Day: 03/18/2022

PTSD looks different in young children – but it’s still treatable

Posted by

0


Taylor, aged four, is playing in the living room when there is loud and aggressive banging on the door. Mum opens the door – it is their neighbour, who has small children the same age as Taylor, and Taylor stands up to see if the children are at the door too. The neighbour starts yelling loudly. Mum yells back and tries to close the front door. The neighbour, still yelling, forces the door open, it hits Mum in the face, and her nose starts bleeding. As blood pours down Mum’s face and she becomes visibly upset, the neighbour leaves. Could this event have a lasting, negative effect on a young child – and what would it look like if that happened?

After a stressful or traumatic event, both children and adults can find themselves thinking about the event more often than they would like, feeling stressed, anxious or low, or have trouble sleeping. Often, this is a normal reaction to what the brain has perceived as a dangerous situation and, for most people, such reactions will subside within a month of the event. Post-traumatic stress disorder (PTSD) is a debilitating mental condition that occurs after the experience of a perceived threat to life, safety or personal integrity. For a diagnosis of PTSD, the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists key problems that must persist at least one month after a traumatic event, including involuntary reliving of the trauma (eg, through intrusive thoughts and images); avoidance of people, things or places that remind one of the trauma; negative changes in thinking and feelings; and heightened arousal.

Young children can develop PTSD after the same variety of events that cause PTSD in adults, such as abuse or assault, exposure to war, car accidents, or witnessing significant violence against another person. However, threatening or harmful experiences that might not produce PTSD symptoms in adults (eg, being attacked by a dog) can sometimes produce them in children. It is the perception of threat that is important – young children might not understand the causes of an event or the intent behind someone’s actions, and often have no active control over what happens. Therefore, PTSD symptoms can sometimes emerge in younger children following events such as aggressive or harmful behaviour toward a caregiver, or invasive medical procedures.

After the instantiation of the formal PTSD diagnosis in 1980, identification and assessment of PTSD increased. Since then, psychologists and other health professionals have recognised that younger children (aged three to six) tend to show a different profile of PTSD symptoms following a traumatic experience.

In Taylor’s case (which is fictional, but based on real cases), she is understandably upset and scared in the immediate aftermath of the event. But one month afterwards, Taylor still sticks close to Mum and doesn’t like Mum to go out without her. She starts refusing to sleep in her own bed like she used to. She has tantrums when taken to the dance class that she usually enjoys. She no longer plays in the living room or the garden. Taylor visibly freezes or becomes upset when the doorbell rings, which might also be expected from an adult with PTSD. But Taylor’s other behaviours do not seem to fit traditional descriptions of the disorder. Does that mean that Taylor is experiencing a normal reaction, or that her difficulties are unrelated to the event? Would she benefit from the support of a health professional?

The criteria outline symptoms specific to young children, such as re-enacting the trauma during play, having scary dreams that they struggle to describe, and temper tantrums

Researchers around the world have been working to improve the identification of young children who are experiencing PTSD – and, critically, to develop psychological treatments that can help them.

Meeting this challenge has required some rethinking of how PTSD is diagnosed in young children. A series of studies in the early 2000s suggested that the standard diagnostic criteria for PTSD were failing to identify a large number of young children who were in need of support. Consequently, researchers proposed an alternative, developmentally sensitive diagnostic algorithm for young children. Following minor refinements to this alternative algorithm, the most recent version of the DSM included new diagnostic criteria for a subtype of PTSD in children aged six and younger.

The core features of the PTSD in young children (PTSD-YC) subtype remain the same as in adults. However, there are important differences. For instance, the developmentally appropriate criteria reduce the extent to which certain kinds of symptoms, such as avoidance symptoms, are required for a diagnosis. (Young children are less able to control where they go: for example, even if a young child would like to avoid the scene of a trauma, a caregiver can pick them up and take them there.) The criteria outline variations on symptoms that might be specific to young children, such as re-enacting the trauma during play, having scary dreams that they struggle to describe, and having temper tantrums. As with adults, diagnosis requires a combination of multiple symptoms to be present, to ensure that normal behaviours are not pathologised, and the symptoms must cause significant disruption to daily functioning. It is also central to diagnosis that the behaviours must have started or worsened since the traumatic event.

When my colleagues and I recently applied the alternative algorithm for diagnosing young children to data from a British national survey, it identified a markedly higher number of very young children as having PTSD compared with the earlier, adult-based PTSD criteria. Our analysis of the survey data indicated that approximately 7 per cent of five- to six-year-old children in the UK had experienced a traumatic event, and that, of those trauma-exposed children, 5.4 per cent met criteria for a diagnosis of PTSD-YC. Data from a similar British survey with children in foster care suggested that 48 per cent of the five- to six-year-olds had experienced a trauma, with 57 per cent of those trauma-exposed children experiencing PTSD.

Much of the time, very young children who have experienced a traumatic event might not be assessed for PTSD, as the symptoms could be regarded as separate, unrelated behavioural problems rather than as representative of an underlying mental health issue. As a result, these children frequently do not receive any trauma-focused treatment. This is problematic for the child – if left untreated, PTSD can last for years, even into adulthood, and severely impact ongoing development, including the child’s ability to learn, form healthy relationships, and enjoy their life. But we do have PTSD treatments designed for adults that are also effective in treating younger children, and these are now recommended for use with children by international health guidelines.

One of the most effective approaches to treating PTSD in adults and older children is trauma-focused cognitive behavioural therapy (CBT). A core feature of trauma-focused CBT is working with an individual’s memory of the trauma – which can often be disjointed and lack coherence – to identify and adapt the unhelpful beliefs they hold about the event (eg, It was my fault; the world is not safe; bad things happen to people I love).

Like all of us, young children may also need reminding of the good things that they did in a scary situation (such as trying to protect a sibling)

Though younger children are still developing their language skills and might struggle to describe their memories and abstract concepts, a number of clinical trials now suggest that trauma-focused CBT can be adapted to successfully treat PTSD in these children. One such treatment protocol, CBT-3M, focuses on changing three key factors that drive PTSD: the trauma memory, the meaning the child makes about the event, and the maladaptive coping strategies the child uses to manage the impact of the trauma.

