in character you need to occur. This is an idea that I originally found out about in James Claire's book, nuclear propensities, which I very suggest, coincidentally, and there's this section close to the start of the book that truly exemplifies it well so I'm simply going to peruse it to you here envision two individuals opposing a cigarette when offer to smoke the principal individual says not this time I'm attempting to stop it sounds like a sensible reaction however this individual is still trusts they are a smoker who is endeavoring to be something different they're trusting that their conduct will change will bearing similar convictions the second individual to customers by saying No much appreciated. I'm not a smoker.

It's a little distinction. In any case, the announcement flags a move in character. Smoking was a piece of their previous life, not their present one, they never again recognize as somebody who smokes. So the general thought here is that once you've grasped the adjustment in your character, you're going to end up acting in arrangement with that change. Furthermore, in case you're asking why precisely this occurs, the third section of Robert youngsters' book affected the brain research of influence has an extraordinary clarification for it. Basically, people feel this common impulse to act reliably with their past choices. As he writes in the book. When we have settled on a decision or standing firm, we will experience individual relational weights to act reliably with that dedication. Those weights will make us react in manners that legitimize our prior choice. Also, moving my outlook along these lines, has been extraordinarily useful in the recent months. What's more, the primary way that I actualized it was by beginning to consider myself a competitor. Presently, I've generally been a truly dynamic individual, and I've had a clothing rundown of athletic objectives on my site for a significant long time now, however I never truly took the jump and kind of reasoning of myself as a competitor and there was some fraud disorder explanations behind this yet as

In the wake of perusing that entry in the book, I chose to take the jump and begin considering myself a competitor, not similarly as someone who acts of things. What's more, that move in attitude has done miracles for my dimensions of self-restraint in a wide range of zones from setting off to the rec center all the more reliably preparing more diligently while I'm there to enhancing my eating routine, which has been significantly superior to anything it used to be over the recent months. So truly, in the event that you don't take anything else from this video, I'm putting this first for a reason, begin pondering conduct change as far as the character that you need to epitomize, instead of the objectives that you need to accomplish.

OK. System number two is to as often as possible help yourself to remember for what reason you're being taught in any case by the day's end. We must have a solid why for our activities on the off chance that we need to do them reliably. Furthermore, every time I consider this idea, I'm helped to remember a tale about the performing artist Jim Carrey and it goes like this after he had touched base in Hollywood. Furthermore, he was still sort of a devastated performing artist. One day he took out a napkin and he drew himself a look at made to himself for $10 million and post dated for a long time and

The future and after that you put that check in his wallet so every time you draw out his wallet, he could see it and help themselves to remember why he was buckling down what he was really going after. What's more, this is something that you may discover accommodating to do also. Take a stab at recording your objective or the personality you need to expect and put it possibly on a sticky note by your work area or by your PC so you can see it each and every day and realize this is for what reason I'm building myself discipline. This is the explanation behind all the work I'm putting in.

Good. Procedure number three is to discover approaches to grasp distress and grasp the opposition you feel towards accomplishing something that takes diligent work or that is upsetting. Much the same as setting off to a genuine rec center and lifting loads improves you at lifting loads later on and ready to lift more weight whenever you go in. Each time you grasp distress, you're basically completing a rep of the activity that is self-control since it is an ability that can be scholarly. It is a muscle that can be worked after some time. This is for what reason I'm such a defender of scrubbing down on the grounds that a virus shower is something that a great many people would prefer not to do. It's most certainly not

Entirely open to remaining underneath that surge of super cold water. Also, that is the point each morning that you get into the shower, and you turn that handle to cold. Rather than hot, you are grasping uneasiness, you're inclining toward the opposition, and that improves you at doing as such later on, paying little mind to what the errand is. So as you experience your day by day life, discover approaches to grasp uneasiness.

It could be cold showers, it could be setting up for 6am ROTC wellness class, it tends to take the stairs rather than the lift. Essentially, whatever your mind hurls, that I don't feel like a reason. That is a chance to construct that self-restraint muscle you should take

Alright, we are on to thing number four of our rundown, which is to focus on the essentials first, and by the basics. I mean the natural necessities of life, your rest, your nourishment, and your activity propensities. These are for the most part pivotal to focus on the grounds that the piece of your cerebrum that handles official working part that controls your wants and your driving forces requires a great deal of vitality and customary rest to work at pinnacle levels. Keep in mind forget that you are most importantly an accumulation of organic frameworks, all of which require the correct information sources on the off chance that you need to get the best yields out of them.

Also, I know it's anything but difficult to get your feedback as independent from this as existing in this supernatural domain, yet the main need to feel sources or inspiration and assurance and healthy images, yet the cerebrum needs rest needs exercise, and it needs the correct equalization of supplements, similarly as whatever remains of your body does. So in case you're restless, which, in light of the measure of perspectives on this video, you likely are, or you haven't gotten enough exercise consistently, or your eating regimen is poop. That is the place you should center your control first.

That expedites us to our fifth thing the rundown. What's more, it torments me to state this one since I for one abhor doing it. Be that as it may, you might need to attempt reflection. What's more, the reason you should need to do this is contemplation has been appeared at help individuals enhance their dimensions of self-control. Indeed, the 2013 investigation at Stanford University demonstrated that individuals who experienced sympathy preparing which was a particular reflection program, we're better ready to direct their feelings. a short time later

Module Do you realize how to state this? Or then again that? Or on the other hand these are those in French? All things considered, today to arrive, we're going to rehearse our illustrative modifiers.

OK, along these lines, previously we begin going straight into a little exercise, let me remind you extremely rapidly what an illustrative modifier is. All things considered, in English, it's either this, or that. All these, every one of those, alright? All things considered, in French, we have four diverse methods for saying this, or that or those.

Thus one and what you need to take in thought is that everything concurs incite and numbers with them then they qualify. So by this I imply that you have to know whether you were the word you're utilizing with this definite descriptive word is a ladylike word mescaline with a plural or does it start with a vowel or a H. Presently we should see how we use

The exhibited modifier utilizing a manly Weren't we would state, Sir, would you be able to state that so thus implies this for the manly weren't that pursues So, so take this pen for instance. So Still, if the word is manly yet starts with a H or vowel, it would be set C e t, so set up for instance, this tree. Presently when you utilize a ladylike solitary thing, it would be sent ce e TT E. So you would state this bloom set stream for instance, or you could state set hole the Boston this postcard for instance, and as should be obvious the distinction between specific settings that setters twofold t so it alludes to a female at this point

Alright, presently if you somehow managed to utilize a plural thing and in any case whether it is ladylike or manly, in any case whether it starts with a H of our, you would state Si, si e S. So on the off chance that we use Fleur, once more, recall in a ladylike structure it's set for, however you need to state these blooms on those blossoms, it will be the equivalent. In French, you would state, say Fleur ce e. s, stream, and the focal Afterburn. In any case, you wouldn't state set out, alright, just when it's in particular structure. Be that as it may, in the event that you need to place it in it's plural structure. At that point you utilize the word Si, si E. So you would state, say Zambia and this accentuation to stick you would state these pens will progress toward becoming see stylo. Alright so this is only a brisk update remind that in French we have three unique or four on the off chance that you can set CT of utilizing this. So this alright so we have so we have set CT we have sets e TT E and we have si e s came yet you may state however how would I know without need to utilize a pre roll or will win? It's simple yet how would you realize how to utilize a female or manly when it's very straightforward you must nobody extremely essential principle is that if the words and with a knee or SEO for instance all things considered, the word is ladylike and the rest will probably be mescaline.

