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Thursday, January 31, 2019

Where do you stand on bystander CPR?

You might call them pain relievers. You might take them for back pain, headache, or arthritis. Your doctor calls them “NSAIDs,” which stands for nonsteroidal anti-inflammatory drugs. Whatever you call them and for whatever reason you take them, NSAIDs are among the most popular medications worldwide. In fact, estimates suggest that about 15% of the US population takes an NSAID regularly (including those that are over the counter and prescription strength). Along with sporadic users, more than 30 billion doses are taken each year.

Some of the most common NSAIDs include ibuprofen (as in Motrin), naproxen (as in Aleve) and celecoxib (as in Celebrex).
Why are NSAIDs so popular?

There are several reasons:

    For many conditions, they work quite well — in addition to working as pain relievers, they can reduce fever and inflammation.
    They are relatively inexpensive, with generic versions available for most of them.
    They’re available over the counter or, in higher doses, by prescription.
    They have a good safety profile.

The downside of NSAIDs

No medication is completely safe, and that’s certainly true of NSAIDs. At the top of the list are digestive problems including stomach upset, heartburn, and ulcers. Kidney injury, easy bruising or bleeding, and mild allergic reactions (such as rash) are common as well. Less common side effects, including severe allergic reactions and liver injury, can be serious. NSAIDs can also raise the risk of heart problems, though this risk varies depending on the particular NSAID and the person taking it. Still, the vast majority of people taking NSAIDs in the recommended doses who have appropriate monitoring (such as the occasional blood test) have no major problems with them.
It’s easy for things to go wrong

The widespread availability and good safety record of NSAIDs makes it easy to misuse them. For one thing, there are more than 20 different NSAIDs, so you could be taking more than one of them without realizing it. In addition, several of them are available over the counter and are included in combination with other medications. Examples include prescription drugs like Arthrotec (a combination of the NSAID diclofenac and misoprostol, a medication that helps protect the stomach) and products available on the drugstore shelf, like Advil PM (ibuprofen plus the antihistamine diphenhydramine). So whether intentionally or by accident, it’s easy to take more than recommended doses.

A new study finds that this may be a bigger problem than anyone realized. Among more than 1,300 people taking ibuprofen:

    More than one-third also took a second NSAID. Less than half of these “double NSAID” users realized that more than one of their medications was an NSAID.
    Up to 15% took more than the recommended dosage.
    Exceeding the recommended maximum dose was especially common among men, those with chronic pain, those with poor knowledge of dosing recommendations, and those who believed in “choosing my own dose.”

The bottom line

NSAIDs can be remarkably helpful medications, but they can cause trouble. The risk of serious side effects goes up when taken in higher than recommended doses.

Except for low-dose aspirin (commonly taken to prevent heart attack or stroke), NSAIDs are taken primarily to relieve symptoms of pain or fever. If you don’t think your NSAID is helping you (or if you aren’t sure), talk to your doctor about stopping it — even minor risks aren’t worth taking if there’s no benefit. Or there may be a better option, such as acetaminophen (as in Tylenol).

Keep an updated list of all of the medications you take, including over-the-counter drugs. Read the labels and instructions and take them only as prescribed. When in doubt, ask your doctor or pharmacist. For men diagnosed with aggressive cancer that’s confined to the prostate and nearby tissues, the overarching goal of treatment is to keep the disease from spreading (or metastasizing) in the body. Doctors can treat these men with localized therapies, such as surgery and different types of radiation that target the prostate directly. And they can also give systemic treatments that kill off rogue cancer cells in the bloodstream. Hormonal therapy, for instance, is a systemic treatment that kills prostate cancer cells by depriving them of testosterone, which fuels their growth.

Now a new study shows that a mix of different treatments, or a “multimodal” approach to prostate cancer therapy, lengthens survival in men who have this diagnosis. The study was limited to men with Gleason 9 and 10 cancers. The Gleason grading system ranks tumors by how likely they are to spread, and 10 is the highest rank on the scale.

“The takeaway finding is that men with high-grade, localized prostate cancer do better when they get multimodal care,” said Dr. Amar Kishan, an assistant professor of radiation oncology at the University of California, Los Angeles David Geffen School of Medicine, who led the study. “If they can tolerate it, then that’s what should be offered.”

Kishan and collaborators from 12 large hospitals in the United States and Norway pooled nearly 20 years of patient data from their respective institutions. The 1,809 men included in the study had each been treated in one of three different ways:

    with surgery to remove the prostate
    with a combination of external beam radiation (which directs high-energy rays at the tumor from sources outside the body) directed at the prostate, along with anti-testosterone hormonal therapy
    with hormonal therapy given together with external beam radiation and brachytherapy (which involves placing radioactive beads directly into the prostate gland).