An organised and coherent memory of a traumatic event aids recovery from PTSD as it helps an individual to understand why the event occurred, and to constrain the meaning of the event to the appropriate context. For example, updating a disjointed memory of a traumatic car accident to include details you had not attended to at the time (eg, you had been obeying the road rules) or that you did not know at the time (eg, the other driver was drunk) can help adjust an unhelpful meaning you made from the event (driving is always dangerous; I will hurt others if I am in a car) to something more adaptive and representative of the situation (cars are dangerous only when driven irresponsibly). Maladaptive coping strategies that perpetuate symptoms must also be addressed. Avoiding reminders of the trauma, for instance, might reduce distress in the immediate term, but it also reinforces the idea that you cannot handle what is being avoided, when in fact you can.

To help a child improve on each of these factors, the therapist will complete therapeutic activities with either the child alone or the child together with a caregiver. Therapeutic tasks can involve using dolls, stuffed animals or toys (eg, cars, ambulances) to re-enact the traumatic event and help the child organise their memory to accurately represent what happened. The child might be guided to draw pictures or select cards with different emotional faces that show how the child feels and reacts to reminders of the trauma. This helps them to link the feelings they’ve been having to the traumatic event, and understand why these feelings suddenly arise, seemingly out of nowhere. Comics or short videos can also be used to explain how and why the brain produces the symptoms that the child is experiencing. Activities such as these seek to challenge maladaptive meanings that the child might have made (eg, I am going crazy; I am broken) by teaching the child that their symptoms are an understandable reaction to the trauma, and showing them that other children have had the same problems following a traumatic event.

A therapist can work with the child’s caregiver to instigate a routine for the child, in order to make their world more predictable and thus feel safer. Caregivers can also provide additional information that helps the child better understand the traumatic event. For example, a child might have felt that no one was coming to help them, when in fact an observer had called an ambulance or a lifeguard was swimming quickly toward them. Like all of us, young children may also need reminding of the good things that they did in a scary situation (such as trying to protect a sibling).

For Taylor, Mum might be able to explain that the neighbour had not intended to hurt her, and that, although there was lots of blood, it did not hurt as much as Taylor had feared. A recent trial has even trained parents in how to deliver sessions of trauma-focussed CBT to their children at home, with promising results. However, the child’s caregiver is often present during a child’s trauma, and as such could be in need of support themselves.

Research is steadily improving our understanding of how best to support young children experiencing PTSD. But it is clear that very young children do experience PTSD, and that we have psychological treatments that can help them overcome it. This support can enable children to escape their continual reliving of the trauma, feel more in control of their emotions, and re-engage with activities that they enjoy – minimising the risk that trauma will have a lasting impact on their future.

Bill Gates-Funded Company Releases Genetically Modified Mosquitoes in US

Posted by

0


Genetically modified mosquitoes have been released for the first time in the United States as part of an experiment to combat insect-borne diseases such as Dengue fever, yellow fever, and the Zika virus.

UK-based biotechnology firm Oxitec, which is funded by the Bill and Melinda Gates Foundation, said it released the mosquitoes in six locations in Monroe County’s Florida Keys: two on Cudjoe Key, one on Ramrod Key, and three on Vaca Key.

It’s part of an effort to help tackle a disease-transmitting invasive mosquito population—the Aedes aegypti mosquito species—that’s responsible for “virtually all mosquito-borne diseases transmitted to humans,” according to the company.

These mosquitoes make up about 4 percent of the mosquito population in the Keys, and transmit dengue, Zika, yellow fever, and other human diseases, as well as heartworm and other potentially deadly diseases to pets and other animals.

The experiment is in collaboration with the Florida Keys Mosquito Control District (FKMCD), and was approved by the U.S. Environmental Protection Agency (EPA), the Florida Department of Agriculture and Consumer Services (FDACS), the U.S. Centers for Disease Control and Prevention, and an independent advisory board.

Over the next 12 weeks, fewer than 12,000 mosquitoes are expected to emerge each week, for approximately 12 weeks. Untreated comparison sites will be monitored with mosquito traps on Key Colony Beach, Little Torch Key, and Summerland Key.

If successful, some 20 million additional genetically modified mosquitoes will be released later in the year.

“We really started looking at this about a decade ago, because we were in the middle of a dengue fever outbreak here in the Florida Keys,” FKMCD Executive Director Andrea Leal said during a video news conference. “So we’re just very excited to move forward with this partnership, working both with Oxitec and members of the community.”

The insects released by the biotechnology firm are all male, so they don’t bite. They’re expected to mate with the local biting female mosquitoes, and in doing so, they will pass on a lethal gene that will ensure their female offspring die before reaching maturity.

According to Quartz, areas including Malaysia, Brazil, the Cayman Islands, and Panama, where similar experiments have been carried out, have seen mosquito populations drop by as much as 90 percent.

The project has faced backlash from residents, who say their consent was not sought for the experiment.

The Genetic Roots of Pompe Disease

Posted by

0


photo of dna molecule concept

When two parents each pass on a mutated copy of a particular gene to their baby, that child can get Pompe disease. Because this rare condition doesn’t affect you if you carry just one faulty gene, parents usually don’t realize they could pass it to their children.

“Most of our families come to us without any knowledge of the disorder,” says Damara Ortiz, MD, director of the Lysosomal Storage Disorders Program at UPMC Children’s Hospital of Pittsburgh.

The gene linked to Pompe disease is known as the GAA gene. In healthy people, it produces the GAA enzyme. This enzyme breaks down a sugar called glycogen into glucose. Your body then uses the glucose for energy. The process takes place inside your cells, in structures known as lysosomes.

When someone has Pompe disease, their body doesn’t produce enough of the GAA enzyme. Glycogen then builds up within the lysosomes. This causes cell damage, especially within muscles. This may include the muscles that control your breathing and your heart.

How Pompe Disease is Inherited

The GAA gene is on what’s known as chromosome 17.

You can get all of your children affected or none of your children affected, because each pregnancy is a separate, random event.Damara Ortiz, MD

“We have two chromosome 17s — one we get from the father, one that comes from the mother,” says Jaya Ganesh, MD, an associate professor of genetics and pediatrics at Icahn School of Medicine at Mount Sinai in New York City. “Consequently, we have two copies of the Pompe gene.”