In any case, there is no set principle to knowing how where the thing is ladylike or manly. So you simply need to learn it once you know and gain proficiency with the new weren't simply learned with its article or LA female, manly or ladylike if that bodes well now the most ideal path for us is to distinguish them in a sentence. So we should view 10 distinct sentences utilizing them Australia of modifiers. What I might want you to do is view them and attempt to figure which definite modifiers you should use in the hole here. We should view the main sentence.

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The main sentence here says ballad, some day by day sews, lyric, some tasty us so we need to put either C or C or set of set Okay in this hole, however what would it be able to be? Presently we have here a pre move How would I know it's turmoil since it's shown here and I'm going to utilize my pen here Have a look here there is a S.

Thus here there is a paper and not just that, I know more than that, I realize that it's provable and ladylike on the grounds that the word dentistry has been changed into it's plural female structure every day shoes alright and this is a marker here ah alright that it is so predominant currently bomb is Apple however we need to state these apples How might you say that utilizing what I've quite recently let you know so bomb

since it isn't alluding to pre move CET no in light of the fact that the word doesn't start with a vowel or specialty so far as that is concerned so it very well may be so it tends to be set alright CET he surely understood in light of the fact that it has a S OK so it will be C taste on that alludes to endorsement basic some day by day shoes OK so in the event that you take a gander at the word here straightforward it doesn't generally demonstrate whether it's female or manly, however it hasn't.

Sexual orientation, that is what's going to give it away. The E and the S discloses to me that this word isn't just female, however it is so pre roll. Alright, so how about we examine Newman, who do number two is disgrace book who live

and after that exhibited descriptive word. A blade now Jim crazy. Like book with a great deal. I like a ton. What do I like? A ton? The books, Becky. The books. Alright. Goodness, and that methods for,

at that point we need to state this. Alright. Also, a blade, Nick, devise an essayist so however you can say well, how would I realize how would I know what the plan of this word is? Alright. Presently in the event that you base your state from the way that in all likelihood the word finishing with a pleasant woman's rights then here it doesn't finish with me. So we will expect it is manly. So examine the manly

For this it is so well done however

alright however we realize that when the word which is manly start with our Nate, we have to include a TT sir. So we will compose set equal. Alright? So we know two things here that the world is mescaline we realize that currently alright and furthermore that the word has its start with an esteem and consequently we use set alright recollect there's two different ways of utilizing this in manly sex so all set alright so Jim book who leave of the city occasion I like the book of this author. I like this journalists book a ton. That is the thing that it implies. View number three. Presently we have machine new people pee now. Better believe it, we realize that we haven't.

They get to Not that it is important into what we need to do. I'm simply calling attention to out currently no methods not a key know before the action word and after the word demonstrate sent refutation. The action word is here capacity it could be pound also new capacity, new mashup, that does not work. Would could it be that does not work love machine? Also, here it has an E toward the end.

So the weren't having any thought is probably going to be female. So knowing this, what do we put so machine set machine CD set machine CT or debilitated machine? ce e s, not pre roll is it doesn't have a S so here it closes with an E so hence it's probably going to be female and in this manner we would put set machine OK set so what I will do

In reality to assist you with this I'm going to underline the machine as female here to enable you to alright and bomb as ladylike too and the rest here is

manly alright presently how about we view numerical get number four o d and after that inn a period OK we have a trouble here suppose that you don't have the foggiest idea what the rest implies however inn is a basic method to realize it implies lodging OK this word starts with a H OK so with we need to know is it female or manly in such a case that it's met ladylike will be set C e TT e yet in the event that it's ladylike

manly alright it will be CET why since it starts with a demonstration Okay for this situation inn does not have a decent

As it's extremely prone to be manly so in this way we are going to put CET alright Auntie could set up a period better believe it so article is a maxim and it implies individuals state that one says that really it happens that alright This inn is exceptionally great alright so inn is and I will compose it here a manly weren't

presently we should view number five beyond any doubt great name BM Femi definitely OK currently discover me better believe it said that you don't have the foggiest idea what your name implies OK however families and simple approach to know for me is family examine the closure of this world It doesn't require so it is probably going to be female so we realize that for this in ladylike structure is set we're finished

Set alright so set Fermi's this family alright beyond any doubt Columbia set Femi I know this family well and that is the place the word originates from. Would you be able to see that you would apia be able to set Femi so what I will do here I'm going to include a

sticker here to my sticker one you know what I mean? Alright we should examine the following one

see man um. Better believe it what I've said everything implies man. Alright so I'm going to disclose to you now and then I do things I reveal to you can't resist that is a man OK on an instance of the view

on Okay, presently, I think for view see is to look for Have you seen alright Have you seen now here the way to see however it's in its past participle from along these lines it implies perceived how

You seen this man now? What would it be a good idea for it to be here? This man ever take a gander at the rundown again. Simply concentrate and dependably take a gander at the rundown is it's set arrangement of wiped out when

I'm is a man. So however it closes with an almost certainly, the word is strong. Alright state I don't have the foggiest idea why I did that incidentally so it is determined to approve set on in light of the fact that the word is mescaline. Furthermore, it starts with an Ah, alright. Set them I've ever visit them. As I'm going to shading coded in blue only for you. Alright, the following word first class, I blew the skillet such huge numbers of feet later. Blue the band such a large number of feet. So we should envision you don't have the foggiest idea what later blue is. You don't have the foggiest idea what numerous individuals simply base yourself on that word here. gasp. OK.

Presently I realize it has an E toward the end, and I realized that you would probably say it's female, sadly. Furthermore, that is the reason I've picked this precedent is that it has a place with the exemption band as an E toward the end, however is manly. So realizing that band which implies painter is mescaline. What's going on here? Is it so terrible?

This painter set gasp see groups when it very well may be said CT since it doesn't start with a vowel or night. It tends to be provocative TD in light of the fact that I've quite recently revealed to you it is a manly word and it very well may be cc ies since it's not in endorsement structure so it must be so terrible. Alright. So gasp minimal blue. Do some talk such huge numbers of feet the depictions of these painter are grand came only a seemingly insignificant detail here.
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Tuesday, February 5, 2019

Why you can’t get a song out of your head and what to do about it

I have always considered myself a happy person, even though I may not always look it thanks to inheriting my father’s furrowed brow. Are there times when I’m not happy? Of course. Do I wish I could be happier more often? Who wouldn’t? While it seems everyone is looking for the answer to the age-old question, “What’s the secret to happiness?” the better question may be, “Is it even possible to be happier?”

About half of our level of happiness is based on genes. Some people are just predisposed to be happier and more upbeat than others. But that does not mean you cannot increase your level of happiness if it does not come naturally. In fact, research has suggested that 40% of people’s happiness comes from the choices they make.
Come on, get happy

So what are the right choices for happiness? You may find inspiration from the participants in the Harvard Study of Adult Development — one of the longest-running studies on happiness.

The project has followed 724 men since they were teenagers in 1938. (Approximately 60 men, now in their 90s, are still left.) The group consisted of men from various economic and social backgrounds, from Boston’s poorest neighborhoods to Harvard undergrads. (President John F. Kennedy was even part of the original group.) Over the years, the researchers have collected all kinds of health information, and every two years they ask members questions about their lives and their mental and emotional wellness. They even interview family members.

They found that specific traits and behaviors were linked with increased levels of happiness across the entire group.
Know when to let go

As the people got older, they tended to focus more on what’s important to them, and didn’t sweat the small stuff to the degree they did when they were younger, according to the project’s director, Dr. Robert Waldinger. Other research supports this mindset, and has found that older adults are better about letting go of past failures. “They tend to realize how life is short and they are more likely to pay more attention on what makes them happy now,” says Dr. Waldinger.

