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Thursday, January 31, 2019

Ways to help get more children immunized

Fibromyalgia is a common condition that causes chronic body-wide pain and affects millions of people. The cause is unknown, and medications approved to treat it often aren’t effective, cause side effects, or both. To say we need better treatments for fibromyalgia is an understatement.

Non-medication treatment of fibromyalgia — especially exercise — is an essential part of treatment. But the last thing people with this condition want to do is exercise! Their pain and fatigue, so typical of this disease, make physical activity more wishful thinking than reality for most fibromyalgia sufferers. Even so, studies suggest that as long as people start “low and slow” (exercising at low intensity and for short duration, and very gradually increasing both), physical activity can be tolerated and even enjoyed.
Is there a “best” type of exercise for fibromyalgia?

A new study compared two types of physical activity among people with fibromyalgia: aerobic exercise (such as brisk walking, as commonly recommended) and tai chi, an ancient form of martial arts often practiced for health benefits. Past studies have demonstrated that tai chi can be effective for people with fibromyalgia.

Researchers enrolled 226 adults with fibromyalgia and randomly assigned 151 to learn and practice tai chi (once or twice a week for 12 or 24 weeks), while 75 were assigned to participate in standard “moderate intensity” aerobic exercise (twice a week for six months, with an aim of raising the heart rate during exercise to an aerobic range). Study subjects were representative of “real world” patients who varied in age, had other health problems, and took a number of medications.
What did the study show?

Compared with aerobic exercise, study participants assigned to the tai chi groups:

    attended their assigned exercise classes more reliably
    reported significant improvement on a standard survey of fibromyalgia symptoms when asked six months after treatment began
    had less anxiety
    felt better able to cope and had higher self-efficacy (a belief that they were able to improve their symptoms through their own actions)
    reported more improvement after 24 weeks of tai chi (vs. 12 weeks of tai chi)

Both groups reduced their use of pain relievers to a similar extent. And no serious injuries or side effects of the treatments were reported.
Does this mean everyone with fibromyalgia should try tai chi?

As is true for most treatments, there is not a single best option in all circumstances. It may not work well for those who don’t like tai chi (or don’t give it a chance), or feel they cannot participate due to poor balance, weakness, or other health problems.

In addition, the study itself is not the last word on which activities are best for people with fibromyalgia. Not everyone will have access to high-quality tai chi instructors (though in this study, results were consistent across three instructors). Skeptics will point out that since study subjects knew which treatment they were getting, the placebo effect could account for the findings. And, of course, there are countless other exercise programs that were not included in this study.
Stand by for more on exercise and other treatments for fibromyalgia

This new research suggests that instead of current recommendations to get aerobic exercise (as with taking brisk walks), tai chi might be just as good or better for many people with fibromyalgia.

In the near future, it’s likely that we’ll have better ways to diagnose and treat fibromyalgia. In addition, a better understanding of why it develops in the first place could lead to preventive approaches. Until then, I’ll keep telling my patients what I’ve been telling them for years: when fibromyalgia gets better, it’s usually because of something the patient is doing, not because of a medication I prescribed. Being physically active does seem to be a particularly necessary part of the approach. Based on the results of this latest research, tai chi may be a good place to start.
It’s almost May and here in the Northeast, front-of-the-pharmacy aisles are filled with myriad brands and types of sunscreen. While sunscreen is essential to lowering your risk for skin cancer, there are other simple, over-the-counter options you can incorporate into your summer skin protection routine.
Nicotinamide may help prevent certain skin cancers

Nicotinamide is a form of vitamin B3 that has been shown to reduce the number of skin cancers. In a randomized controlled trial performed in Australia (published in the New England Journal of Medicine), the risks of basal cell carcinoma and squamous cell carcinoma were significantly reduced — by 23%. Nicotinamide has protective effects against ultraviolet damage caused by sun exposure. The vitamin is safe and can be purchased over the counter. We recommended starting the vitamin (500 mg twice a day) to all our patients with a history of a basal cell carcinoma or squamous cell carcinoma, or with extensive skin damage due to sun exposure. One caveat is that the vitamin must be taken continuously, as the benefits are lost once stopped.
Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs, such as ibuprofen and aspirin, may have a modest effect on skin cancer prevention. A systematic review showed that the risk of squamous cell carcinoma was reduced by 15% with non-aspirin NSAIDs, and by 18% with any NSAID. Some studies of melanoma have also shown positive results; one found a 43% reduction in melanoma with continuous aspirin for five years, while other studies have failed to show any risk reduction. NSAIDs are known to inhibit an enzyme responsible for inflammation and pain, known as COX-2, which is overexpressed in squamous cell carcinomas. A limitation to many of the studies on NSAIDs in skin cancer is that the amount of NSAID taken varied. Especially at higher doses, NSAIDs are associated with other side effects, such as ulcers, and so I do not routinely recommend that my patients take these drugs to lower skin cancer risk.
Polypodium leukotomos

Polypodium leukotomos is a tropical fern found in Central and South America that has antioxidative, immunomodulatory, and anti-inflammatory effects, and is being marketed as an oral “sunscreen.” A recent small study of 22 patients showed that the fern extract altered the effects of UVB light (the more carcinogenic form of ultraviolet light) in 17 of the 22 patients to varying degrees. However, it is important to recognize that there are limitations to this study. First, it was unable to evaluate UVA light, which also causes skin cancer. Second, it is difficult to determine the most appropriate dose from the study. The participants received two doses of 240 mg of polypodium leukotomos two hours and one hour before ultraviolet exposure, but it is not clear how best to advise patients to use it. So, you may wonder whether I recommend this to my patients. The answer is, not yet. But I do plan to try the extract myself and on my husband (who has a history of skin cancer) this summer. Just keep in mind, this does not replace sunscreen and sun-protective clothing.
Watch your alcohol intake