When someone is a carrier for Pompe disease, they have one GAA gene that works the right way and one that doesn’t. The working gene is dominant. So their bodies produce the enzyme needed to convert glycogen into glucose, and they don’t get Pompe disease.

Even when both parents have the mutated gene, all their children won’t necessarily get Pompe disease, or be carriers for it. When both parents are Pompe disease carriers, babies inherit two working GAA genes 25% of the time. They inherit two nonworking GAA genes — which leads to Pompe disease — 25% of the time. The rest of the time, they get one of each.

“[When] a healthy parent has a working copy and nonworking copy … they have [a] 50% chance of their child being a carrier,” says Ortiz, who is also medical director of medical genetics residency at the children’s hospital.

“You can get all of your children affected or none of your children affected, because each pregnancy is a separate, random event,” she says.

If one parent has Pompe disease and the second is a carrier, each of their children would have a 50-50 chance of inheriting the disease and a 50-50 chance of being a carrier. If both parents have Pompe disease, every child would inherit it.

Hundreds of Gene Variants

Researchers have found hundreds of GAA gene mutations that can cause Pompe disease.

DID YOU KNOW?

Pompe disease affects all races and ethnic groups equally.

“There are now about 700 or more mutations, or variants, known in the GAA gene,” says Deeksha Bali, PhD, a professor of pediatrics at Duke University School of Medicine in Durham, NC.

Different GAA gene variants may affect how much working GAA enzyme your body produces. People who have 1% or 2% of normal enzyme activity usually get Pompe disease as infants. Those with 30% or 40% may not have symptoms until later in childhood or as adults.

Pompe disease affects all races and ethnic groups equally. Some groups may seem to have higher rates but are simply affected earlier in life.

“The African-American and the Taiwanese populations … have common infantile-onset Pompe disease variants,” Ortiz says. “Here, we see more commonly the late-onset variants, because our population happens to be more Caucasian.”

Genetic Testing for Pompe Disease

Couples who want to start families sometimes visit genetic counselors to learn if they’re at risk of passing genetic disorders to their children.

“Prenatal carrier screening has become very common,” Bali says. “In a lot of patients, carriers get picked up during prenatal carrier screening.”

When couples learn that they’re both carriers, they may decide to get pregnant naturally, then test the fetus to learn whether the baby has Pompe disease. Other couples do in-vitro fertilization, then test embryos.

“[They] then choose to implant the embryos that are either carriers or completely unaffected, so their children don’t have the same decision burden that they do,” Ortiz says.

Sometimes, prenatal genetic testing reveals that an adult has Pompe disease, although they don’t have symptoms — at least not yet.

“We are … picking up patients who we are screening for carrier status, but actually, they’re turning out to have mutations associated with later-onset disease and actually are diagnosed with Pompe disease,” Ganesh says.

Newborn Screening for Pompe Disease

In 2015, the U.S. Department of Health and Human Services added Pompe disease to the list of disorders that it recommends newborn babies be screened for. Now, many states screen all newborns for the condition.

“I’m actually very pleasantly surprised that in the past 5, 6 years since it started, about 27 states are already doing newborn screening for it,” Bali says.

When newborns are diagnosed with Pompe disease, they’re able to get treatment early. Enzyme replacement therapy extends the lives of people with the disorder.

“It is saving lives,” Bali says. “Kids who need treatment are getting treatments, and there is more awareness.”

Why Do Plexiform Neurofibromas Form?

Posted by

0


Plexiform neurofibromas are tumors that grow along nerves. That’s how they get their name: “neuro” means nerves, and “fibroma” is a type of tumor. These growths have nerve tissue and many different types of cells in them. They can form deep inside the body or right under the skin.

Plexiform neurofibromas are benign tumors, but they can turn into cancer. When these tumors become cancerous, doctors call them malignant peripheral nerve sheath tumors (MPNST).

It helps to know how these tumors grow so that you can tell your or your child’s doctor about any changes you notice.

Where Do They Form?

Plexiform neurofibromas can grow on the inside or outside of the body, including on the:

  • Face, often around the eye
  • Neck
  • Arms and legs
  • Back or chest
  • Belly

Tumors can also form inside the body on organs. About the only places plexiform neurofibromas don’t grow are in the brain and spinal cord. Tumors inside the body may only be visible with imaging tests, such as magnetic resonance image (MRI).

As plexiform tumors grow, they make the nerve thicker. Sometimes little clusters of tumors pop up along the same nerve. They can grow on a single nerve or on bundles of nerves and on large nerves or small ones. Plexiform neurofibromas often weave themselves into normal tissues as they grow, which makes them hard to remove with surgery.

Who Gets Them?

DID YOU KNOW?

Plexiform neurofibromas affect up to 50% of people with NF1.

Neurofibromas affect many people with neurofibromatosis type 1 (NF1) — a condition that causes tumors to grow along the nerves, among other features.

A change to a gene causes NF1. About half of the time, a parent passes that faulty gene to their child. The other half of the time, the gene change happens on its own and doesn’t run in the family.

There are a few types of neurofibromas. But they don’t always cause symptoms or require treatment.

Most of the time children who have plexiform tumors are born with them. But sometimes these tumors don’t appear or cause problems for many years.

Why Do They Grow So Large?

Plexiform tumors often form early in life, or they are already there at birth. They start out as a soft lump under the skin. The tumors keep growing as the child gets older, although they usually grow slowly. Fast growth can be a sign that the tumor has turned into cancer.

Over time, plexiform neurofibromas can become so large that they press on and damage the bones, skin, muscles, and organs around them. That damage can cause pain, along with more serious problems, such as hearing loss, high blood pressure, and trouble moving.

An injury can make the tumor grow faster, too. The neurofibroma may suddenly swell up if the injury damages the blood vessels around it.

What Do They Look and Feel Like?

These tumors look like lumps under the skin. The skin over the lump may feel thicker and appear darker than the skin around it. The lump itself may feel like a bundle of thick cords or knots.

Plexiform neurofibromas have a type of cell that releases histamine, a chemical in the body that can cause itching. Histamine is the same chemical that makes you itch when you have an allergic reaction. For that reason, plexiform neurofibromas may itch.