You could do the same. What activities make you happy and what’s stopping you from doing them? Think back to your childhood. What did you enjoy when you were younger? Singing? Playing games? Doing certain hobbies? “When you are older you have more opportunity to return to the activities you associate with happiness,” says Dr. Waldinger. So begin that coin collection, join a choir, or play poker or bridge.
Stay connected

The Harvard Study has found a strong association between happiness and close relationships like spouses, family, friends, and social circles. “Personal connection creates mental and emotional stimulation, which are automatic mood boosters, while isolation is a mood buster,” says Dr. Waldinger. This is also an opportunity to focus on positive relationships and let go of negative people in your life, or at least minimize your interactions with them.

If you need to broaden your social life, try volunteering for a favorite cause. Odds are you will meet more like-minded people. Volunteering also is another way to boost happiness by providing a sense of purpose. In fact, a study published online May19, 2016, by BMJ Open found that this benefit was strongest among people age 45 to 80 and older. Look for volunteering opportunities in your area that match your interests. Richard Hoffman, a professor of internal medicine and epidemiology at the University of Iowa Carver College of Medicine in Iowa City, led a team that reviewed survey data that men filled out one, two, five, and 15 years after they were treated for prostate cancer. All 934 men included in the study were 75 or younger when diagnosed, each with localized tumors confined to the prostate gland. Approximately 60% of the men had low-risk prostate cancer that was expected to grow slowly, and the others had riskier cancers. Most of the men (89%) were treated with surgery or radiation. The rest were lumped together as having had conservative treatment: either medications to suppress testosterone (a hormone that makes prostate cancer grow faster), or “watchful waiting,” meaning doctors delayed treatment until there was evidence that the cancer was spreading.

Overall, 14.6% of the entire group expressed some treatment regret — 16.6% of the radiation-treated men, 15% of the surgically-treated men, and 8.2% of the men treated conservatively. Among the causes of regret, treatment-related bowel and sexual problems were cited most frequently. Surgically treated men reported the highest rate of significant sexual side effects (39%), while radiation-treated men reported the highest rate of significant bowl problems (15.6%). Remarkably, complaints over urinary incontinence differed little between the groups, ranging from a low of 15.5% for the conservatively-treated men to a high of 17.6% among men treated with radiation.

Results also showed that regret tends to increase with time, suggesting that when initial concerns over surviving prostate cancer wear off, the quality-of-life consequences of treatment become more apparent. Regrets were especially pronounced among men who felt they hadn’t been sufficiently counseled by their doctors before settling on a particular treatment option, and also among men who were preoccupied with changing levels of prostate-specific antigen, a blood test used to monitor cancer’s possible return.

Given these findings, the authors emphasized how important it is that men be counseled adequately and informed of the risks and benefits associated with various treatments. But men should also be reassured that treatment for prostate cancer has improved since the mid-1990s, and that bowel and urinary side effects in particular “don’t occur as frequently now as when the men in this study were diagnosed,” says co-author Peter Albertsen, a professor of surgery and chief of the division of urology at UConn Health in Farmington, Connecticut. “Earworms” are unwanted catchy tunes that repeat in your head. These relentless tunes play in a loop in up to 98% of people in the western world. For two-thirds of people they are neutral to positive, but the remaining third find it disturbing or annoying when these songs wriggle their way into the brain’s memory centers and set up home, threatening to disrupt their inner peace.
Which songs become earworms?

Certain songs are catchier than others, and so more likely to “auto repeat” in your head. When music psychologist Kelly Jakubowski and her colleagues studied why, they found these songs were faster and simpler in melodic contour (the pitch rose and fell in ways that made them easier to sing). And the music also had some unique intervals between notes that made the song stand out. The catchiest tunes on the UK charts between 2010 and 2013 were “Bad Romance” by Lady Gaga, “Can’t Get You Out Of My Head” (somewhat ironically) by Kylie Minogue, and “Don’t Stop Believin’” by Journey.
What predisposes to earworms?

In order to get stuck in your head, earworms rely on brain networks that are involved in perception, emotion, memory, and spontaneous thought. They are typically triggered by actually hearing a song, though they may also creep up on you when you are feeling good, or when you are in a dreamy (inattentive) or nostalgic state. And they may also show up when you are stressed about having too much to think about. It’s as if your stressed-out brain latches onto a repetitive idea and sticks with it. Also, if you have a musical background, you may be more susceptible to earworms too.

Certain personality features also may predispose you to being haunted by a catchy tune. If you are obsessive-compulsive, neurotic (anxious, self-conscious, and vulnerable), or if you are someone who is typically open to new experiences, you may be more likely to fall prey to an earworm.
Why might earworms be good for you?

There is a particular characteristic of music that lends itself to becoming an earworm. In contrast to our daily speech, music typically has repetition built into it. Can you imagine how absurd it would be if people repeated themselves in chorus? Yet, though repetition of speech is associated with childishness, regression, and even insanity, in the case of music it may signify a process that becomes pleasurable when it is understood through repetition. Also, each time music repeats, you hear something subtly different. This learning may constitute one of the positive aspects of earworms. Also, earworms are a form of spontaneous mental activity, and mind-wandering states confer various advantages to the brain, contributing to clear thinking and creativity.
Are earworms ever worrisome?

Not all “stuck songs” are benign. Sometimes they occur with obsessive-compulsive disorder, psychotic syndromes, migraine headaches, unusual forms of epilepsy, or a condition known as palinacousis — when you continue to hear a sound long after it has disappeared. Persistent earworms (lasting more than 24 hours) may be caused by many different illnesses, such as stroke or cancer metastasizing to the brain. A physician can help you determine if your earworm is serious or not.
How do you get rid of earworms?

If you’ve had enough of your earworm and need to stop it in its tracks, you would be well warned not to try to block the song out, but rather to passively accept it. A determined effort to block the song out may result in the very opposite of what you want. Called “ironic process” and studied extensively by psychologist Daniel Wegner, resisting the song may make your brain keep playing it over and over again.

Some people try to distract themselves from the song, and it works. In one study, the most helpful “cure” tunes were “God Save The Queen” by Thomas Arne and “Karma Chameleon” by Culture Club. Others seek out the tune in question, because it is commonly believed that earworms occur when you remember only part of a song; hearing the entire song may extinguish it. Other techniques found to be helpful include those from cognitive behavioral therapy, such as replacing dysfunctional thoughts like “These earworms indicate I am crazy” with “It is normal to have earworms.” A less intuitive cure for earworms is chewing gum. It interferes with hearing the song in your head.
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Women and pain: Disparities in experience and treatment

Medication side effects are a big problem. It’s estimated that about half of filled prescriptions are not taken as directed, and a major reason for this is side effects. If you’ve ever had diarrhea, felt sleepy, or developed a rash after taking a new medication, you know how unpleasant side effects can be. And sometimes it’s much worse than unpleasant: drug side effects can cause permanent damage and even be deadly.
Predicting success… and side effects

Wouldn’t it be great if your doctor could predict which medication is most likely to work for you and least likely to cause side effects? Pharmacogenetics — the use of genetic information to predict the risks and benefits of a medication — could do just that. The idea is that your genes may provide helpful clues regarding which medication is best in your particular case. There are already examples of this, such as:

    Azathioprine: this is an immune-suppressing medication that some people have trouble metabolizing due to the genes they inherited; a blood test prior to the start of treatment can identify those most at risk.
    Allopurinol: certain ethnic groups (e.g., those of Han Chinese or Thai extraction) are more likely to carry a gene that increases the risk of a severe allergic reaction to allopurinol, a medication primarily used to treat gout.

