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Stories about shootings are becoming far too common. The news is full of stories of shootings at schools, workplaces, and other public places. While stories of mass shootings get the headlines, guns kill people every day. According to the Centers for Disease Control and Prevention (CDC), guns killed almost 40,000 people in 2017, the highest amount in the nearly 50 years since the CDC started their electronic database.

Here are some other important facts:

  • Firearm injury is the cause of death in 74% of all homicides and 87% of all youth homicides.
  • Every day, 78 children, teens, and young adults are injured or killed by guns in the US.
  • The risk of death by suicide is four to 10 times higher in homes with guns. Firearms are used in 50% of all suicides, and 42% of youth suicides.
  • One in three homes with children in the US has a gun.
  • Children as young as 3 years old may be strong enough to pull the trigger on a handgun.
  • Three out of four children (including children less than 10 years old) living in a house with a gun know where the gun is, even when their parents think they don’t.
  • While many people feel that having a gun keeps them safer, the research suggests that the opposite is true.
Three ways to keep everyone safer

Gun ownership is a polarizing issue here in the US. But whatever anyone thinks about gun ownership, all can agree that we need to work to keep people safe — particularly our children. Here are three things all parents can do:

  • If you own a gun, lock it up, unloaded. Keep ammunition locked up separately.
  • Ask if there is an unlocked gun where your child plays. This simple question can save your child’s life. If the answer is yes, ask if it can be locked up (unloaded, with the ammunition locked separately). If the gun isn’t stored safely, your child shouldn’t play there.
  • If your child has a history of depression or other mental health problems, don’t keep a gun at home. Locking it up may not be enough to keep your child safe.

Somehow, we need to come together to put some common sense laws to keep people safe. As a country, we have a very high rate of gun deaths compared to other developed countries. That’s something that should alarm us. Background checks and waiting periods make good sense, as do measures that work to make guns less available to people with mental health problems.

Our children rely on us to keep them safe — including from gun injury.

Follow me on Twitter @drClaire

The post Children and gun safety: What to know and do appeared first on Harvard Health Blog.

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If you’ve been diagnosed with kidney stones (urolithiasis), you may have several options for treatment. These include medical therapy, extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotripsy (PCNL), and ureteroscopy.

A brief anatomy of the urinary tract

The urinary tract includes

  • kidneys (two organs that filter waste and extra water from the blood)
  • ureters (two tubes bringing urine from each kidney to the bladder)
  • bladder (organ that collects urine)
  • urethra (a single tube through which urine in the bladder passes out of the body).
The evaluation for kidney stones

If your symptoms suggest kidney stones, imaging is often the first step in an evaluation. For many years the standard of care was a type of abdominal x-ray called an intravenous pyelogram (IVP). In most medical centers, this has been replaced by a type of computed tomography (CT) called unenhanced helical CT scanning. In some cases, such as when a person has impaired renal function or a contrast dye allergy, renal ultrasound may be used as an alternative.

You will also have blood tests, including tests for renal function (creatinine, BUN). Your doctor may suggest other blood tests as well. A urinalysis will be obtained and if infection is suspected, a urine culture will be sent.

Keeping kidney stone pain under control

If you are experiencing the intense discomfort of kidney stones (renal colic), pain control is a top priority. A 2018 analysis of multiple randomized trials looked at different pain relief medicines given to people treated in the emergency department for acute renal colic. It compared nonsteroidal anti-inflammatory drugs (NSAIDs, such as aspirin, ibuprofen, or naproxen) with paracetamol (similar to acetaminophen) or opioids. The study found NSAIDs offered effective pain relief with fewer side effects than paracetamol or opioids. NSAIDs directly inhibit the synthesis of prostaglandins, which decreases activation of pain receptors and reduces renal blood flow and ureteral contractions.

Medical therapy for kidney stones

Most evidence suggests that stones less than 10 mm in diameter have a reasonable chance of passing through the urinary tract spontaneously. You may be offered medical expulsive therapy (MET) using an alpha blocker medication, such as tamsulosin. It’s important to understand that this is an off-label use of the drug. Rarely, tamsulosin causes a condition called intraoperative floppy iris syndrome that can complicate cataract surgery.

Not all experts feel MET is worthwhile, and its use remains controversial. Discuss your options with your doctor or a urologist.