Although alcohol is not a classic “over-the-counter” product, it has been in the spotlight in the past year, as alcohol is estimated to be responsible for 3.5% of all cancer deaths. Two meta-analyses suggested an association between skin cancer and alcohol intake. One study found that the risk of basal cell carcinoma increased by 7% and squamous cell carcinoma by 11% for every standard beer or small glass of wine each day. Another study showed a 20% increase in melanoma in drinkers, and the risk increased with the number of drinks. However, these studies didn’t take into account other factors that could affect the results, some of which cannot be measured. One example is that ultraviolet light is the main factor that increases basal cell carcinoma and squamous cell carcinoma, and alcohol consumption has been associated with behaviors that increase one’s risk of getting a sunburn. So what is the recommendation? The American Cancer Society recommends limiting alcohol consumption to one drink per day for women and two drinks per day for men.
And you still need sunscreen!

Since we have yet to find a magic pill that completely prevents sunburns and eliminates skin cancer risk, this is my plug for good old-fashioned sunscreen. Sunscreen has been shown to reduce both melanoma and squamous cell carcinoma. Randomized prospective studies in Australia showed that individuals who used daily sunscreen had a 50% reduction in melanoma and a 40% reduction in squamous cell carcinoma, compared to individuals who used sunscreen intermittently. So when the sun and warm weather beckon, remember to apply a broad-spectrum sunscreen with at least SPF 30 prior to going out in the sun, reapply every two hours, and apply liberally: 1 teaspoon to each arm, head and neck, front torso, and back; and 2 teaspoons to each leg.
Substance use disorders affect millions of Americans, and overdose is now the leading cause of accidental death in the United States. The need for treatment and recovery services has never been greater. This increasing demand has led to rapid growth in the number of detox and treatment service providers, which has burgeoned into a $35 billion a year industry. Most of these service providers work hard to provide honest, quality care to save lives.

Yet historically, addiction treatment and recovery services have been largely unmonitored, and remain so. As a result, the field is riddled with its share of corruption that seeks to exploit vulnerable individuals in desperate need of medical care. Because the news is saturated with stories about rehab scams and various patient abuses, it’s easy to think that “ one bad apple spoils the whole bunch.”
Unethical marketing of addiction treatment

Common unscrupulous practices include:

Patient brokering. This can take several forms. Lead selling involves paying brokers a finder’s fee or kickback for referring patients to their treatment facility (e.g., financial compensation of $500 to $1000 per patient or special future consideration). This is happening not only with patients new to treatment, but also in agreements made between recovery residences and treatment centers, or between two separate treatment centers. Lead buying is another approach. Call centers generate commission based on the number of placed referrals. Call center agents pose as caregivers, and unbeknownst to the patient, auction him or her off to the highest bidding treatment center. Treatment facilities that appear as separate centers may all route to the same call center. Finally, “addiction tourism” is the practice of sending a patient to a treatment facility in a state other than his or her home state.

Patient enticement. This is providing unethical incentives (money, gifts, free rent, flights, food, or other amenities) to get patients to enter, stay, or switch addiction treatment facilities.

Listing hijacks. Google Business or Google Maps listings can be altered through the suggested edits feature. Unaffiliated individuals can go into an organization’s profile and change listed phone numbers to reroute calls and online correspondences to other treatment programs or call centers, and change listed addresses to deceive patients about the actual location.

Misleading language or misrepresentation of services. Treatment facilities may deny their affiliations to other facilities or organizations; inaccurately portray the services they provide, their accreditation status, the types of conditions they treat, the credentials of clinical staff, accepted insurances; or misrepresent facilities, locations, and amenities in various ways.

Patient privacy violations. It isn’t unusual for unethical treatment centers to use a patient’s personal information — without his or her permission — as part of a sales or marketing pitch. This is in violation of HIPAA and other laws intended to protect sensitive personal health information.

Insurance overbilling and fraud. This is the process of billing insurance companies excessively for unnecessary treatment or services. A common instance is urine drug screens. For example, $10 drug tests are performed every two days and billed at $1,000. Under the guise of free insurance or care, patients may be enrolled in insurance plans utilizing false addresses to take advantage of the “change in address” exception, which allows a person to get coverage outside the open enrollment period. Unethical facilities may also enroll patients, without their knowledge, in premium plans with generous coverage (e.g. out-of-network coverage and low out-of-pocket costs) so that the treatment center gets reimbursed at a higher rate than from other plans or providers.
Fighting unethical addiction treatment marketing practices

Awareness is the first step in combating unethical addiction marketing practices, and has led to new legislation and increased scrutiny of addiction treatment providers by law enforcement, and even for-profit corporations such as Google.

Beyond ongoing criminal investigations led by local and state law enforcement agencies, the National Alliance for Recovery Residences (NARR) officially established a code of ethics for recovery residences in 2016. More recently, in an attempt to thwart aggregate call centers, Google has temporarily ceased the sale of pay-per-click advertisements on thousands of rehab-related search terms that previously generated over $100 per click. And beginning this year, the Joint Commission on Accreditation of Healthcare Organizations will require evidence-based practices in order for treatment facilities to be accredited.

Protecting patients from corrupt addiction marketing practices is necessary in order to provide honest and effective treatment for substance use disorder. While decisions on what treatment facility to enter are often made in states of distress, it is important to emphasize that individuals and families should protect themselves by learning about what constitutes quality addiction treatment, where to find trusted local providers, and how to choose the right option for them.

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