While these examples deal with medication risks, individual genetic testing may also be able to identify which medications are most likely to help a person based on their genes.
A new study looks at statins

Statin drugs are among the most widely prescribed medications in the world. They lower cholesterol, reduce inflammation, and have been proven to reduce the risk of heart attack and stroke in those at high risk for these conditions. However, a limiting side effect is muscle pain, an annoying symptom that may require discontinuation of the drug. (A more serious muscle disease may develop, especially when statins are combined with other drugs, but fortunately these more serious reactions are rare.) As there are several formulations of statin drugs, for any given person one statin drug might cause trouble while another might not. These variations might also be determined, at least in part, on that person’s genes.

Prior research has suggested that people who carry certain genes are more likely to develop muscle pain when taking statins, and certain statins might cause more trouble than others for people with a higher-risk gene. These genes direct the synthesis of a protein involved in transporting drugs into liver cells.

A new study enrolled 159 people who had previously developed muscle pain when taking a statin to determine whether sharing the results of their genetic tests could be helpful in choosing a statin drug that would not cause muscle pain.

The researchers divided study subjects into two groups:

    One group was provided with the results of their genetic testing. If a high-risk gene was found, they were offered a statin considered to be less risky; for those without the high-risk gene, the group was offered any of several statins.
    The other group (the “usual care” group) wasn’t told their genetic test results until the study was completed. For this group, decisions regarding statin choice were based on “standard guidance regarding statin selection and dosing.”

In the first three months, nearly 60% of those in the first group decided to take a statin; only a third of those in the other group did so. As a result, within eight months cholesterol levels tended to be better in those receiving their genetic test results. The impact of this approach could be large, as all of the study subjects had previously stopped statin medications due to side effects.
Is it in the genes… or the “nocebo effect”?

One interesting aspect of this study is that the “nocebo effect” could have been responsible for at least some of the study subjects’ past side effects. The nocebo effect is a phenomenon in which the expectation of a side effect makes it more likely to occur, similar to how the expectation of benefit may make a placebo more likely to work. People who had previously had muscle pain with a particular statin might have the expectation of recurrence with any statin, but armed with genetic information that might help reduce risk, that expectation of trouble might be lessened. Genetic testing could lead to fewer side effects, not only by directing the choice of medications but also through a reduction in the nocebo effect.
We’re not there yet

Here’s the part where I’m obligated to mention the limitations of using genetic testing to direct drug treatment. First, in most cases, prediction isn’t perfect. Some people with a high-risk gene are fine when they take the medication; similarly, those lacking the high-risk gene can still react badly to the drug. One reason for this is that the benefits and risks of drugs are rarely determined by a single gene and many other factors matter, such as other medications taken and other medical problems. Another concern is cost. Many genetic tests are costly and it’s often unclear whether the benefits (which may be modest) are worth the expense. It’s possible that as genetic testing becomes more common and extensive, costs will come down; and as more genes are studied, the benefits of testing may become clearer (and, hopefully, more robust). Let’s face it: we are all getting older. As I write this, I am aging, and as you read this, you are, too! Today I want to talk about an aspect of aging that we don’t often think about, but which research shows we can do something about: osteoporosis, or brittle bone disease.

As we age, our bones naturally tend to become weaker. This is one reason that people often become slightly shorter as they age. Particularly for women, this process accelerates more quickly after menopause. Because bones become weaker, it is easier for them to break, sometimes with very little provocation. Hip fractures are an especially dreaded complication of osteoporosis, because they require hospitalizations and painful surgeries to repair, because recoveries can be particularly complicated, and lastly, because it sounds absolutely terrifying to break a hip! For all these reasons, the medical community worries about osteoporosis and we are constantly thinking of ways to prevent or ameliorate it.

There is a growing body of evidence that physical activity later in life (as well as earlier in life!) can help combat the effects of aging on our bones. Now, I know what you are thinking — I don’t have time to exercise! Well, I have good news for you. Just a little bit of the right type of exercise for just a few minutes a day may help.
You don’t need to train for a marathon to strengthen your bones

A recent study looked at the quantity and quality of exercise required to make a real change in bone strength, as well as how to measure that exercise. Researchers accessed pre-existing data from a large, public database in the UK in order to learn more about how exercise affects bone health in a group of healthy women at risk for brittle bones. In this study, both pre- and post-menopausal women wore accelerometers to record the intensity of their movements. The researchers wanted to see if they could learn about the patients’ movements with very brief measurements, and they found that they could.

More interestingly, what they found was that the women who had the most intense activity, recorded for what amounted to just one to two minutes each day, had a reduction in risk for brittle bones. Furthermore, they had a higher reduction than those women who did less intense activity, although those women saw some reduction in risk too. And the intensity required to achieve this? One to two minutes of running for a pre-menopausal woman and slow jogging for a post-menopausal woman.
More support for exercise and bone health

The study had some limitations. First, it measured bone health by looking at bone density in the heel by ultrasound. The best way to measure bone density is really with a special x-ray called a DEXA scan. We also care less about bone health in the heel and more about bone health in the spine and hip — places where a fracture is more dangerous. However, the general finding of better bone health in those who exercise has been seen throughout the medical literature, so I think we can still safely depend on the results of this study. Another potential limitation is that the patients they studied were all Caucasian females. However, there is no reason to presume that the research wouldn’t apply to healthy women of other ethnicities as well.

This study is so important because it really gives all of us such a reasonable goal. Can we give it our strongest effort for one to two minutes a day? I think we can. It also shows that if we make a small, measurable, but regular change, we can all dance, run, jog, jump, or hop our way to better health! The news these days is overwhelming in its awfulness. There have been horrible hurricanes, the earthquake in Mexico — and the incomprehensible shootings in Las Vegas. It’s been so awful, and so unrelenting, that it is hard to even process it.

Imagine processing it as a child?

Our first instinct is usually to shelter our children from the news and not say anything about it to them at all. That’s completely understandable, and if your child is very young or you are certain for some other reason that they aren’t going to hear about it, then not saying anything is a viable option.

But if they aren’t very young, or if you ever have the news on where they can see, or if they are ever in settings where people might have the news on or talk about it, it might not be so viable. If children are going to hear about something, they really should hear about it from you.

Also, as parents it’s important that we give our children the perspective and skills they need to navigate this scary world where, let’s be honest, bad things happen. The way you talk to children about tragedies in the news can help them cope not just now, but in the future.

The American Academy of Pediatrics has all sorts of resources to help parents talk with children about tragedies. Here are four simple things all parents can and should do:

1.  Tell them what happened, in simple terms. Be honest, but skip the gory details. Answer their questions just as simply and honestly. If you think — or know — that your child has already heard something, ask them what they’ve heard. That way you can correct any misinformation, and know not only what you need to explain but also what you may need to reassure them about.

2.  Be mindful of the media that your child sees. The news can be very graphic — and because the media are as much in the business of gaining viewers as of delivering news, they tend to make things as dramatic as possible and play footage over and over again. When the planes flew into the Twin Towers on 9/11, my husband and I were glued to the television, not realizing that one of our daughters, who was 3 years old at the time, thought that planes were literally flying into buildings again and again. It wasn’t until she said, “Are those planes going to come here too?” that we shut off the TV and didn’t turn it back on again until all the children were in bed.