Extracorporeal shock wave lithotripsy

All shock wave lithotripsy machines deliver shock waves through the skin to the stone in the kidney. Most but not all of the energy from the shock wave is delivered to the stone.

Stone size is the greatest predictor of ESWL success. Generally:

  • stones less than 10 mm in size can be successfully treated
  • for stones 10 to 20 mm in size, additional factors such as stone composition and stone location should be considered
  • stones larger than 20 mm are usually not successfully treated with ESWL.

Stones in the lower third of the kidney can also be problematic because, after fragmentation, the stone fragments may not be cleared from the kidney. Due to gravity, these fragments don’t pass out of the kidney as easily as fragments from the middle and upper thirds of the kidney.

Obesity also influences whether ESWL treatment will be successful. The urologist will calculate the skin-to-stone distance (SSD) to help determine whether this treatment is likely to be effective.

The possible complications of ESWL include:

  • Injury to kidney tissue, such as bruising (hematoma), can occur in a small number of cases, but usually heals without additional treatment.
  • Fragmented stones may accumulate in the ureter and form an obstruction. This is known as a steinstrasse (“street of stones”). A ureteral stent often minimizes any problems associated with steinstrasse. The stent is removed in a few days or weeks.
  • A small percentage of patients undergoing ESWL develop hypertension, although the mechanism is not well understood.
  • An increased risk of diabetes mellitus following ESWL has also been reported. However, these results were not confirmed by a large population study done at the same institution.
Percutaneous nephrolithotripsy

Using ultrasound or fluoroscopic guidance, a surgeon gains access to kidney stones through a small incision in the lower back during percutaneous nephrolithotripsy. A power source, such as ultrasound or laser, breaks the stones into fragments, which are flushed out of the kidney through an external tube or internal stent.

This treatment is usually considered for larger kidney stones (2 cm or more), complex stones, or lower pole renal stones larger than 1 cm. Possible complications may include bleeding, infection, and injury to surrounding organs.


During ureteroscopy, a surgeon places a tube through the urethra and bladder into the ureter, possibly going all the way up into the kidney. Ureteroscopy employs either semirigid or flexible instruments through which the surgeon has an excellent view of everything inside the urethra. The surgeon then uses a power source threaded up through the ureteroscope to fragment the stones under direct visualization. A postoperative stent can be placed for a few days at the discretion of the urologist.

Complications are infrequent, but may include injury to or narrowing of the ureter, as well as sepsis.

The post Kidney stones: What are your treatment options? appeared first on Harvard Health Blog.

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Osteoporosis is a condition in which bones become porous (less dense) and weaker. It affects 10 million people in the United States: approximately eight million women and two million men. As bone weakens, people are more likely to experience fractures, especially in the spine, hip, and forearm. This causes pain, diminishes a person’s ability to function, and reduces quality of life. Anything that can lower the risk of osteoporosis and fractures has major positive public health implications. That’s why a new drug called romosozumab is getting a lot of attention.

Which medications can help treat osteoporosis?

There are currently several medications available to treat osteoporosis. These include medications that

  • block the breakdown of bone (anti-resorptive therapies). Examples include bisphosphonates such as alendronate (Fosamax), which is a pill, and zoledronate (Reclast), which is given intravenously. Other types of anti-resorptive agents include raloxifene (Evista) and denosumab (Prolia).
  • enhance the formation of bone (anabolic therapies). Examples include teriparatide (Forteo) and abaloparatide (Tymlos).

Now, for the first time since 2010, a new class of medication is available to treat osteoporosis. Romosozumab (Evenity) is in a class called sclerostin inhibitors and is considered an anabolic agent.

Sclerostin is a protein that helps regulate bone metabolism. Produced by osteocytes (bone cells), it inhibits bone formation (making new bone). Romosozumab binds sclerostin, which keeps it from blocking the signaling pathway for new bone formation. The result is an increase in new bone. To a lesser degree, it also decreases bone resorption (breakdown of bone).

Romosozumab is approved by the FDA to treat osteoporosis in women who have completed menopause and are at high risk for fracture. A history of fracture due to osteoporosis, multiple risk factors for fracture, no success with other therapies, or being unable to tolerate other therapies are reasons to consider romosozumab.

How is romosozumab given?