These tumors can sometimes hurt as they grow and press on other tissues and structures inside the body causing significant pain. They may also turn into cancer. It’s important to stay in touch with your doctor when a tumor begins to hurt or changes in other ways.

Alternative Sweeteners in Drinks Can Reduce Weight, Diabetes Risk: Study

Posted by

0


Replacing sugar-sweetened beverages with low- or no-calorie sweetened beverages is associated with small decreases in weight and risks for diabetes, according to a new study published in JAMA Network Open.

Alternative sweeteners in drinks traditionally full of sugar — such as soda, energy drinks, tea, coffee, juice, and sports drinks — could reduce risk factors, such as high body mass index, body fat percentage, and blood lipids.

“Universally, everyone is recommending a reduction of sugar. Now the next question is: What’s the best way to replace it?” John Sievenpiper, MD, the senior study author and a nutritional sciences professor at the University of Toronto, told CNN.

The ideal way to replace sugary beverages is to drink water as often as possible, he said, but alternative sweeteners such as aspartame, saccharin, and sucralose can help.

“Some beverages will give you that intended benefit and in a way that’s similar to what you would expect from water,” he said.

Sievenpiper and colleagues looked at data from 17 clinical trials that compared sugar-sweetened beverages, low- and no-calorie sweetened beverages, and water. Among the 1,700 adults included, about 77% were women with overweight or obesity who were at risk for or had diabetes.Slideshow

‘Healthy’ Snacks That Aren’t

photo of bowl of trail mix
1/13Trail MixNuts and fruits seem like the perfect combination for your health. But dried fruit can be high in sugar. So can add-ins like yogurt-covered raisins and dark chocolate. Check the label and compare brands — or make your own. Low-sugar cereals and air-popped popcorn are good alternatives.
photo of granola bars
2/13Granola BarsThese may have ingredients that are good for you, but they also can hide a lot of sugar. Be sure to read labels carefully and choose ones that are low in that sweet stuff. Not able to find one you like? You could always go with an apple or banana instead.
photo of flavored yogurt
3/13Flavored YogurtSome fruit-infused varieties have as much as 32 grams of sugar in one 6-ounce container. That’s about 8 teaspoons. Beware of sugar-free yogurt, too.  It has aspartame, which can cause digestive problems for some people. A serving of plain yogurt with fresh fruit or jam is a good alternative.
photo of pretzels close up
4/13PretzelsThese salty snacks aren’t too bad for you. But they’re simple carbs, so they won’t fill you up for long. If pretzels are your snack of choice, have them with some sort of protein, like cheese.
photo of baked veggie chips close up
5/13Baked Veggie Chips or Veggie StrawsThese may sound like good options, but they don’t give you any of the health benefits of vegetables. Like pretzels, they’re simple carbs, and their calories can add up. They also won’t make you feel full for long unless you pair them with some type of protein.
photo of 100 calorie snack packs
6/13100-Calorie Snack PacksThe health benefits of these depend on the snack itself. For example, ones with nuts have nutritional value and may give you a quick pick-me-up, but 100 calories of cookies or chips still aren’t good for you. And the 100-calorie label doesn’t mean a lot if you have more than one pack at a time.
photo of honey roasted nuts
7/13Honey-Roasted NutsNuts are packed with protein and “good” fats, but the honey-roasted kind are also loaded with salt and sugar, thanks to their salty-sweet coating. Instead, spice up plain nuts by toasting them and adding spices like cayenne or paprika. Need a sweet fix? Add some cinnamon or vanilla extract, instead.
photo of rice cake with peanut butter
8/13Rice CakesYou probably aren’t eating these for their taste, but you’re not getting any health benefits from them, either. They’re simply empty calories. To add some protein — and flavor — spread a little peanut butter on top.
photo of canned peaches
9/13Canned FruitIt has a long shelf-life and it’s inexpensive, but if yours is packed in syrup, it’s also packed in sugar. Look for fruit that’s sealed in water or its own juice. And watch for cans that bulge or are damaged. That can let more air in the can, which could allow bacteria to grow.
photo of bowl of oatmeal and nuts
10/13Flavored Instant OatmealOn its own, instant oatmeal is a good source of iron and fiber. But you cut into those benefits when you add high-sugar flavors like maple syrup or brown sugar. You’re better off making plain oatmeal and topping it with fresh fruit or nuts.
photo of beef jerky
11/13Beef JerkyThis isn’t a bad choice if you go with types made from poultry, salmon, or lean meat. It also helps to not have it too often. But be aware that any kind of jerky is high in sodium. Check the label for a preservative called sodium nitrate. It can cause issues with the way your body uses sugar and damage your blood vessels. That could lead to diabetes or heart disease.
photo of store bought smoothie
12/13Store-Bought SmoothiesSugar from the fruit in these giant chilled drinks can add up. The blender can strip away some of the nutrients, too. To get the biggest benefit, keep yours between 4 and 6 ounces (that’s the recommended serving size for a smoothie or juice). The healthiest kind is one you make yourself. That way, you control the size and what goes in it.
photo of microwave popcorn
13/13Microwave PopcornIf you hold off on the unhealthy toppings, popcorn can be a good high-fiber snack. But many microwaveable versions have loads of salt and artificial flavors. Studies also suggest that the chemicals in the lining of the bag may affect your hormones, cholesterol levels, and immune system. Research continues on that. Air-popping the kernels and adding your own seasonings is a much healthier way to go.  

Reviewed by Mahammad Juber on 3/2/2022

Overall, using sweeteners besides sugar in drinks was associated with lower body weight, body mass index, body fat percentage, and blood lipids.

Importantly, the research team noted the timeframe of the trials, as well as the funding sources. The studies spanned from 3 to 52 weeks, with 12 weeks as an average. Eight trials were funded by government or nonprofit health agencies, four were funded by industry sources, and five were funded by both agency and industry.

The study adds evidence “that in the moderate term, [low- and no-calorie sweetened beverages] are a viable alternative to water for those with overweight or obesity,” but more evidence is needed to know the long-term effects, Julie Grim, director of nutrition for the American Diabetes Association, told CNN.

On average, Americans eat about 60 pounds of sugar each year, and almost half of that comes from drinks, according to the latest data from the American Heart Association. The numbers are typically even higher for children, adding up to more than 65 pounds of added sugar per year.