3.  Make sure your child knows that not only are tragedies uncommon, but that you and others are always doing everything you can to keep them safe. Talk about some of the ways you keep them safe, ways that are relevant to the tragedy you are talking about. Make a safety plan as a family for things like extreme weather or getting separated. Help them think about what they might do if they are ever in a scary situation, and who they could turn to for help. Which leads me to the most important thing to do…

4.  Look for the helpers. The wonderful Fred Rogers often talked about how when he saw scary things on the news, his mother would tell him to look for the helpers, because there are always people who are helping. That may be the best thing we can do as parents: help our children look for the helpers. In all of the recent tragedies, as in all tragedies, there were so many helpers and heroes. When we concentrate on those people, not only do we give our children hope, we may empower them to one day be helpers too. In August, The New York Times published a guest op-ed by a man named David Roberts who suffered from severe chronic pain for many years before finally finding relief. The piece immediately went viral, with distinguished news journalist and personality Dan Rather posting it to his Facebook page with the addendum that it could “offer hope” to some pain patients. However, for many of us in the chronic pain community, particularly women, the piece was regarded with weariness and frustration.

The first and most prominent source of annoyance for me regarding this piece was the part when the author finally discloses his pain to his employer and it is taken with the utmost seriousness. He is immediately offered leave to find treatment, despite the lack of a definitive diagnosis. This stands in stark contrast to the experiences of many (if not most) women, where our pain is often abruptly dismissed as psychological — a physical manifestation of stress, anxiety, or depression.
Women with chronic pain may suffer more and longer than men

Consider this: women in pain are much more likely than men to receive prescriptions for sedatives, rather than pain medication, for their ailments. One study even showed women who received coronary bypass surgery were only half as likely to be prescribed painkillers, as compared to men who had undergone the same procedure. We wait an average of 65 minutes before receiving an analgesic for acute abdominal pain in the ER in the United States, while men wait only 49 minutes.

These gender biases in our medical system can have serious and sometimes fatal repercussions. For instance, a 2000 study published in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack. Why? Because the medical concepts of most diseases are based on understandings of male physiology, and women have altogether different symptoms than men when having a heart attack.

To return to the issue of chronic pain, 70% of the people it impacts are women. And yet, 80% of pain studies are conducted on male mice or human men. One of the few studies to research gender differences in the experience of pain found that women tend to feel it more of the time and more intensely than men. While the exact reasons for this discrepancy haven’t been pinpointed yet, biology and hormones are suspected to play a role.

As for Roberts, his lab tests yielded no apparent findings to explain his back pain. Eventually he enrolled in a program through the Mayo Clinic that treated chronic pain as “a malfunction in perception,” that is, a self-reinforcing addiction to and dramatization of pain.

The solution, as Robert explains, was: “…don’t dwell on the pain, and don’t try to fix it — no props, no pills. Eventually the mind should let go.”
Treatment must be individualized

This tactic may have worked for the author, but I doubt it would work as well for many of us women with clearly definable conditions like rheumatoid arthritis, multiple sclerosis, and chronic migraine, or sex-specific diseases like endometriosis. In my case, ignoring the heavy bleeding and cramping I experienced every month (often multiple times a month) and the daily gastrointestinal distress I had for years did not make the attending pain go away, despite the repeated dismissals I received from doctors. Trying to ignore the pain didn’t stop endometriosis from strangling my large intestines and adhering my ovaries and fallopian tubes to my colon. To gain actual relief from that agony, I needed surgery, and I might need it again. Likewise, ignoring my back pain does not stop the nerve compression that contributes to sporadic incidences of severe cramping and involuntary muscle twitches and jerking in my right leg. What I do need are doctors willing to listen, empathize, and work with me to identify the most appropriate treatment plan that will minimize my pain and address the underlying condition as best as possible.

While I congratulate Roberts that he was able to put away his “props” such as his ankle braces, those of us with genuine degenerative conditions like arthritis and connective tissue disease need such aids to stabilize our joints and prevent further damage and further pain. I would implore those in the medical community for whom the Times piece resonated to understand that applying blanket solutions to chronic pain may not work for many pain patients, as the vast majority of us are women. In fact, since most studies on pain have focused on men, broadly applying their findings to everyone can be dangerous, and reinforces the same gender disparities from which they arise. The result of that would inevitably be that many more women stand to die or suffer in silence, without accessing the treatments they require and deserve in order to find adequate relief.In August, The New York Times published a guest op-ed by a man named David Roberts who suffered from severe chronic pain for many years before finally finding relief. The piece immediately went viral, with distinguished news journalist and personality Dan Rather posting it to his Facebook page with the addendum that it could “offer hope” to some pain patients. However, for many of us in the chronic pain community, particularly women, the piece was regarded with weariness and frustration.

The first and most prominent source of annoyance for me regarding this piece was the part when the author finally discloses his pain to his employer and it is taken with the utmost seriousness. He is immediately offered leave to find treatment, despite the lack of a definitive diagnosis. This stands in stark contrast to the experiences of many (if not most) women, where our pain is often abruptly dismissed as psychological — a physical manifestation of stress, anxiety, or depression.
Women with chronic pain may suffer more and longer than men

Consider this: women in pain are much more likely than men to receive prescriptions for sedatives, rather than pain medication, for their ailments. One study even showed women who received coronary bypass surgery were only half as likely to be prescribed painkillers, as compared to men who had undergone the same procedure. We wait an average of 65 minutes before receiving an analgesic for acute abdominal pain in the ER in the United States, while men wait only 49 minutes.

These gender biases in our medical system can have serious and sometimes fatal repercussions. For instance, a 2000 study published in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack. Why? Because the medical concepts of most diseases are based on understandings of male physiology, and women have altogether different symptoms than men when having a heart attack.

To return to the issue of chronic pain, 70% of the people it impacts are women. And yet, 80% of pain studies are conducted on male mice or human men. One of the few studies to research gender differences in the experience of pain found that women tend to feel it more of the time and more intensely than men. While the exact reasons for this discrepancy haven’t been pinpointed yet, biology and hormones are suspected to play a role.

As for Roberts, his lab tests yielded no apparent findings to explain his back pain. Eventually he enrolled in a program through the Mayo Clinic that treated chronic pain as “a malfunction in perception,” that is, a self-reinforcing addiction to and dramatization of pain.

The solution, as Robert explains, was: “…don’t dwell on the pain, and don’t try to fix it — no props, no pills. Eventually the mind should let go.”
Treatment must be individualized

This tactic may have worked for the author, but I doubt it would work as well for many of us women with clearly definable conditions like rheumatoid arthritis, multiple sclerosis, and chronic migraine, or sex-specific diseases like endometriosis. In my case, ignoring the heavy bleeding and cramping I experienced every month (often multiple times a month) and the daily gastrointestinal distress I had for years did not make the attending pain go away, despite the repeated dismissals I received from doctors. Trying to ignore the pain didn’t stop endometriosis from strangling my large intestines and adhering my ovaries and fallopian tubes to my colon. To gain actual relief from that agony, I needed surgery, and I might need it again. Likewise, ignoring my back pain does not stop the nerve compression that contributes to sporadic incidences of severe cramping and involuntary muscle twitches and jerking in my right leg. What I do need are doctors willing to listen, empathize, and work with me to identify the most appropriate treatment plan that will minimize my pain and address the underlying condition as best as possible.

While I congratulate Roberts that he was able to put away his “props” such as his ankle braces, those of us with genuine degenerative conditions like arthritis and connective tissue disease need such aids to stabilize our joints and prevent further damage and further pain. I would implore those in the medical community for whom the Times piece resonated to understand that applying blanket solutions to chronic pain may not work for many pain patients, as the vast majority of us are women. In fact, since most studies on pain have focused on men, broadly applying their findings to everyone can be dangerous, and reinforces the same gender disparities from which they arise. The result of that would inevitably be that many more women stand to die or suffer in silence, without accessing the treatments they require and deserve in order to find adequate relief.In August, The New York Times published a guest op-ed by a man named David Roberts who suffered from severe chronic pain for many years before finally finding relief. The piece immediately went viral, with distinguished news journalist and personality Dan Rather posting it to his Facebook page with the addendum that it could “offer hope” to some pain patients. However, for many of us in the chronic pain community, particularly women, the piece was regarded with weariness and frustration.

