Friday, April 5, 2019

The times, they are a-changin’ (and bringing new syndromes)

If your doctor told you that she was giving you a placebo and that it would help you, would you believe her? As it turns out, based on new research, maybe you should.

Placebos are often considered “fake” treatments. You may have heard them described as “sugar pills.” They usually take the form of pills, injections, or even entire procedures that are used in clinical trials to test “real” treatments. For example, one group of study participants is given an active drug and another group is given a placebo, which looks exactly like the active medication but is completely inactive. The participants can’t tell whether they’re getting the fake drug or the real drug. The researchers wait to see if the people taking the real one do better (or worse) than those taking the fake one.

To complicate matters, there is a documented “placebo effect,” which means that some people actually respond to a placebo even though it shouldn’t have an effect on the body. This has been thought to be largely due to their beliefs or expectations that they are getting the real treatment and not the fake one. But what if people were told, up-front, that they were getting a placebo and not an active medication? It stands to reason the placebo would have no effect. Right?

What an “open-label placebo” can do for you

Dr. Ted J. Kaptchuk, a professor of medicine at Harvard Medical School and director of the Harvard-wide Program in Placebo Studies and the Therapeutic Encounter (PiPS) at Beth Israel Deaconess Medical Center in Boston, has been studying placebos for more than 20 years. His most recent work on these “open-label placebos,” as they’re called, is fascinating. I had a chance to interview him in person earlier this year.

In one study, Kaptchuk looked at people with irritable bowel syndrome (IBS), a common condition that causes abdominal cramping and diarrhea or constipation that can be debilitating for many. Half of the study volunteers were told they were getting an “open-label” placebo and the others got nothing at all. He found that there was a dramatic and significant improvement in the placebo group’s IBS symptoms, even though they were explicitly told they were getting a “sugar pill” without any active medication.

Kaptchuk says placebos won’t work for every medical situation—for example, they can’t lower cholesterol or cure cancer. But they can work for conditions that are defined by “self-observation” symptoms like pain, nausea, or fatigue.

“People can still get a placebo response, even though they know they are on a placebo,” he adds. “You don’t need deception or concealment for many conditions to get a significant and meaningful placebo effect.”
Are open-label placebos a promising new strategy?

Kaptchuk says more research is needed — and some is currently under way. He has another study at the Dana-Farber Cancer Institute studying cancer-related fatigue. And a recent study overseas looking at open-label placebo for chronic low back pain looks promising. If placebo works for chronic pain, explains Kaptchuk, it could allow patients to reduce their doses of opioid medications and help prevent addiction.

“Our hope is that in conditions where the open-label placebo might be valuable, instead of putting people on drugs immediately — for depression, chronic pain, fatigue — that people would be put on placebo,” says Kaptchuk. “If it works, great. If not, then go on to drugs.” Antibiotic resistance occurs when bacteria mutate to “outsmart” or resist antibiotic medicine, making the bacterial infection more difficult for doctors to treat and cure with standard medications. According to the Centers for Disease Control and Prevention (CDC), more than 2 million people are infected with antibiotic resistant bacteria every year, and more than 23,000 people die from these infections.

While some bacteria become resistant to a particular antibiotic, other, more dangerous strains have grown resistant to almost every treatment option. This means that doctors must use stronger and less common antibiotics to treat these infections. But a recent discovery now has doctors concerned about the success of even these last-resort antibiotics.
The appearance of a serious superbug

In May, a woman in Pennsylvania became infected with a form of E. coli infection resistant to the drug colistin. Colistin is usually reserved for infections that don’t respond to the strongest antibiotics. Scientists from the Multidrug Resistant Organism Repository and Surveillance Network (MSRN) at the Walter Reed Institute of Research (WRAIR) showed that a gene called mcr-1 was responsible for the bacteria’s resistance to colistin.

MCR-1 is found on a plasmid, which is a portable piece of DNA that can replicate on its own. The presence of mcr-1 means that the bacteria can develop a resistance to colistin, weakening its effectiveness as a treatment. “This development is distressing because colistin is a drug that most doctors will never need to use but it’s nice to have in your back pocket, just in case,” says John Ross, MD, an assistant professor of medicine at Harvard Medical School. “If there is a potential that bacteria can become resistance to colistin, it’s kind of like losing your security blanket.”