The association recommends no more than 9 teaspoons — about 36 grams or 150 calories — of added sugar per day for men and no more than 6 teaspoons — about 25 grams or 100 calories — of added sugar per day for women.

Researchers often debate the benefits of alternative sweeteners. Previous studies have found that diet soda may be as harmful for the heart as regular soda, CNN reported, while others have found that drinking two or more artificially sweetened drinks per day is still linked with health issues such as heart attacks and strokes.

But alternative sweeteners could help people slowly cut back on sugary beverages and move toward water.

“You know that you’ve got a choice, and I think that’s important for a lot of people that they have that,” Sievenpiper told CNN.

Signs You’re Mentally Exhausted

Posted by

0


What Is Mental Exhaustion?

It’s kind of like physical tiredness, except it’s your mind instead of your muscles. It tends to show up when you focus on a mentally tough task for a while. You might also feel this kind of brain drain if you’re always on alert or stressed out. Your job, caring for children or aging parents, and other things can lead to mental exhaustion.

You’re Angry or Impatient

Mental fatigue can put you in a bad mood. You may be short-tempered or irritated, snapping at people more often. It’s harder to control your emotions when you’re mentally tapped out.

You Can’t Get Work Done

Everyone’s productivity goes up and down. But mental exhaustion can make it really hard to concentrate. It also saps your motivation. You might get distracted easily or start to miss deadlines. Even small tasks may seem overwhelming.

You Zone Out

This can look like mind wandering or drowsiness. It makes it hard to pay close attention to what you’re doing, and you may not react to things very fast. That can be dangerous in certain situations, such as driving. Mental fatigue is linked to car wrecks.

You Don’t Sleep Well

You might think it’d be easier to snooze when your brain is tired. But that’s not always the case. Research shows people who have jobs with a high “cognitive workload” report more symptoms of insomnia than those who don’t have mentally exhausting work. A lack of shut-eye can make mental fatigue worse. Tell your doctor if you can’t sleep or get really tired during the day. Treatment can help.

You Do Unhealthy Things

You may start to drink or use drugs more than normal. Mental fatigue can take an even harder toll on those who already have a substance use disorder. Experts think that’s because drug addiction changes parts of the brain that help you manage stress and control impulsive behavior.

You’re Depressed

You may not have any energy or feel like you’re moving in slow motion. Some people say they feel numb. That can make it hard to finish things at work or do daily activities. Tell your doctor if you have really low feelings or a sense of hopelessness for longer than 2 weeks. That can be a sign your depression is more serious.

You Worry a Lot

Mental fatigue triggers your sympathetic nervous system. That’s your “fight or flight” mode. Anxiety is an alarm that tells you something is wrong. If you’re always mentally exhausted, you might start to feel panicked or worried all the time. That often happens alongside symptoms of depression.

Exercise Feels Harder

Experts aren’t sure why mental fatigue affects physical activity. Some think your tolerance for exercise might go down. So it may seem like you’re putting in more effort than you really are.

Your Eating Habits Change

Mental fatigue can affect your appetite in different ways. You may snack more than normal and not pay attention to what you eat. Stress can also make you crave sugary, salty, or fatty foods. Or you may not be hungry at all.

You Make More Mistakes

It’s impossible for your work to be perfect all the time. But mental fatigue lessens your ability to catch and fix your mistakes quickly or at all. That can cause serious problems in certain jobs, such as ones where you use machines, drive a vehicle, or fly a plane.

You Feel More Pain

Everyone is different, which makes it hard to say how mental fatigue will affect your body. But you might get headaches, sore muscles, back pain, or stomach problems. If you have an ongoing illness, such as fibromyalgia, you may hurt a little bit more than usual.

Take Breaks

You might feel less drained if you take short breaks during long stretches of mental work. There isn’t an exact amount of rest time that works best for everyone. But you may want to recharge for a few minutes every 1-2 hours.

Some people like to use something called the Pomodoro Technique. Here’s how it works:

  1. Set a timer for 25 minutes.
  2. Focus on one task the whole time.
  3. Take a 5-minute break when the timer goes off.
  4. After the fourth 25-minute block, take a break for 15-30 minutes.

Repeat until your task is done (or your workday is over).

Get Active

There’s evidence that you may feel even more energized if you exercise during your breaks. Try some jumping jacks and stretches for a few minutes each. Or go for a 10-15 minute brisk walk.

Find Ways to Relax

It’s hard to avoid mental exhaustion completely. But you can learn to switch on your body’s natural relaxation response. You can get a massage. Or you can try meditating, yoga, or something as simple as watching a funny movie.  Reach out to friends, family, or a mental health professional if you need more support.

Foods for Healthy, Supple Skin

Posted by

0


What to Favor

Looking to make your skin its best? Along with smart habits — like wearing sunscreen every day — check out what’s on your plate. From fighting free radicals to smoothing fine lines, some types of foods are packed with the good stuff for glowing skin. No need to obsess about a particular “superfood” or exotic ingredient. There are plenty of options in regular grocery stores. What matters most is your overall eating pattern. In a nutshell, most people need to eat more fruits and vegetables, cut down on sugar and salt, and choose whole foods over processed ones.

Flaxseeds

These tiny brown seeds are rich in ALA (alpha-linolenic acid), a type of omega-3 fatty acid found in plants. Omega-3s are fats that are good for you because they can reduce the harmful effects of UV radiation, smoking, and pollution. They can also lessen wrinkles in your skin and improve dry skin. Flaxseed oil, which is made from pressed flaxseeds, is known to make skin smoother and to appear less scaly. Other foods that are high in omega-3 fats are chia seeds, pumpkin seeds, salmon, albacore tuna, and sardines.

Kiwis

Did you know that kiwis have more vitamin C than oranges? Kiwis are helpful foods for skin health because vitamin C is a powerful antioxidant that help zaps free radicals in cells. Some studies show that vitamin C may protect skin against UV damage, help with the production of collagen, and make skin more hydrated. Eat kiwis when they’re fully ripe, as this is when they have the most antioxidants. Other good sources of vitamin C include blackcurrants, blueberries, citrus fruits, guava, red peppers, parsley, strawberries, and broccoli.