The first and most prominent source of annoyance for me regarding this piece was the part when the author finally discloses his pain to his employer and it is taken with the utmost seriousness. He is immediately offered leave to find treatment, despite the lack of a definitive diagnosis. This stands in stark contrast to the experiences of many (if not most) women, where our pain is often abruptly dismissed as psychological — a physical manifestation of stress, anxiety, or depression.
Women with chronic pain may suffer more and longer than men

Consider this: women in pain are much more likely than men to receive prescriptions for sedatives, rather than pain medication, for their ailments. One study even showed women who received coronary bypass surgery were only half as likely to be prescribed painkillers, as compared to men who had undergone the same procedure. We wait an average of 65 minutes before receiving an analgesic for acute abdominal pain in the ER in the United States, while men wait only 49 minutes.

These gender biases in our medical system can have serious and sometimes fatal repercussions. For instance, a 2000 study published in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack. Why? Because the medical concepts of most diseases are based on understandings of male physiology, and women have altogether different symptoms than men when having a heart attack.

To return to the issue of chronic pain, 70% of the people it impacts are women. And yet, 80% of pain studies are conducted on male mice or human men. One of the few studies to research gender differences in the experience of pain found that women tend to feel it more of the time and more intensely than men. While the exact reasons for this discrepancy haven’t been pinpointed yet, biology and hormones are suspected to play a role.

As for Roberts, his lab tests yielded no apparent findings to explain his back pain. Eventually he enrolled in a program through the Mayo Clinic that treated chronic pain as “a malfunction in perception,” that is, a self-reinforcing addiction to and dramatization of pain.

The solution, as Robert explains, was: “…don’t dwell on the pain, and don’t try to fix it — no props, no pills. Eventually the mind should let go.”
Treatment must be individualized

This tactic may have worked for the author, but I doubt it would work as well for many of us women with clearly definable conditions like rheumatoid arthritis, multiple sclerosis, and chronic migraine, or sex-specific diseases like endometriosis. In my case, ignoring the heavy bleeding and cramping I experienced every month (often multiple times a month) and the daily gastrointestinal distress I had for years did not make the attending pain go away, despite the repeated dismissals I received from doctors. Trying to ignore the pain didn’t stop endometriosis from strangling my large intestines and adhering my ovaries and fallopian tubes to my colon. To gain actual relief from that agony, I needed surgery, and I might need it again. Likewise, ignoring my back pain does not stop the nerve compression that contributes to sporadic incidences of severe cramping and involuntary muscle twitches and jerking in my right leg. What I do need are doctors willing to listen, empathize, and work with me to identify the most appropriate treatment plan that will minimize my pain and address the underlying condition as best as possible.

While I congratulate Roberts that he was able to put away his “props” such as his ankle braces, those of us with genuine degenerative conditions like arthritis and connective tissue disease need such aids to stabilize our joints and prevent further damage and further pain. I would implore those in the medical community for whom the Times piece resonated to understand that applying blanket solutions to chronic pain may not work for many pain patients, as the vast majority of us are women. In fact, since most studies on pain have focused on men, broadly applying their findings to everyone can be dangerous, and reinforces the same gender disparities from which they arise. The result of that would inevitably be that many more women stand to die or suffer in silence, without accessing the treatments they require and deserve in order to find adequate relief.
Read More »

Monday, January 28, 2019

Comparing medications to treat opioid use disorder

My first day returning to work after being treated for a severe opiate addiction was one of the most daunting moments of my life. Everyone in the office, from my manager to the administrative assistants, knew that forged prescriptions and criminal charges were the reason I had been let go from my previous job. My mind was spinning. What would my coworkers think of me? Who would want to work alongside an “addict”? Would they ever come to trust me? Did I even deserve to be here?

When my life was crashing and burning due to my addiction (detailed in my memoir Free Refills: A Doctor Confronts His Addiction), a return to work seemed like a distant prospect, barely visible on a horizon clouded by relapses, withdrawal, and blackouts. My finances, my professional reputation, and my family life were in terrible shape due to my drug-seeking behavior. Working was not a tenable option until I received treatment and established a solid track record of recovery, which a potential employer could rely on.

The fact that I was now in recovery was a great development, and it was further ratification of my progress that I had landed a job and was returning to work. So, why wasn’t I feeling overjoyed?
How stigma affects the return to work

As it turns out, the transition back to work after someone is treated for an addiction can be profoundly stressful. People recovering from addiction already tend to suffer disproportionately from guilt, shame, and embarrassment, and these feelings are often brought to the forefront during the unique challenges of returning to work.

Stigma is what differentiates addiction from other diseases, and is primarily what can make the return to work so difficult. If I had been out of work to receive chemotherapy or because of complications from diabetes, I certainly wouldn’t have felt self-conscious or self-doubting upon resuming my employment. With addiction, due to the prejudices that many people in our society hold, the return is psychologically complex and anxiety-producing. As I entered my new office, I was walking right into the fears, preconceptions, and potential disdain that my new officemates might share toward people suffering from a substance use disorder. For all I knew, I was the “dirty addict” that they now, against their wishes, had to work with.
“Bring your body and your mind will follow”

What I was taught in recovery, to deal with situations like this, is to “just keep your head up” and to “put one foot in front of the other.” Or, “bring your body, and your mind will follow.” When I first heard these phrases, I thought that they were mere platitudes, phrases without content, provided to motivate us through dark times. Now, I think they hold a great deal of wisdom.

As I walked through the door on my first day back, I did feel everyone’s eyes on me, and I did wonder if they were judging and criticizing me, but I made it to my desk without incident, and managed to power through my self-consciousness and get into the flow of my work. Every day, it became easier as I did a good job, deepened my connections with my colleagues, and accumulated good will, which would eventually replace any negative images that may have accompanied my arrival. Within weeks this was a non-issue, though at office get-togethers, my co-workers still somewhat awkwardly don’t know whether to put a wine glass at my place setting.

With all I had learned in recovery about communication, about humility, about connecting with others, I feel that I was in a better position to thrive in my workplace than I was before my addiction started in the first place. As more of my brothers and sisters in recovery return to employment, and as we succeed, the more difficult will it be for people to hold on to their negative attitudes and prejudices about substance use disorders. We can defeat the stigma by confronting it, putting one foot in front of the other, one step at a time.
This one got by me. I’d never heard of “man flu” but according to a new study of the topic, the term is “so ubiquitous that it has been included in the Oxford and Cambridge dictionaries. Oxford defines it as ‘a cold or similar minor ailment as experienced by a man who is regarded as exaggerating the severity of the symptoms.’”

Another reference called it “wimpy man” syndrome. Wow. I’d heard it said (mostly in jest) that if men had to carry and deliver babies, humankind would have long ago gone extinct. But wimpy man syndrome? I just had to learn more.
What is man flu?

As commonly used, the term man flu could be describing a constitutional character flaw of men who, when felled by a cold or flu, embellish the severity of their symptoms, quickly adopt a helpless “patient role,” and rely heavily on others to help them until they recover. Another possibility is that men actually experience respiratory viral illnesses differently than women; there is precedent for this in other conditions. Pain due to coronary artery disease (as with a heart attack or angina) is a good example. Men tend to have “classic” crushing chest pain, while women are more likely to have “atypical” symptoms such as nausea or shortness of breath. Perhaps the behavior of men with the flu is actually appropriate (and not exaggerated), and based on how the disease affects them.