As more cases of bacteria with mcr-1 are discovered around the globe, many doctors are concerned that this gene could transfer to a type of bacteria known as carbapenem-resistant bacteria, or CRE, that is resistant a group of antibiotics called carbapenems. When an infection doesn’t respond to carbapenem, doctors normally use colistin. But if a plasmid-carrying mcr-1 transfers to CRE bacteria, then these bacteria would be resistant to both carbapenem and colistin, says Ross. If this happens, CRE would become a superbug –– it would be completely resistant to all forms of antibiotics.

Although the creation of a CRE superbug would cause problems in hospitals where bacterial infections are more common, CRE infection is rare, as there are fewer than 600 reported cases each year.
Explaining the rise in antibiotic resistance

There are multiple factors that are speeding up the process of antibiotic resistance:

    Antibiotics in agriculture. Today, the most widespread use of antibiotics occurs on farms. According to the CDC, using antibiotics in food-producing animals has contributed to the rise of antibiotic resistant bacteria in animals, which are then transferred to humans when we eat foods from these animals like meat or milk.
    Evolution of bacteria. Currently, bacteria are evolving to develop resistance to antibiotics faster than we can create new medicines to treat them, leaving doctors with fewer tools in their arsenal to fight against bacteria.
    Overuse of antibiotics. Many people take antibiotics when it isn’t medically necessary. “Most upper respiratory tract infections, whether it’s a sore throat or sinus symptoms, are due to viruses and will get better without the use of antibiotics,” says Ross.

Protecting yourself and your family

The appearance of super bugs doesn’t mean that healthy people will suddenly become infected with different types of untreatable infections. The threat of antibiotic resistance is much larger in hospital settings, especially in people who are recovering from surgery or have weakened immune systems. Falling short of creating brand-new medicines to treat bacterial infections, doctors urge patients to take antibiotics only when absolutely necessary.

“Often times people with an infection will feel better without antibiotics, and antibiotics, in a lot of cases, won’t speed up the process of getting better,” says Ross. “We need to have a conversation about how we can limit antibiotic use as a society as a whole.” The results are in from the 2015 National Youth Risk Behavior Survey (YRBS). There is a lot to celebrate — but there are also some trends that parents, and everyone who spends time with or works with teens, should know about.

The YRBS is a nationwide survey of high school students conducted every two years. More than 15,000 students participated in the 2015 survey. The point of the survey is to monitor behaviors that can put the health and safety of teens at risk. It’s a confidential survey that allows teens to admit to things they might not want to admit to their parents and teachers. The more we know what is going on, the more we can put things in place to keep teens healthier and safer.

Here’s the good news:

    Cigarette smoking among teens has dropped to its lowest level since the survey began in 1991. Back then, 28% smoked; in 2015, that number was 11%.
    Soda consumption is down too; the percentage of teens having one or more sodas a day dropped from 27% in 2013 to 20% in 2015.
    Physical fighting is also the lowest it’s been since 1991; it has dropped from 42% to 23%.
    Fewer teens are having sex. In 1991, 38% of high schoolers reported having had sex; in 2015 that number was 30% (down from 34% in 2013).

This is all good news. But there were also some worrisome trends:

    While they aren’t smoking as much, they are using e-cigarettes more: 24% reported using one in the past month. This could lead to nicotine addiction and other health problems.
    They aren’t getting into fights, but they don’t necessarily feel safer: 6% of students reported missing at least one day of school in the past month because of safety concerns.
    They are having less sex, but they aren’t using condoms: after going up in the late 90s and early 2000s, condom use has dropped from 63% in 2003 to 57% in 2015.
    Not surprisingly, technology is leading to some risky behavior:
        Computer use for more than 3 hours a day (for non-school stuff) has nearly doubled, from 22% in 2003 to 42% in 2015. That’s a lot of sedentary time.
        Among teens that drive, 42% report texting or e-mailing while driving in the past month. That is terrifying.

If you have teens in your life, talk to them about this survey. Find out what they are doing — and talk to them about making choices that keep them safe and healthy, not just now but in the future too. These aren’t easy conversations to have, but they are incredibly important. They could literally save lives.

Even more than conversations, as a society we need to work to put education, laws, services and supports in place to be sure that we are doing everything possible to take care of our youth. They are our responsibility, and our future. When are symptoms due to a medical condition, and when are they just a part of life? That’s the question that came to mind as I read about “computer vision syndrome.”
So, what is a syndrome, anyway?