The medication is injected once a month using two separate prefilled syringes for a full dose. Romosozumab should only be taken for one year, because its bone-making activity wanes after 12 months. Women using this therapy should also make sure they get enough calcium and vitamin D during treatment.

What does research tell us?

Two large trials in The New England Journal of Medicine (which were funded by the drug manufacturer) have looked at this new medication. One trial enrolled over 7,000 postmenopausal women with osteoporosis based on low bone density measurements. Half received romosozumab and half placebo (inactive medication) for one year. Women using romosozumab versus placebo had far fewer new vertebral fractures: 16 in the treatment group, 59 in the placebo group.

In the second year of the study, all participants — including those who had been taking a placebo — were given the anti-resorptive agent denosumab. The group that received romosozumab followed by denosumab had 21 vertebral fractures, compared to 84 in the group that received placebo followed by denosumab.

Another trial enrolled more than 4,000 postmenopausal women with osteoporosis and a history of related fractures. Half were treated with a monthly injection of romosozumab for one year, followed by alendronate once a week for the second year. The other half received alendronate once a week for both years.

At the end of the study:

  • those assigned to receive romosozumab in the first year had fewer new spine fractures than those receiving alendronate for both years (127 vs. 243)
  • hip fractures also occurred less often among those receiving romosozumab (41 versus 66)
  • bone density was higher in the group that received romosozumab.
What are the possible side effects?

Joint pain and headache are the most common side effects of romosozumab. Very rarely, some people experience loss of bone tissue (osteonecrosis) in the jaw and atypical thigh bone fractures. (This also occurs very rarely with bisphosphonates and denosumab.)

Additionally, the risk of heart attacks, stroke, and cardiovascular death was slightly higher among those given romosozumab in the first year than it was among those given alendronate for both years. If you have had a heart attack or stroke, or are at high risk for either, ask your doctor whether you should choose a different type of osteoporosis medication.

The bottom line

We do not yet have long-term data on romosozumab. But a dual effect (increasing bone formation and decreasing bone resorption) makes it a welcome addition to available treatments for osteoporosis — at least for postmenopausal women at high risk for fracture.

Based on this research, a year of romosozumab therapy, followed by an anti-resorptive agent like alendronate, zoledronate, or denosumab, is a new and effective option for certain women to prevent fractures related to osteoporosis. However, cost may be a factor, and there may be small but important risks to understand about this approach when discussing your treatment options with your doctor. Ultimately, more long-term research is needed to help determine safety and effectiveness over time.

The post A new therapy for osteoporosis: Romosozumab appeared first on Harvard Health Blog.

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We hear a lot about the three trimesters of pregnancy. But many women (and even some medical professionals) know little about a newly described and critical time period in women’s lives that desperately needs our attention: the fourth trimester.

As a practicing obstetrician-gynecologist, I know that the medical care of women before, during, and immediately after pregnancy has long focused on the goal of achieving a healthy pregnancy and a healthy baby. But too often, the fourth trimester — that time between birth and 12 weeks postpartum — is swept aside.

For example, we encourage all women to start taking prenatal vitamins before conceiving and meet with their primary care providers to optimize their health before conception. During pregnancy, women’s schedules are filled with appointments for prenatal care visits, ultrasounds, and lab tests, and perhaps even nutrition and social work consultations. Weekly visits in the final month of pregnancy provide opportunities for fetal heart checks, maternal blood pressure and weight evaluations, paired with slow and steady counseling and anticipatory guidance for the process of labor and birth. Though some attention is given to preparing pregnant women for the challenges of breastfeeding and the pitfalls of postpartum depression, women, families, and healthcare providers tend to focus on a healthy outcome at birth.

What happens during the fourth trimester?

After birth, the close attention given to mothers in the last few weeks of pregnancy is picked up with a similar intensity by pediatric providers caring for newborns. Usually, babies have their first pediatric visit within one week of birth. Their well-being is closely monitored over the first weeks and months of life.

And for the mothers? Well, your routine postpartum visit (yes — usually there’s only one) is scheduled for six to eight weeks after childbirth. Perhaps for many low-risk women, this long interval between giving birth and a postpartum visit with their obstetric provider is adequate. But let’s review: by the time they arrive at their office at six weeks, most women who give birth have survived the pain caused by tearing during a vaginal birth, a surgical incision after cesarean delivery, and/or hemorrhoids in the first two to three weeks. Many are coping with the physical and emotional challenges of breastfeeding. They’ve grappled with sleeplessness and may have overcome their initial baby blues.