Here are the highlights from the study:

    Influenza vaccination tends to cause more local (skin) and systemic (bodywide) reactions and better antibody response in women. Testosterone may play a role, as men with the highest levels tended to have a lower antibody response. A better antibody response may lessen the severity of flu, so it’s possible that vaccinated men get more severe symptoms than women because they don’t respond to vaccination as well.
    In test tube studies of nasal cells infected with influenza, exposure to the female hormone estradiol reduced the immune response when the cells came from women, but not in cells from men. Treatment with antiestrogen drugs reduces this effect. Since flu symptoms are in large part due to the body’s immune reaction, a lessened immune response in women may translate to milder symptoms.
    In at least one study reviewing six years of data, men were hospitalized with the flu more often than women. Another reported more deaths among men than women due to flu.
    A survey by a popular magazine found that men reported taking longer to recover from flu-like illnesses than women (three days vs. 1.5 days).

Taken together, these findings suggest that there may be more to “man flu” than just men exaggerating their symptoms or unnecessarily behaving helplessly. While the evidence is not definitive, they suggest that the flu may, in fact, be more severe in men.
If it’s true that men get sicker with the flu, why?

Some have suggested that early man evolved to require more prolonged rest while sick to conserve energy and avoid predators. In more modern times, the advantage of a longer recovery time is less clear beyond the obvious. When you don’t feel well, it’s nice to be taken care of. Of course, that’s true for women as well.
The bottom line

Diseases can look different in men and women. That’s true of coronary artery disease. It’s true of osteoporosis, lupus, and depression. And it may be true of the flu. So, I agree with the author of this new report, who states “…the concept of man flu, as commonly defined, is potentially unjust.” We need a better understanding of how the flu affects men and women and why it may affect them differently.

Until then, we should all do what we can to prevent the flu and limit its spread. Getting the flu vaccination, good handwashing, and avoiding others while sick are good first steps. And they’re the same regardless of your gender. Using medications to treat opioid use disorder is a lifesaving cornerstone of treatment — much like insulin for type 1 diabetes. The flawed but widely held view that medications like methadone or buprenorphine are “replacing one addiction for another” prevents many people from getting the treatment they need. In actuality, people successfully treated with these medications carefully follow a prescribed medication regimen, which results in positive health and social consequences — as in patients with many types of chronic medical conditions.

However, even among those who embrace treating opioid use disorder (OUD) with medication, there is a difference of opinion as to which medications are most effective. A new study offers important insight into the advantages and disadvantages of the two medications for OUD that can be prescribed in a doctor’s office (that is, on an outpatient basis). These medications are buprenorphine and extended-release (ER) naltrexone. This study was widely covered in the press, and many of the sound bites and headlines reporting the two treatments to be equally effective were a bit misleading.
The advantages and disadvantages of buprenorphine (Suboxone, Subutex, Zubsolv, Probuphine, Sublocade)

Buprenorphine is a partial opioid agonist medication. This medication activates the same receptors in the brain as any opioid, but only partly. Because its effects are long-lasting, it can be taken once a day to relieve cravings, prevent withdrawal, and restore normal functioning in someone with opioid use disorder. Because it is a partial agonist, it has a ceiling effect. This means once all the receptors are occupied by the medication, even if a person takes 20 more tablets she wouldn’t feel any additional effect or be at risk of overdose.

Any doctor who has completed special training (a primary care provider, addiction specialist, OB/GYN, etc.) can prescribe buprenorphine. The advantage is, theoretically, that a person with OUD could receive treatment from any provider he or she might see for a routine health issue. I say theoretically because, despite its availability, only about 4% of physicians have done the necessary training to be able to prescribe it. The research on buprenorphine is robust, with multiple studies showing it reduces the risk of death by more than 50%, helps people stay in treatment, reduces the risk that they will turn to other opioids (like heroin), and improves quality of life in many ways.
The advantages and disadvantages of naltrexone (Vivitrol, Revia)

Naltrexone is a pure opioid antagonist. It sticks to an opioid receptor, but instead of activating it to relieve craving and withdrawal it acts as a blocker, preventing other opioids from having any effect. The research on naltrexone has been mixed. Naltrexone in pill form is basically no better than placebo because people simply stop taking it. Studies on extended-release naltrexone are more promising and have shown it to be better than no medication at all. However, there has never been a US trial comparing extended-release naltrexone to either methadone or buprenorphine, until this study.
The X-BOT study: Comparing buprenorphine and extended-release naltrexone

This study enrolled individuals with opioid use disorder who had voluntarily gone to a detoxification program. Researchers then randomly assigned them to either daily buprenorphine or monthly extended-release naltrexone. Both groups were followed for 24 weeks, to see how many people relapsed.

One of the most important things investigators learned is just how hard it was to get participants onto extended-release naltrexone, revealing a potential barrier to its usefulness. Before a person can start taking ER naltrexone, they must be completely off opioids for seven to 10 days. Only 72% of the group assigned to ER naltrexone even got the first dose, and among those who were randomized during the detoxification process, only 53% started the medication. In contrast, 94% of the group assigned to buprenorphine started the medication.

The other important finding was what happened with relapses. The researchers analyzed their data using an “intention to treat analysis.” This means that once a person is randomly assigned to a treatment (or placebo), their data counts even if they don’t stick with the treatment. Here’s why this is important: if you don’t include that data, then you miss other important outcomes that influence how effective a treatment really is. Thanks to this type of analysis, researchers learned that relapse was significantly more likely in the extended-release naltrexone group (65% compared to 57% in the buprenorphine group).

Immediate relapses were even more likely in the naltrexone group due to failures to start the medication — 25% of the naltrexone group had a relapse on day 21, compared to 3% in the buprenorphine group. Overall there were more overdoses in the naltrexone group, but no difference in fatal overdoses between the groups. Most of the overdoses occurred after the study medication was stopped, highlighting the lifesaving importance of getting on, and staying on, treatment. The naltrexone group also had a longer length of stay in inpatient detoxification programs, which may be an important consideration when we think about overall healthcare costs.

So, why did many headlines claim extended-release naltrexone was as effective as buprenorphine? Well, that was the finding of a separate analysis that looked only at people who successfully started each medication. When the data was viewed that way, there was no difference between the two medications, but that’s just part of the picture. If it’s harder to get a person to successfully start and stick with a medication, that should factor in evaluating its “effectiveness.”
Take-home messages from X-BOT

This is an incredibly important study. The findings are generally consistent with what I see in my clinical practice. Overall buprenorphine is a more effective treatment for opioid use disorder, in part because it’s easier to get patients started on it and they are more likely to stick with it. Extended-release naltrexone may be as good for people who can successfully complete the detoxification required before starting on it. Both medications have a place, but as with so many conditions and treatments, one size does not fit all.
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Another option for life-threatening allergic reactions

It’s a new year, the gyms are unusually busy, and many of us started a new physical activity. Several health clubs are offering fun, interactive, and dynamic exercises such as whole-body workouts, functional training, CrossFit, high-intensity interval training, spinning, etc.

Some of these classes are incorporating intense workouts, which was a hot topic in exercise physiology in 2017. There is significant enthusiasm around these programs among my friends, family, and patients. Some of these classes have loud music, lights, and trainers whose job is to push you to a new level. Increasing the intensity of a workout may bring significant health benefits for some; however, lately we are starting to see cases of a potentially life-threatening disease as a result of these activities. It’s called rhabdo.

The other day I saw someone wearing a shirt that said “Pushing until Rhabdo.” That made me cringe. And I realized that, although rare, some people do not understand how serious rhabdo can be.
What is rhabdo?

