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Thursday, January 31, 2019

Prescription monitoring programs Helpful or harmful?

I’ve always thought it sounded counterintuitive to use an acid to alleviate indigestion, but the number of times I’ve heard people treat their symptoms of heartburn with apple cider vinegar is too large to count. So, I decided to look into whether this strategy works, and to do some investigation about the idea behind its use. To my surprise, there is no research published in medical journals that addresses using raw apple cider vinegar to treat heartburn, despite widespread use and recommendations from blogs and websites.
What is heartburn?

Heartburn is most commonly caused by stomach acid contents traveling up into the esophagus, the pipe that connects the mouth to the stomach. Unlike the stomach, the esophagus is not used to the presence of acid. The stomach acid irritates the esophagus, leading to several symptoms including throat clearing, burning sensation in the chest and neck, sour sensation in the mouth, cough, and bloating. It is not a pleasant feeling. It’s what we call GERD, or gastroesophageal reflux disease.

There are several reasons why gastric contents move up into the esophagus instead of going down to the bowel. The relaxation of the lower esophageal sphincter (LES), a valve that sits between the esophagus and the stomach, is the most common culprit. The LES is usually closed, creating a contained system to digest food. But it opens from time to time, to let air out in the form of belching. Reflux mostly happens when the valve relaxes too much, or too often. It allows not only gas but also gastric acid to move up, causing the discomfort.

There is a theory stating that what controls the LES is the stomach’s acidity. If for some reason the stomach is not producing enough acid, the muscles around the LES would relax, resulting in more reflux. However, the mechanism that controls this valve is much more complex than the level of gastric acidity. It involves a complex network of involuntary muscles and several different hormones and neurotransmitters.
Medications for heartburn

The gold standard to treat heartburn is to take an over-the-counter class of medications called proton pump inhibitors (PPIs) that reduce stomach acidity. Using these drugs will not prevent reflux, but can reduce inflammation in the esophagus, allowing it to heal. Avoid taking these medications for more than a month, unless recommended by your doctor. It is not unusual to become used to PPIs. After taking them for a few weeks it may be hard to wean off of them, because stopping can cause rebound symptoms. PPI side effects are minimal, but long-term use can cause osteoporosis, infections, and a decrease in the absorption of nutrients.

Antacids and medications such as ranitidine and famotidine (H2 blockers) may work well and have fewer side effects, but if these strategies do not make you feel better within a few weeks, it is a good idea to consult with your doctor. Although rare, heartburn could be a sign of other serious illnesses. My interest in reaping the brain health benefits of exercise comes not only from my work as a physical therapist and researcher in this field, but is also driven from a very personal place that unfortunately many of us have witnessed or will witness in our lifetime: a family member with disabling memory loss. In my case, it was seeing the crippling effects Alzheimer’s disease had on my grandfather, who passed away from complications related to his condition not so long ago.
What do we know about exercise and brain health?

As of today we know: 1) adults 65 and older are the fastest growing demographic group, reaching 20% of the world population by 2030; and 2) maintaining a sharp mind is a top priority for them. The idea that a healthy mind lives in a healthy body dates back at least 2,000 years, and the benefits of exercise beyond physical health is not a new idea either. The New England Journal of Medicine said this in 1887:

Exercise sustains and improves bodily health by expanding the lungs, quickening the circulation, and promoting growth in muscles and bones. But we know that besides doing all these things, exercise may be made to contribute to brain growth and to the symmetrical development of the mental faculties.

The key question that remains unanswered 130 years since that NEJM article is: what type of exercise should we do, and how much of it is needed to specifically target brain health?
What is the ideal exercise for brain health?

The verdict is still out on an ideal exercise “dose” for brain health, because in short, it’s complicated. The long answer is that we are still learning about all the ways in which exercise changes our biology, since not all exercise is created equal, and of course it ultimately depends on who we are, for we are all different. The best exercise program for one person may be quite different from the best one for another. A wealth of studies both in humans and animals have linked the cognitive improvements following exercise (mainly aerobic, such as running and cycling) to the increased capacity of the heart, lungs, and blood to transport oxygen. As a result, generalized brain effects, such as a boost in the number of blood vessels and synapses, increasing brain volume, and decreasing age-related brain atrophy, have all been reported. Aside from this, more localized effects in brain areas related to thinking and problem solving have also been reported, such as a boost in the number of new nerve cells and increases in proteins that help these neurons survive and thrive.

On the other hand, in recent years cognitive improvements have also been demonstrated with other forms of exercise, such as low-intensity mind-body exercises (think some forms of yoga and tai chi) and resistance (i.e., weight) training. Because these exercises either do not work the heart as hard, or do so in a different way, we know less about exactly how they promote these cognitive changes. However, I see this as an encouraging finding for two reasons. First, some sedentary people may need to start with a more gentle routine, eventually building up to more vigorous exercise practices; and second, many people already engage in resistance training for other reasons, such as building stronger muscles and bones.
What can I do now?