While this early postpartum period is a time of great joy for many, it’s also a very vulnerable time. Women and their families experience substantial physiological, social, and emotional changes. Why, then, do we not offer careful monitoring, support, and anticipatory guidance with the same fervor as in the weeks before childbirth, in order to keep women safe? Most women would benefit from much closer follow-up during the fourth trimester.

Attitudes are changing

Fortunately, attitudes toward the fourth trimester are changing. The American College of Obstetrics and Gynecology (ACOG), which governs standards of care and guides practice, now recommends that medical professionals view postpartum care through the lens of maternal health. A committee report

  • calls for closer follow-up of women after birth
  • provides doctors with specific recommendations
  • emphasizes that a change in reimbursement policies is needed to support individualized, continuous postpartum care for each woman.

Their focus on the fourth trimester clearly acknowledges that the goals of pregnancy care must go beyond achieving a healthy pregnancy and a healthy baby to include a healthy mother!

How can you gain support during the fourth trimester?

If you are pregnant, start by talking to your obstetric team to learn what sort of support they can offer you during the fourth trimester.

Online resources are available to help you and your family create a “postpartum plan,” such as this one created by Mara Acel-Green, LICSW. Having a plan can help you anticipate difficulties and be prepared to get the types of support you need, which can be very challenging to access from scratch during the sleep-deprived early weeks after childbirth.

It helps to add your own individualized medical section to any postpartum plan you fill out. Discuss these questions with your obstetric team and any other healthcare providers you typically see:

  • Do you have medical or emotional conditions that are expected to change during the postpartum period?
  • Will any medications you take need to be adjusted?
  • What warning signs should you or your family look for?
  • When is the best time for your first postpartum check-up?

Finally, pregnancy is a window into future health. Ask your providers about how best to maintain the medical discoveries made during pregnancy as part of your long-term health maintenance plan.

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The four major structural components of our face are skin, fat, muscle, and bone. As we age, volume loss in these structures contributes to many of the visible signs of aging. Dermal fillers may help.

Over time, age-related bone loss in the face can lead to retraction of the jawline, descent of the nose, and loss of high cheekbones. The facial muscles also decrease in volume and elasticity, and deflation and movement of facial fat further accentuates the signs of aging. Finally, the skin stretches and loses elasticity — compounded by the loss of scaffolding provided by fat, muscle, and bone, this leads to wrinkles, sagging skin, and other familiar signs of aging.

Dermal fillers, an injectable treatment performed in a doctor’s office, can help smooth lines and replenish lost volume, restoring a more youthful appearance.

What are dermal fillers?

Dermal fillers are soft, gel-like substances that are injected under the skin. They can address a number of common concerns including smoothing of deep under-eye circles, lifting of cheekbones, volumization of the lips, smoothing of lip lines and nasolabilal folds (the creases that run from the side of the nose to the corners of the mouth), and rejuvenation of the hands.

Dermal fillers can be composed of a variety of substances, some naturally occurring and some synthetic. One of the most common compounds used in dermal fillers is hyaluronic acid (HA). HA is a naturally occurring substance found in our skin, and it plays a major role in keeping skin hydrated and volumized. HA fillers, depending on their specific chemical makeup, can last from six months to much longer before being gradually absorbed by the body.

One of the main benefits of HA fillers, aside from their natural appearance when injected, is that they can be dissolved by a special solution in case of an adverse event, or if the person dislikes the appearance. Also, most HA fillers are premixed with lidocaine, a numbing agent, to maximize comfort during treatment.

Other available dermal fillers include those made from calcium hydroxylapatite, poly-L-lactic acid, polymethyl methacrylate, and autologous fat (fat that is transplanted from another part of your body). Calcium hydroxylapatite is a mineral-like compound naturally found in human bones. It has been used in dentistry and reconstructive plastic surgery for years with a long track record of safety. Poly-L-lactic acid is a synthetic filler that helps to stimulate collagen production. This filler is different from other fillers because its results are gradual; volumization occurs over several months as it stimulates the body to produce collagen. Polymethyl methacrylate is a semi-permanent filler. While it is more durable compared to other more readily biodegradable fillers, it has potential complications such as forming lumps or being visible under the skin.