Rhabdo is short for rhabdomyolysis. This rare condition occurs when muscle cells burst and leak their contents into the bloodstream. This can cause an array of problems including weakness, muscle soreness, and dark or brown urine. The damage can be so severe that it may lead to kidney injury. Intense physical activity is just one of the causes. Others include medication side effects, alcohol use, drug overdose, infections, and trauma/crush injury. Fortunately, most people who have rhabdo do not get sick enough to require hospitalization. But if you develop any of these symptoms after a hard workout, it’s a good idea to set up an appointment with your doctor. A simple blood and urine test could help establish the diagnosis.
How to avoid rhabdo

I know you are probably excited about your new exercise program, and you want to excel. And that’s great. But take it easy, especially if this is a new exercise routine. You want to challenge your body, but avoid extremes. If you are working with a trainer, make sure you tell him/her where you stand in terms of fitness level and health concerns. In addition:

    Drink lots of water. That will help prevent problems and help flush your kidneys.
    Avoid using anti-inflammatory medications such as ibuprofen and naproxen. These drugs may worsen kidney function.
    Avoid drinking alcohol. Alcohol is a diuretic, which means it will make you more dehydrated. You need more fluids in your system, not the opposite.

If you experience intense pain and fatigue after your workout, you should call your doctor. Most cases of rhabdo are treated at home simply by increasing fluid intake. If muscle enzyme levels are high, or if there are signs of kidney problems, IV fluids may be needed. In some cases, we have to admit patients to the hospital and even to the ICU for close monitoring and further treatment.
Ramping up safely

Be smart and train your muscles to adapt to new activity. Exercise is better if it is enjoyable and entertaining, and I have to say that some of these classes are incredibly fun. But make sure that you listen to your body. Watch out for trainers who may push you too hard to the point of exhaustion. That should not be your goal when you are first starting a brand-new routine, especially if you haven’t been active for a while. A good trainer should get to know you and will tailor the exercise routine to your level of fitness. Adding a new workout to your day is probably one of the healthiest habits you can incorporate in 2018, but don’t “push until rhabdo.” Instead push slowly but consistently, challenging your body toward wellness and better function. Attention deficit hyperactivity disorder, or ADHD, is very common — according to the most recent statistics, one in 10 children between the ages of 4 and 17 has been diagnosed with this problem. So it’s not surprising that when parents notice that their child has trouble concentrating, is more active or impulsive than other children, and is having trouble in school, they think that their child might have ADHD.

But ADHD isn’t the only problem that can cause a child to have trouble with concentration, behavior, or school performance. There are actually lots of problems that can cause symptoms that mimic ADHD, which is why it’s really important to do a careful evaluation before giving that diagnosis. Here are five common problems that parents and doctors should always think about:

1.  Hearing problems. If you can’t hear well, it’s hard to pay attention — and easy to get distracted. Now that more newborns are being screened for hearing problems before leaving the hospital, we are able to catch more cases early, but some slip through the cracks, and children can also develop hearing problems from getting lots of ear infections. Any child with behavioral or learning problems should have a hearing test to be sure their hearing is normal.

2.  Learning or cognitive disabilities. If children don’t understand what’s going on around them, it’s hard for them to focus and join in classwork. Children who have trouble understanding may also have difficulty with social interactions, which can be very quick, complex, and nuanced. Any child who is doing poorly in school should be evaluated and given the help they need. All public schools have a process for evaluating children and creating an Individualized Education Program, or IEP, for those who need help. Even if a child goes to an independent school, they can still get an evaluation through the public schools. Parents should talk to their child’s teacher and their pediatrician for guidance.

3.  Sleep problems. Children who don’t get enough sleep, or whose sleep is of poor quality, can have trouble with learning and behavior. Any child who snores regularly (not just with a bad cold) should be evaluated by their doctor, especially if there are any pauses in breathing or choking noises during sleep. Parents of teens should be sure that their children are getting at least eight hours of sleep and aren’t staying up doing homework or on their phones. In general, any time a diagnosis of ADHD is being considered, it’s important to take a close look at a child’s sleep and make sure there aren’t any problems.

4.  Depression or anxiety. It is hard to concentrate when you are sad or worried, and it’s not uncommon for a depressed or anxious child to act out and get in trouble. More than one in 10 adolescents has suffered from depression, and the numbers are higher for anxiety. Even more alarming, both depression and anxiety often go undiagnosed — and untreated — among children and adolescents. As part of any evaluation for ADHD, a child should also be evaluated for other mental health issues, not just because they can mimic ADHD, but because other mental health issues can occur with, or because of, ADHD.

5.  Substance abuse. This is something that should always be considered in an adolescent, especially if the ADHD symptoms weren’t present earlier in childhood (by definition, you have to have the symptoms before age 12 to get the diagnosis). Nobody wants to think that their child could be using drugs or alcohol, but by 12th grade about half of youth have tried an illicit drug at least once, and for some, it can turn into a habit — or worse. For some people, many foods, medicines, and bee stings mean life-threatening allergic reactions that require immediate treatment with injectable epinephrine. For many people, January means the start of a new drug deductible to be met. In June 2017 the FDA approved a new form of emergency epinephrine called Symjepi, which may be good news for people who must be prepared in the event of a life-threatening allergic reaction.
The seriousness of a severe allergic reaction

Severe allergic reactions affect anywhere from 5% to 70% of persons, depending on age and prior exposure. Anaphylactic or “type 1” (immediate hypersensitivity) reactions are the most severe forms of allergic reaction to a substance: insect venom, foods, or some drugs. People who have had prior exposure to an allergic substance are “sensitized” and when they are re-exposed, can have a reaction within seconds to minutes. Anaphylactic reactions are caused by the release of histamine and other chemicals throughout the body, resulting in leaky blood vessels that contribute to swelling of tissues in the mouth and airway and very low blood pressure. These symptoms can lead to difficulty swallowing and speaking, wheezing and severe shortness of breath, and death.
Treating severe allergic reactions

The treatment for severe allergic reactions is the administration of epinephrine (adrenaline) at the first sign of symptoms. Epinephrine is one of the chemicals in the body that raises blood pressure and heart rate. Epinephrine can be administered through an IV in the hospital, but since the 1980s, epinephrine has been available as a pre-filled syringe that can be obtained with a prescription and immediately injected into the thigh muscle when severe allergic symptoms are recognized.

The prevalence of severe allergies has been increasing since 2000. Anaphylaxis to some external chemical or allergen occurs in 2% of the population, and it is estimated that approximately 500 people die from anaphylactic reactions per year in the US. Because of this, more and more people need to have epinephrine available wherever they are (home, school, when traveling). So it is no surprise that the manufacture and marketing of pre-filled epinephrine syringes has been big news in the last two years.
Keeping epinephrine at the ready

Spring-loaded autoinjectors that contain epinephrine have been manufactured by several companies since 1987. In the last 30 years, changes in pharmaceutical companies and patent transfers resulted in a near-monopoly in the production of pre-filled epinephrine products. From 2009 to 2016, one company with a 90% market share dramatically increased the consumer cost for epinephrine injectors, resulting in an investigation and eventual settlement with the US Department of Justice.

Although not a spring-loaded autoinjector, Symjepi consists of two single-dose, pre-filled syringes of epinephrine, for the emergency treatment of anaphylactic and severe allergic reactions in adults. Each pre-filled syringe contains 0.3 mg epinephrine, the recommended initial dose for emergency treatment of anaphylaxis.

At an anticipated lower cost and small size, Symjepi could be an attractive addition to this slice of the pharmaceutical world. In November 2017, the company also submitted a second new drug application to the FDA for a junior version (0.15 mg dose for children between 33 and 65 pounds).
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