Avocados

They are good sources of vitamins C and E, which are two of the many antioxidants that help protect cells from damage. Avocados also contain lutein and zeaxanthin, which some early studies show may help improve skin tone. And avocados are rich in monounsaturated fat, which (like other fats and oils) helps your body absorb certain vitamins, including A, D, E, and K.    

Collards, Kale, Spinach

Really, any dark leafy green is an all-around nutritional powerhouse. You’ll get a virtual alphabet of vitamins from them, including lots of the antioxidants that are skin-friendly. Some studies show that people who eat two to three servings per week of dark leafy greens are less likely to develop skin cancer.

Yogurt

Not only is yogurt packed with protein, which makes it a filling snack, it’s also loaded with probiotics. Probiotics are live, friendly bacteria that help fight inflammation, including inflammation that worsens skin conditions such as acne, atopic dermatitis, and psoriasis. Probiotics can help with skin sagging and increasing skin’s hydration, too. Other foods that contain probiotics are kefir, kombucha, and sauerkraut. 

Green Tea

For smoother skin, try swapping a cup of coffee for green tea. Green tea is packed with polyphenols, a type of antioxidant found in tea leaves. Polyphenols help to lower the amount of sebum (oil) your body makes, and some evidence shows this makes green tea a good option to treat acne. Green tea also contains flavonoids, which help with DNA repair, and are even shown to help lessen fine lines. One study shows that you’ll get the most flavonoids from green tea if you steep it in cold water for a long time.

Drink Up

Water is an easy way to give your skin a healthy glow, especially if you’re prone to dry skin. You may have heard you need 8 cups a day, but there is no set advice on how much to drink. You’ll get some water from food. Watermelon, cucumbers, and celery all have high water content.

Olive Oil

When it’s part of a regular diet, olive oil is known to help curb inflammation. This may be because of the antioxidants in olive oil, some of which are being studied for use in products to curb eczema and psoriasis. Of the more than 200 types of chemical compounds that are naturally in olive oil, the main types of antioxidant in olive oil are called phenols.

Oily Fish

Coenzyme Q10, or CoQ10, is a vitamin-like substance found naturally in your body. CoQ10 helps with cell growth and fights against the free radicals that damage skin. One small study showed that CoQ10 supplements helped lessen fine lines and wrinkles in addition to smoothing overall skin texture. But starting in your mid-30s, levels of CoQ10 begin to drop. A poor diet and stress can also lower levels of CoQ10. But you can find plenty of CoQ10 in cold-water fish such as herring, salmon, and tuna.

Carrots

A good snack choice, these vegetables are in high in beta-carotene, which protects your skin against the harmful rays of the sun. Beta-carotene is what gives plants their orange color and is found in other fruits and vegetables such as apricots, cantaloupe, mango, papaya, pumpkin, and sweet potatoes. Carrots are also a good source of magnesium, which relaxes nerves and muscles. Not getting enough magnesium can lead to poor sleep, and getting enough shut-eye is something that’s always good for your skin!

Nuts

Foods that are high in vitamin E — such as almonds, peanuts, and hazelnuts — are helpful to counter some of the ways our skin ages. Vitamin E does this by helping to prevent collagen destruction, which is needed for skin support. Vitamin E is also a potent antioxidant that fights against cell damage caused by free radicals. 

More Tips for Better Skin

Good nutrition helps take care of the body from the inside out. But there’s more to great skin than what you eat. Make sure you also get a full night’s sleep, wear a broad-spectrum sunscreen with a SPF of 30 or higher, stay physically active, manage stress, and don’t smoke. These healthy lifestyle habits will get, and keep, your skin glowing. And if you have a specific skin problem or concern, see a dermatologist. 

Signs You’re Low on Vitamin B12

Posted by

0


Numbness

Do your hands, feet, or legs feel like they’re on “pins and needles”? Shortage of B12 can damage the protective sheath that covers your nerves. Diseases like celiac, Crohn’s, or other gut illnesses may make it harder for your body to absorb the vitamin. So can taking some heartburn drugs.

You’re Colder Than Usual

Without enough B12, you might not have enough healthy red blood cells to move oxygen around your body (anemia). That can leave you shivering and cold, especially in your hands and feet.

Brain Fog

A lack of B12 may lead to depression, confusion, memory problems, and dementia. It also can affect your balance. B12 supplements are usually safe. For adults, doctors recommend 2.4 micrograms a day. If you take more than what you need, your body passes the rest out through your pee. Still, high doses could have some side effects, like dizziness, headache, anxiety, nausea, and vomiting.

Weakness

Your muscles may lack strength. You also might feel tired or lightheaded. Your doctor can check how much B12 is in your body, but not all of it may be useable. So it’s important to pay attention to any symptoms — which can grow slowly or pop up more quickly — and to alert your doctor.

Smooth Tongue

Your doctor might call it atrophic glossitis. Tiny bumps on your tongue called papillae start to waste away. That makes it look and feel kind of smooth and glossy. Infections, medication, and other conditions can cause it, too. But if not enough B12 or other nutrients is to blame, your tongue also may be sore.

Herbivores Beware

B12 deficiency is rare because your body can store several years’ supply of the stuff. But plants don’t have any B12. So vegans and vegetarians who don’t eat any animal products should add some processed grains like fortified breads, crackers, and cereals.

Heart Palpitations

This is when your heart suddenly races or skips a beat. You might feel it in your throat or neck. You can get more vitamin B12 from chicken, eggs, and fish. But one of best sources by far is something that may not be a regular on your menu: beef liver.

Reason for Shortage: Age

As you get older, your body may not absorb B12 as easily. If you don’t treat it, low levels of B12 could lead to anemia, nerve damage, moodiness, and other serious problems. So watch for any symptoms, and get a blood test if your doctor recommends it.

Reason for Shortage: Weight Surgery

One of the more common weight loss operations is called “gastric bypass.” After the surgery, food bypasses parts of your stomach and small intestine. That’s usually where B12 breaks down into usable form. Your doctor likely will monitor your B12 levels and suggest supplements or shots if you need them.

Mouth Sores

You may get these ulcers on your gums or tongue. They could be a sign of low B12, anemia, or another condition. The sores usually clear up on their own, but it helps to avoid ingredients that might be irritating or painful, like vinegar, citrus, and hot spices like chili powder. Some over-the-counter medicines could soothe your pain.