Each of these substances has its own pros and cons, as well as a unique density, longevity, and texture, which means a particular material may be more or less suited to a specific area of the face or desired result. Choosing the right type of dermal filler requires the guidance of an experienced, board-certified dermatologist or cosmetic surgeon with a thorough understanding of facial anatomy, and familiarity with the variety of available fillers and their respective injection techniques. A medical professional will thoroughly evaluate any specific areas of concern, understand what you hope to get out of the procedure, and review what to expect before, during, and after the treatment to ensure the best cosmetic outcome.

Avoid black market dermal fillers

 Dermal filler procedures can be expensive, which has prompted some consumers to turn to the online black market to purchase do-it-yourself fillers. In the last month, there have been multiple reports in media outlets and in the medical literature of dangerous complications resulting from self-injection of fillers by non-health professionals.

One risk is that fillers purchased online can contain a variety of nonsterile substances, such as hair gel. When injected, these substances can cause allergic reactions, infections, and the death of skin cells. Another risk is that improper injection technique can lead not only to swelling and lumpiness, but also more serious side effects such as death of skin cells, and embolism leading to blindness. The FDA has issued an official warning urging consumers to “never buy dermal fillers on the internet. They may be fake, contaminated, or harmful.”

Dermal fillers are safe and effective in the right hands

So where does this leave the savvy consumer interested in noninvasive treatments to reduce the signs of aging? Finding the right physician to perform your dermal filler procedure is key. Don’t be afraid to ask about training and certification to ensure you’re receiving care from a board-certified, experienced dermatologist or cosmetic surgeon.

With the right preparation and communication between you and your physician, you can achieve natural, beautiful, and safe results.

Follow me on Twitter @KristinaLiuMD

The post Dermal fillers: The good, the bad and the dangerous appeared first on Harvard Health Blog.

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Infant car seats are crucial for keeping infants safe when transporting them in cars or other vehicles. That’s what they are meant for — and that’s all that they should be used for, or the consequences can be lethal.

When you have one of those infant car seats that detaches from a base and can be carried, it’s very tempting to leave Baby in it after transporting him. If he’s asleep, you can bring him to wherever you are going and let him sleep — nobody wants to wake a sleeping baby — while you do chores or visit or whatever you were going to do. If you are leaving him with a babysitter, the car seat seems like a convenient place for him to sleep. And when you are home, the car seat can seem like a great place to put Baby when you need your hands free.

Except that none of this is a good idea.

In a study published in the journal Pediatrics, researchers looked at information about 11,779 infant sleep-related deaths. They found that 3% of these deaths took place in sitting devices, and of those, 63% were in infant car seats.

The majority of these deaths took place in the child’s home and in the presence of a parent or guardian — but the risk was higher when the child was being cared for by a child care provider or babysitter. There were other risk factors, too:

  • the person supervising the child was asleep (34%)
  • history of maternal drug use during pregnancy (24%)
  • exposure to secondhand smoke (23%)
  • baby born before 37 weeks of pregnancy (23%)
  • item (like a blanket) present (20%)
  • a new sleep environment (18%)
  • low birth weight (16%).

There was also a higher risk when the baby was loosely buckled into the seat — and when left alone in the car.

This is why the American Academy of Pediatrics recommends that infant car seats only be used for travel. That’s what they were designed for: to keep babies safe in the event of a crash or other travel event. They weren’t designed to keep babies safe during sleep; for that, babies need to be on a flat, firm surface without any bedding or anything else around them.

At a minimum, if you bring Baby inside in his car seat, you must

  • keep your eyes on him at all times
  • make sure he is safely buckled in, the same way you’d do it in the car.

But the better idea is to simply take him out. If there isn’t a crib or bassinet or other safe place to put him where you are going, bring a portable one with you. Talk to your doctor about the safest, most affordable choice if you have any questions. If you are home and Baby needs attention and you need your hands free, consider a baby carrier.

Convenience is key to making life work as a parent. But safety comes first.

The post Infant car seats are for cars only (how not to use an infant car seat) appeared first on Harvard Health Blog.