Before considering the health hazards of working long hours in front of a computer screen, it’s worth asking what a syndrome is. In medicine we often use the word syndrome to describe a group of features, such as symptoms, examination findings or test results, that tend to occur together but without a clear enough understanding of their cause to be considered a specific disease.

Some syndromes are described by the part of the body involved: carpal tunnel syndrome, for example, is caused by the compression of a nerve in a narrow part of the wrist called the carpal tunnel. Other syndromes are named for the person or persons who were among the first to describe them: Down syndrome is a genetic disorder named for the British physician Dr. John Langdon Down, who described it in 1862 — well before its cause (an extra copy of chromosome 21) was recognized. Still others are named for the problems they cause. For example, restless legs syndrome” tells you a lot about the symptoms that people with this condition experience. But in many cases, the difference between calling a condition a “syndrome” and simply describing a cluster of symptoms is more about language than about science or medicine.
Eye strain? Or computer vision syndrome?

My medical dictionary lists more than 600 conditions as “syndromes.” Well, now we can add one more: a recently published report describes a new syndrome: “computer vision syndrome.” This is a condition increasingly recognized among people working long hours on a computer who complain of eye problems including:

    blurry vision
    double vision
    a burning sensation in the eyes.

Symptoms may be severe enough to interfere with continued computer work.
Is computer vision syndrome a major public health problem?

The authors of the report suggest that up to 70 million people worldwide are at risk for computer vision syndrome. And this number is likely to grow, considering the large (and increasing) numbers of students and employees who rely on their computers for many hours each day. According to the researchers, up to 90% of people who use a computer for prolonged periods of time will report one or more of these symptoms. And that’s not counting other health problems linked to extensive computer use, including back, neck, and shoulder pain; carpal tunnel syndrome; and headaches. Together, it’s enough to make you view an ordinary computer as a potential health hazard.
Why are vision problems so common with computer use?

The authors of this paper suggest several explanations for computer vision syndrome:

    The text and images on a computer screen are made up of pixels with blurry edges. The eyes have to work harder to focus on them compared with text and images on a printed page. This may lead to eye strain.
    Reduced blinking is another potential issue. People tend to blink less frequently than usual when working on a computer. (Normally, we blink about 17 times a minute, but this often drops to 12-15 times a minute during computer use.) Less blinking can lead to dryness.

What’s to be done?

There are a number of ways to combat computer vision syndrome:

    Don’t sit so close. Ideally, the computer screen should be about two feet away from your face.
    Position the monitor well. Experts recommend that the center of the monitor should be 4 to 8 inches lower than eye level. Looking down a bit while working means the eyes are less exposed and therefore less likely to become dry.
    Optimize contrast. Black text on a bright white screen is best.
    Minimize glare. Dimming overhead lights, lowering window shades, using an anti-glare flat-screen monitor, and wearing special glasses can all be helpful.
    Take breaks. Try the 20-20-20 rule, for example: take a 20-second break every 20 minutes and focus your eyes on something at least 20 feet away. While you’re at it, stretch your neck and shoulders.
    Combat dryness. Blink often and use moisturizing eye drops if necessary. Avoiding air drafts and using moisturizing compresses can also help.
    Change the font size. Use a larger font or magnify the viewing display if that makes it easier to see.
    Get your eyes checked at least yearly. Many people strain their eyes while using their computers because their prescription for glasses or contacts is outdated. Let your eye doctor know of any problems you’re having. Bifocals or progressive lenses can make a big difference, especially if you do a lot of moving back and forth between the computer screen and printed material.

What’s next?

Computer vision syndrome may be the newest technology-related threat to public health, but new syndromes related to changes in how we work and play is nothing new. I recall a form of tendinitis called “Blackberry thumb” being described as a “scourge” in 2005, when texting on the new wireless device was becoming common. It’s a reminder that as our technology changes, some impact on our health is probably inevitable.

And whether we consider it a new disease, a new syndrome, or just a part of working long hours in front of a computer screen, the most important thing is to recognize the problems described by computer vision syndrome and take measures to prevent and treat them. That’s particularly true because computer vision syndrome may be the latest technology-related syndrome to be described, but it probably won’t be the last.

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