Reason for Shortage: Medications

Some drugs drop your B12 levels or make it harder for your body to use the vitamin. They include:

  • Chloramphenicol, an antibiotic used to treat infection
  • Proton pump inhibitors like lansoprazole (Prevacid) and omeprazole (Prilosec)
  • Peptic ulcer meds like cimetidine (Tagamet) and famotidine (Pepcid)
  • Metformin for diabetes.

Tell your doctor and pharmacist about all drugs and supplements you take.

Digestive Woes

You might lose your appetite, drop too much weight, or have trouble pooping (constipation). If your B12 levels are low, your doctor will often inject it into a muscle to be sure your body absorbs it. Sometimes, high doses of pills work just as well. But remember that symptoms of B12 deficiency can be similar to signs of many other illnesses.

Caution for Pregnant Vegetarians

Talk to your doctor about B12 supplements, both during pregnancy and breastfeeding. Infants who don’t get enough could have serious and permanent damage to their nerves or brain cells. Your baby might need supplements, too.

The ‘Difficult’ Gallbladder: Approaches to Different Clinical Scenarios

Posted by

0


Laparoscopic cholecystectomy, one of the most commonly performed and straightforward operations for the general surgeon, usually comes off without a hitch. But difficult cases of acute cholecystitis can quickly turn morbid, and management varies dramatically from patient to patient.

“Cholecystitis is thought to be a disease process that all general surgeons can take care of—there’s an expectation that it should go well every time,” said Michael Martyak, MD, an assistant professor of surgery at Eastern Virginia Medical School, in Norfolk. “But with the increasing number of patients with comorbidities such as obesity and diabetes, and patients who struggle with access to care who present for evaluation in a delayed fashion, sometimes surgical management can be difficult.”

At the 2021 virtual American College of Surgeons Clinical Congress, Dr. Martyak and other experts in the treatment of acute cholecystitis discussed alternative approaches to difficult gallbladders, considerations for the sickest patients, and how to manage the most dreaded complication: common bile duct injury (CBDI).

To Drain or Not to Drain

Percutaneous cholecystostomy has historically been used as either a bridge to surgery or a definitive treatment in patients who are too frail to undergo surgery. Mortality related to the procedure is less than 0.5%, and percutaneous cholecystostomy is successful from a clinical point of view, relieving fever, pain and inflammatory markers in 85% to 90% of patients.

img-button

“When you look at our population of high-risk surgical patients, [percutaneous cholecystostomy] is superior to conservative management followed by delayed laparoscopic cholecystectomy,” said Raul Coimbra, MD, PhD, a professor of surgery at Loma Linda School of Medicine, in California. There are a couple of algorithms that can help guide what to do with patients after drain placement (Front Surg 2021;8:616320; Abdom Radiol 2020;45[4]:1193-1197). The second and simpler one advises following up on all patients at two weeks with cholangiography (Figure). “If the patient is a surgical candidate, they should undergo cholecystectomy; if they are not a surgical candidate, one option is percutaneous cholecystolithotomy, though that’s performed in the minority of patients,” Dr. Coimbra said.

A novel alternative to percutaneous cholecystostomy worth watching is endosonography-guided gallbladder drainage. “You locate the gallbladder through the stomach or duodenum, perform a cholecystogastric or cholecystoduodenal fistula through a stent, and remove the stones,” Dr. Coimbra said.

A recent multicenter, randomized controlled trial found this technique resulted in lower rates of recurrence, and fewer 30-day reinterventions, unplanned admissions, and 30-day and one-year adverse events than percutaneous cholecystostomy (Gut 2020;69[6]:1085-1091).

“Both are technically and clinically successful procedures, so both work. But it seems that the performance of the novel technique is much superior,” Dr. Coimbra noted.

Subtotal Cholecystectomy: A Safer Bailout

When a CBDI appears imminent during a difficult cholecystectomy, the default has been converting from laparoscopic to open surgery. But it might be counterintuitive for the most recent generation of surgeons, well trained in laparoscopy, to turn to a less familiar option when surgery becomes challenging.

ADVERTISEMENT

“The truth of the matter is that inflammation doesn’t vanish when it’s exposed to air; a difficult gallbladder laparoscopically is a difficult gallbladder open,” said Sharmila Dissanaike, MD, the Peter C. Canizaro Chair of the Department of Surgery at Texas Tech University, in Lubbock.

Enter subtotal cholecystectomy, a relatively new approach that is gaining traction. “It’s probably accepted these days as the safest option to prevent severe bile duct injury,” Dr. Dissanaike said.

The two types, reconstituting and fenestrating, are both easy to perform laparoscopically and open, Dr. Dissanaike said. “The key is staying high, away from the danger zone; opening into the gallbladder antero-laterally; leaving only about 1 cm of infundibulum; taking as much of the posterior wall as you safely can; and clearing all the stones.”

How do you choose between the two? It’s a bit of a toss-up, weighing potential complications. “Fenestrating will usually give you a bile leak and it has slightly more reinterventions, but reconstituting seems to have more recurrent biliary symptoms,” Dr. Dissanaike said.

ADVERTISEMENT

Finally, she recommended reserving subtotal cholecystectomy for the most difficult cases, when dissection is truly dangerous. “If we drop the threshold to perform subtotal cholecystectomy too low, we might have unacceptably high rates of patients needing reoperation,” Dr. Dissanaike said.

Cholecystitis and Cirrhosis: Managing the Sickest Patients

Patients with cirrhosis and cholecystitis are at increased risk for a number of complications and difficult surgery. The decision to proceed with surgery begins with an assessment of the patient’s capacity to tolerate it.

“Clearly there is a large spectrum of cirrhosis, and stratifying the perioperative mortality is important,” said Kristin Ellen Raven, MD, a transplant surgeon at Beth Israel Deaconess Medical Center and faculty member at Harvard Medical School, both in Boston.

ADVERTISEMENT

For example, patients classified as Childs A are likely to survive surgery; similarly, those with a Model for End-stage Liver Disease (MELD) score less than 15 who have not been decompensated also have a relatively low mortality risk of 10% to 15%.