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10,000 steps a day has become the gold standard for many people. That number has sold many step-counting devices and inspired interoffice competitions. But it’s a big number that can be hard to reach. When people continue to not hit five digits, eventually some ditch the effort altogether.

Dr. I-Min Lee is an associate epidemiologist at Brigham and Women’s Hospital, a professor of medicine at Harvard Medical School, and a researcher on physical activity. She and her colleagues wanted to look at the basis for 10,000 steps and its validity. Their new study in JAMA Internal Medicine answers two questions about mortality: How many steps a day are associated with lowering the mortality rate? Does stepping intensity level make a difference in mortality when people take the same number of steps?

Where does 10,000 steps a day come from?

Dr. Lee discovered that the origins of the number go back to 1965, when a Japanese company made a device named Manpo-kei, which translates to “10,000 steps meter.” “The name was a marketing tool,” she says. But since the figure has become so ingrained in our health consciousness (it’s often the default setting in fitness trackers), she wanted to see if it had any scientific basis for health.

She had already been studying the relationship of physical activity and health in older women, and it made sense to stay with that population, she says. This group tends to be less active, yet health issues that occur more often as people age become more important. The research looked at 16,741 women ages 62 to 101 (average age 72). Between 2011 and 2015, all participants wore tracking devices called accelerometers during waking hours. The central question was: are increased steps associated with fewer deaths?

What did the research find?

Key findings from the study include these:

  • Sedentary women averaged 2,700 steps a day.
  • Women who averaged 4,400 daily steps had a 41% reduction in mortality.
  • Mortality rates progressively improved before leveling off at approximately 7,500 steps per day.
  • There were about nine fewer deaths per 1,000 person-years in the most active group compared with the least active group.

So, if mortality — death — is your major concern, this study suggests you can reap benefits from 7,500 steps a day. That’s 25% fewer steps than the more common goal of 10,000 steps.

What are the study’s limitations?

Dr. Lee notes that this study was designed to look at only two factors. One is mortality — not anything related to quality of life, cognitive functions, or physical conditions. So, this particular study doesn’t tell us how many steps to aim for in order to maximize our quality of life, or help prevent cognitive decline or physical ailments.

The second question Dr. Lee hoped to answer is whether the intensity of the steps a person took mattered. It doesn’t. “Every step counts,” she says.

What’s the bigger picture?

While the scope of this study is narrow, Dr. Lee draws some bigger-picture findings.

  • Exercise recommendations are often measured in time: at least 150 minutes of moderate aerobic activity a week has been the federal government’s recommendation since 2008. People who aren’t active may find it difficult to know exactly how long they’ve been moving. Quantifying exercise by counting steps can feel more doable and less overwhelming.
  • If you’re sedentary, add 2,000 more daily steps so that you average at least 4,400 daily steps. While 2,000 steps equals one mile, it’s not necessary to walk it all at once. Instead, try to take extra steps over the course of each waking hour.

She offers good advice for everyone, particularly those looking for extra steps:

  • Take the stairs instead of the elevator.
  • Park at the first empty space you see, not the one closest to the entrance.
  • Get off the bus one stop earlier than your destination.
  • At home, break up chores. Make more than one trip to bring the dinner dishes into the kitchen, or when bringing groceries in from your car.

“Those little things collectively add up,” Dr. Lee says. “Don’t be intimidated or dissuaded by the 10,000 number.”

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Although urinary incontinence is not a life-threatening medical condition, it can significantly affect quality of life. When urinary incontinence becomes bothersome, people often stop traveling, exercising, visiting family and friends — in short, people stop doing the activities they enjoy.

Surprisingly, approximately 70% of urinary incontinence can be significantly improved just by changing behavioral habits. This is called behavioral therapy. In a recent study published in Annals of Internal Medicine, behavioral therapy, either alone or in combination with medication therapy, was more effective than medication treatment alone for treating urinary incontinence.

This means if you are motivated enough to stick with a behavioral treatment program, there’s a strong chance you can improve your bladder control yourself.

Urinary incontinence: The basics

Urinary incontinence can be very minimal, leaking only a few drops. Or it can be severe, leaking so much that your pants are soaked.

The two most common types of urinary incontinence are stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). SUI is the type of leaking that happens when you cough, sneeze, lift, or exercise. UUI is when you get the urge to urinate, and leak before you make it to the toilet.