The reality is that less than 40% of adults 65 and older engage in at least 150 minutes of physical activity per week, and 20% don’t do any type of formal exercise. While these recommendations were drafted by the Centers for Disease Control and Prevention (CDC) for physical health (and are not brain health-specific), a target of 30 daily minutes, five days a week is a reasonable goal, guaranteed to promote physical health. However, we don’t yet know if this is the correct dose for brain health. So in the meantime, it seems that since aerobic exercise, resistance training, and mind-body exercises are all associated with evidence specifically supporting benefits for brain health, you should maintain a diverse practice, using these exercises as the building blocks of your regimen.
And where is the science on exercise and brain health headed?

I am confident that through research we will learn the optimal dose of exercise to maintain our brain health, but as of now my educated guess is that the answer won’t be a one-size-fits-all “prescription.” I also hope that we will discover the answers to many other incredibly intriguing questions related to physical activity and cognitive health, such as: what are the exercises that people will do, and do these lead to any cognitive benefit, on an individual level? I would like to invite you to join this conversation. What type of exercise do you enjoy? Have you noticed any positive effects of exercise on your mental sharpness? Would you consider this experiment: embark on a month-long exercise routine and share with us what results you noticed on your brain health? As the weather gets better and school vacations begin, along with sunburns and water safety there is something else parents need to think about: ticks and Lyme disease.

Lyme disease is spread by the bite of the blacklegged tick. While there are cases in various parts of the country, it’s most common in the Northeast and mid-Atlantic states, as well as around the Great Lakes. The early symptoms of Lyme include fever, body aches, and a bull’s-eye rash. It’s very treatable with antibiotics, but if not caught and left untreated, it can lead to serious health problems.

Here is information from the Centers for Disease Control and Prevention on four things that everyone should know and do:
1.  Prevention is key

As is true with all health problems, preventing them in the first place is always best. Be mindful of where your children play, as brush and tall grasses are where the ticks hang out. As much as possible, try to keep to the center of paths. Use a repellent with DEET (at least 20%), picaridin, or IR3535 on exposed skin (the Environmental Protection Agency has a great online tool that can help you choose the best insect repellent), and spray clothing (including socks and shoes) and gear like backpacks with permethrin.
2. Do tick checks at the end of every day

Even if your kids were just playing outside in the yard, get in the habit of looking them over. Ticks like warm, moist areas like the armpits, groin, and scalp, so you should particularly check there. Be sure to look carefully, because the blacklegged tick often transmits when it’s in the nymph stage, and nymphs are really tiny.

If you find an attached tick, grab it at the base with a tweezer and pull it upward with steady pressure. You can get rid of a live tick by wrapping it tightly in something or flushing it down the toilet.

Along with checking your human family members, be sure to check pets that have been outside, as they can carry ticks inside with them. You should also check clothing. Anything that isn’t going into the wash can be thrown into the dryer for 10 minutes or so (when washing clothes, be aware that if they aren’t washed in hot water, they may need extra time in the dryer to kill any ticks on them).
3. Be on the lookout for symptoms

If you do tick checks at the end of every day you should be fine, because it takes at least 24 hours — more often 36 to 48 hours — for an infected tick to transmit Lyme. This is a really important point that many people don’t know.

The classic rash of Lyme is an expanding bull’s-eye rash at the site of the bite. The rash is present in 70% to 80% of cases. Of course, that means it isn’t present in 20% to 30% of cases, so if someone in your family had a tick on them for more than 24 hours, or if you live in an area where there are many cases of Lyme and there may have been a tick bite, you should call your doctor if the person has a fever, chills, aches and pains for no clear reason, along with swollen lymph nodes or swelling of one or more joints. While having these symptoms doesn’t mean for sure that a person has Lyme, it’s worth getting checked out, as early treatment generally leads to a complete cure.
4. Be a cautious consumer of information when it comes to testing and treatment of Lyme

As with many conditions, there is a lot of misinformation out there about Lyme testing and treatment. It’s important to use laboratories that use evidence-based norms and processes. There are many advertised tests for Lyme disease, but some of them are simply not reliable — and it’s really important to have reliable information when making a diagnosis. It’s also not recommended to do testing for Lyme in someone who does not have clear symptoms of Lyme disease.

Most people recover completely after treatment of Lyme, but there are some people who have chronic symptoms such as fatigue, pain, or joint swelling after Lyme disease. This is called post-treatment Lyme disease syndrome or post-Lyme disease syndrome. The cause of these syndromes is unknown. Prolonged use of antibiotics is not recommended. Studies have shown that it doesn’t help, and there can be serious health problems when antibiotics are taken for prolonged periods of time.

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