To further determine surgical risk in cirrhotic patients, Dr. Raven uses a calculator available on Mayo Clinic’s website that takes into account age and American Society of Anesthesiologists physical status in addition to MELD score (https://mayocl.in/ 32ICYIo). “I find this calculator extremely valuable to discuss risk with patients and family, and to provide solid data to nonsurgical colleagues who may be pushing for an operation.”

When surgery is deemed feasible, Dr. Raven advocates for the least invasive operation possible, noting that risk rises with procedure length. “The cumulative risk for perioperative complications is four times higher past two hours than it is for a 30- to 60-minute laparoscopic cholecystectomy. I have a low threshold to open.”{ARTICLE-AD5} 

For decompensated patients, she recommends starting initial nonoperative management with NPO order and IV antibiotics. “I require that decompensated cirrhotics really force me to operate, meaning they’ve failed several days of conservative management,” Dr. Raven said.

But surgery is only part of the challenge in managing patients with cirrhosis. Postoperative care requires hemodynamic monitoring, possible ICU admission, optimal coagulopathy, management of ascites and other considerations.

“The ability of your institution to care for these patients postoperatively should weigh heavily in your decision to operate,” Dr. Raven said.

Managing Common Bile Duct Injury

Despite such precautionary measures as achieving a critical view of safety and bailing out to subtotal cholecystectomy, common bile duct injuries still occur in up to 0.4% of all laparoscopic cholecystectomies. Katherine Morgan, MD, suggested steps for managing this daunting complication.{ARTICLE-AD6} 

“The first step, to quote my hilarious partner, is to take your own pulse; it’s terrifying to see an unexpected bile leak, which can compromise your judgment, so take pause,” she said.

Second, call a senior partner or phone an accessible hepato-pancreatico-biliary (HPB) surgeon for help, said Dr. Morgan, a professor of surgery and the head of the Division of Hepato-Pancreatico-Biliary Surgery, Medical University of South Carolina, in Charleston. Although she was trained to convert to open when laparoscopic cholecystectomy becomes difficult, like Dr. Dissanaike, Dr. Morgan thinks this approach may no longer be the safest option for surgeons trained more in minimally invasive surgery than open procedures. “Opening does not make this operation any easier,” she said.

Third, and most important, obtain drainage. “Controlling the bile leak will prevent sepsis and allow for the inflammatory physiology to resolve to allow the patient to be prepared for a more definitive repair later on,” Dr. Morgan said.{ARTICLE-AD7} 

Finally, consider an early referral to an HPB center. “Management of CBDI really is a multidisciplinary effort. It involves the therapeutic endoscopist, interventional radiology and HPB surgery,” she said, noting that attempting CBDI repair at the primary hospital has been identified as an independent risk factor for poor outcomes.

Mesh Removal: How Much Does Surgical Approach Matter?

Posted by

0


Does surgical approach have a role in inguinal hernia mesh removal? At the 2021 annual meeting of the Americas Hernia Society (abstract 50176), researchers of a new study sought to answer this question.

image

The study led by Desmond Huynh, MD, a PGY-4 general surgery resident at Cedars-Sinai Medical Center, in Los Angeles, included 113 patients, 39 of whom had open, 23 of whom had laparoscopic and 51 of whom had robotic mesh removal. The approach was based on initial mesh placement. Mesh that was placed anteriorly in an open fashion was removed via the open technique, and preperitoneal mesh was removed either laparoscopically or robotically.

ADVERTISEMENT

Patients were evaluated two weeks after removal, and long-term follow-up occurred at a mean of 2.5 years. The patients in the three cohorts were well balanced in terms of comorbidities and indications for mesh removal, which included foreign-body sensation, meshoma, reaction, neuralgia and infection.

Table. Operative Complications
OpenLaparoscopicRoboticP Value
Intraoperative injury4 (10%)8 (39%)8 (16%)0.044
Minor vascular (inferior epigastric, gonadal)4 (10%)4 (17%)7 (14%)NS
Major vascular (external iliac)0 (0%)3 (13%)1 (2%)0.019
Nerve01 (4.3%)0NS
Organ000NS
NS, nonsignificant

The operative time was longest with the robotic approach (226 minutes), followed by open (181 minutes) and laparoscopic procedures (169 minutes). There was a significantly different rate of intraoperative injury and major vascular injury among the three approaches, with the laparoscopic group having the highest rate of injury (Table). The mean blood loss was 77 mL in open, 96 mL in laparoscopic and 52 mL in robotic procedures, with significant variance. There was no difference in postoperative complications among approaches. There was no difference in pain scores among groups at two-week and long-term follow-up with a mean of 2.5 years. There was a significant improvement in pain scores in all patients after mesh removal. There was no difference in pain score improvement among the approaches.

ADVERTISEMENT

The authors concluded that all mesh removal approaches were effective in treating chronic postoperative inguinal pain after inguinal hernia repair. The three groups were equally affected by treating postoperative chronic inguinal pain, yielding durable improvement. There was significant variance among the groups with regard to operative time, rate of injury and blood loss, with post hoc analysis suggesting that a robotic approach may confer some advantage, Dr. Huynh said. However, these observed differences were small.

“Based on [what the authors say], open repair is always going to be the procedure of choice for meshes that were placed anteriorly. In these cases, open removal was as good as robotic,” said Kamal Itani, MD, the chief of surgery at VA Boston Health Care System, a professor of surgery at Boston University and a faculty member at Harvard Medical School, who was not involved with the study. “It then becomes a comparison between the laparoscopic and robotic approach for posteriorly placed meshes. Although the surgery was longer with the robot, there were less complications with the robotic approach compared to laparoscopic. The numbers are too small, and possible confounders too many to reach solid conclusions. However, [this study] could be hypothesis-generating for a larger prospective multicenter study looking at laparoscopic versus robotic explantation of meshes in patients that had posteriorly placed mesh.”

ADVERTISEMENT

Dr. Huynh noted that mesh removal is safe and effective for treating chronic postoperative inguinal pain in the right patients, regardless of the approach taken. “Due to the reoperative setting and distorted anatomy, these cases should be approached judiciously by surgeons who are practiced in it,” Dr. Huynh said. “Based on our group’s own experience and trends in this data set, we prefer a robotic approach when appropriate. However, we continue to regularly employ the open and laparoscopic techniques when necessary.”