Behavioral modifications help both types of urinary incontinence.

Restrict fluids

Many women do not realize that too much fluid, such as water, soft drinks, juices, and coffee, can increase the likelihood of urinary incontinence. Too much fluid can lead to an overactive bladder (OAB). The symptoms of OAB are having to urinate frequently, having to urinate urgently (possibly with urge incontinence), and having to get up throughout the night to urinate.

Drinking too much fluid can also increase the likelihood of stress incontinence. A bladder is like a balloon filled with water, with a rubber band (the urethral sphincter muscle) wrapped around the neck. If the balloon is really full and you squeeze it, the water will leak or squirt out.

It is best to keep your fluid intake in the range of 48 to 64 ounces per day. That’s just six to eight 8-ounce glasses. Spread your fluid intake throughout the day.

Limit caffeine

Caffeine is another important contributor to urinary incontinence. Caffeine stimulates the kidneys to make more urine at a faster-than-normal rate. Bladders do not like to be filled rapidly. They react by becoming overactive, or squeezing down (spasming) when they shouldn’t, making it more likely that you’ll experience UUI.

Try to minimize or even stop your caffeine intake. If you have to have some caffeine, limit your intake to 8 ounces per day.

Train your bladder

If you need to urinate frequently, you can treat this with bladder training. Bladder training involves spacing out your voids. So if you currently urinate every hour, make yourself wait 1 1/2 hours before your next trip to the bathroom. Once you can do that easily, make yourself wait two hours, and so on. Your goal should be three to four hours between urinating. This may take several months to achieve.

Try pelvic floor exercises

When you perform pelvic floor exercises, also called Kegels, you tighten up, or contract, the pelvic floor muscles as if you need to prevent gas from escaping. You should feel the contraction more in the back (near the anus) than in the front.

Kegels can help with both SUI and UUI, but you’ll time the exercise differently depending on which type you are trying to control.

To prevent UUI: If you feel the urge to void and do not think you will make it to the toilet in time, stop, do a Kegel, wait until you feel the urgency subside, then walk to the toilet under control. The more times you do this, the more your bladder control will improve. It may take three months to see a significant improvement.

To prevent SUI: When you Kegel, the muscles pull up tissue under the urethra and help to keep the urethra closed when pressure hits the bladder. The trick is you need to Kegel before the pressure hits the bladder. This means if you are going to sneeze, you need to tighten at the moment you are inhaling. This takes practice, and it may take two to four months before you see a difference.

It is helpful to do approximately 30 Kegels every day. You can do 10 in a row (hold each Kegel for five to 10 seconds), three times every day.

If you don’t improve on your own, you can ask your PCP or gynecologist to refer you to a pelvic floor physical therapist, or search for one here. If your incontinence still does not improve, see a urogynecologist or a urologist who specializes in female bladder control problems.

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Morning sickness — the common term for nausea and vomiting during early pregnancy — is not unusual, as many women know. Starting around the sixth to eighth week of pregnancy, as many as 80% of women report having nausea and 50% experience vomiting. But as comedian Amy Schumer can attest, hyperemesis goes well beyond what people generally think of as morning sickness. Marked by doggedly persistent nausea and vomiting, hyperemesis occurs in up to three out of 100 pregnancies. Not surprisingly, women who have hyperemesis often lose weight: losing approximately 5% of pre-pregnancy weight is common.

Why does hyperemesis occur?

We don’t know why women experience nausea and vomiting during pregnancy. Nor do we know why some women experience such an extreme version of symptoms. One possibility is higher levels of certain hormones, such as estrogen or the hormone human chorionic gonadotropin (hCG), which is sometimes called the pregnancy hormone.

We do know that certain women are at higher risk for hyperemesis. This includes women with twin or triplet pregnancies, a history of motion sickness or migraine headaches, or a family history of hyperemesis. Women who had hyperemesis in a prior pregnancy are also more likely to experience it again.

What happens when women have hyperemesis?

Hyperemesis is the most common reason for admission to the hospital in the first trimester of pregnancy, most often due to severe dehydration. Kate Middleton was hospitalized during her first pregnancy due to the severity of her symptoms. Women who are severely affected may develop electrolyte abnormalities that require treatment with intravenous fluids.