After an average of five years of follow-up, 3% of the men given all three treatments (external beam radiation, brachytherapy, and hormone therapy) had died from prostate cancer. By contrast, 12% of the men treated with a combination of hormonal therapy and external beam radiation, and 13% of the men treated with surgery only, had died of their illness. Findings of metastatic cancer were similar, averaging 8% in the group given all three treatments, and 24% in the two other groups.

Side effects data from each group were not available.

This is the largest study yet to compare the three approaches, and importantly, it was restricted to men who began treatment no earlier than 2000. Radiation therapy has improved over time: the doses are higher and the treated areas are more precisely defined. Therefore, the evaluated approaches are consistent with the kind of treatments men would still get today.

Kishan said it’s possible that combining hormonal therapy with high-dose radiation and brachytherapy eliminates cancer in the prostate completely, so that metastases are held in check. Or, he says, radiation might stimulate the immune system to attack cancer. These hypotheses are now under investigation by researchers around the world.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, said the study adds to growing evidence that therapies directed solely to the prostate gland, namely radiation or surgery by itself, may be improved by adding other treatments; in this case, hormonal therapy and a second form of radiation. “The study didn’t evaluate the addition of hormonal therapy to surgery, which would have been of interest,” he added. “However, the findings support multimodal therapy, though many unknowns, such as the potential for greater long-term side effects, still need to be addressed.” Recently a journalist colleague of mine put out a call for quotes from those who suffer from severe premenstrual syndrome and premenstrual dysmorphic disorder (more commonly known as PMS and PMDD, respectively) who also suffered a history of childhood abuse. Her interest was piqued by a 2014 peer reviewed article that appeared in the Journal of Women’s Health linking the disorders with early onset abuse. I answered the call, having both PMS and PMDD, as well as a history of child abuse by both my stepfather and my mother.

Yet despite having both a history of abuse and several diagnoses that contribute to chronic pain, it’s only been in the past few years that I’ve become aware of the connection between the two. It wasn’t until I started writing a collection of personal essays about my youth, and researching scientific literature about childhoods like mine, that I stumbled upon the now-famous 1998 ACE study, which explored “adverse childhood experiences.” Specifically, the study surveyed 17,000 middle-income adults who had health data stretching back to their early childhoods. The ACE research indicated that the more adversities an individual experienced as a child — whether poverty, parental death or incarceration, neighborhood violence, or abuse — the more likely that person would suffer from serious physiological disorders as an adult.
Understanding the connection

While the causality between childhood adversity and adult chronic illness has yet to be fully determined, researchers now have enough knowledge about the way chronic stress impacts physiological health to make some educated guesses about their potential link. When we are threatened, our bodies have what is called a stress response, which prepares our bodies to fight or flee. However, when this response remains highly activated in a child for an extended period of time without the calming influence of a supportive parent or adult figure, toxic stress occurs and can damage crucial neural connections in the developing brain. According to Harvard’s Center on the Developing Child, the impacts of experiencing repeated incidents of toxic stress as a child “…persist far into adulthood, and lead to lifelong impairments in both physical and mental health.”
Why addressing pain and trauma should go hand in hand

The fact that childhood adversity is so intimately intertwined with adult illness does not mean that those physiological diseases experienced by adults who had traumatic childhoods are not real or valid, or that their causes are “psychosomatic.” The biological impacts of childhood adversity are not only genuine, but can be very difficult (and sometimes impossible) to completely undo.

However, it does offer hope that psychological care for those with a history of childhood trauma may help tame their overactive stress response in the present day, and in turn provide some complementary health benefits for those also dealing with physiological diseases. In my case, while processing my traumatic childhood history in psychotherapy has not automatically cured my physical ailments (and will not), it does help me relearn how to react to stress.

Pediatric health care providers and educators should understand how far into the future the effects of childhood abuse and adversity may extend. This knowledge should serve as further motivation to help children in these situations access necessary supports as quickly as possible, to guard against some of the biological changes that could make them suffer later on in life. Likewise, those who work in the mental health field with adults who suffered childhood trauma would well do to study the link between that and chronic pain and illness, so that they can better support their patients. A recent survey confirmed what many have suspected: if you collapsed, there’s a good chance that the average bystander would not be prepared to perform cardiopulmonary resuscitation (CPR). And if they tried to revive you, there’s an even better chance they wouldn’t do it correctly.

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