If vomiting is so severe that a woman cannot take in any liquid or solid food, she may need a feeding tube placed through her nose to carry a nutritious liquid supplement to her stomach. This is helpful when a woman is losing weight or having electrolyte abnormalities, which can affect heart rhythms. Particularly if hospitalization occurs, hyperemesis can interfere with a woman’s ability to work and perform daily activities. Research suggests women with severe symptoms may have higher rates of depression and pregnancy termination.

Are there health risks to the fetus?

Usually, health risks to the fetus are minimal. Women with hyperemesis have lower rates of miscarriage. Possibly, this is due to the increased levels of pregnancy hormone hCG, which may be linked to their symptoms in the first place. No research on women with hyperemesis shows problems with fetal organ development. However, a systematic review of studies did show an increased risk of low-birthweight infants and premature infants. The long-term effects of hyperemesis on children are unknown, but generally it is unlikely to be linked to permanent harm.

Can hyperemesis be prevented or eased?

The first step is prevention, though clearly this will not solve the problem for every woman.

  • Women who take a multivitamin before getting pregnant, such as a prenatal vitamin, are less likely to have severe symptoms.
  • If women develop hyperemesis, the American College of Obstetrics and Gynecology recommends lifestyle changes. Examples include eating small, frequent meals that are high in protein; avoiding spicy, fatty, or oily foods; and not taking a prenatal vitamin that contains iron.
  • Ginger, such as ginger tea, capsules, or candy, may help decrease symptoms of nausea. However, one systematic review of studies found that it did not decrease the incidence of vomiting.
What treatments help relieve hyperemesis?

Acupressure, acupuncture, and acustimulation have been studied in women with hyperemesis.

  • Acupressure applies pressure alone to certain trigger points on the body.
  • Acupuncture involves placing very thin needles at those trigger points.
  • Acustimulation involves mild electrical stimulation of acupressure points.

The research is mixed, but some evidence suggests acupressure may be helpful in treating symptoms. I advise my patients that it is safe. If they feel it could help, they can try it.

Pharmacologic therapy is also recommended to keep symptoms from getting worse. First-line treatment is vitamin B6 with the antihistamine doxylamine (Unisom). If this fails, a woman might try a combination of antinausea and antihistamine medications. If severe bouts of nausea and vomiting last beyond 10 weeks of pregnancy, her healthcare team may recommend a short course of high-dose steroids.

What’s the good news?

Generally, symptoms of hyperemesis peak in the first trimester. Most likely this is due to rapidly increasing levels of the pregnancy hormone hCG, although increasing levels of estrogen also contribute to nausea and vomiting. Most women find their symptoms resolve by 20 weeks of pregnancy — halfway to a full-term pregnancy. However, some women have persistent symptoms beyond that time. And a very few women may have symptoms until they give birth.

The best options for women with persistent symptoms may be a combination of

  • rest
  • hydration
  • avoiding a somewhat lengthy list of triggers that provoke nausea and vomiting
  • trying complementary and pharmacologic treatments.

The post Hyperemesis: (Way) beyond morning sickness appeared first on Harvard Health Blog.

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For more than a century, clinicians have noticed a paradoxical phenomenon: certain patients who are taking opioids (which are supposed to numb pain) become more sensitive to pain than those who are not taking opioids.

The earliest observation of this phenomenon can be traced back to the British physician Sir Clifford Allbutt, who, in 1870, described it: “at such times I have certainly felt it a great responsibility to say that pain, which I know is an evil, is less injurious than morphia, which may be an evil. Does morphia tend to encourage the very pain it pretends to relieve?” Research studies and clinical observations over the years have identified the phenomenon Dr. Allbutt noticed as opioid-induced hyperalgesia (OIH).

What is opioid-induced hyperalgesia?

Hyperalgesia is an increased pain response from a stimulus (cause) that usually provokes a minor pain response. For example, getting your blood drawn for lab testing usually causes mild discomfort, but this common medical procedure would be very painful for certain patients who are taking opioids chronically. OIH is a lesser known side effect of long-term opioid therapy, but a serious one, and yet another reason doctors should carefully select who may benefit from extended use of these pain medications.

What causes OIH?

The mechanism behind opioid-induced hyperalgesia is complex and involves molecular and chemical changes in the brain and spinal cord. Opioids tend to activate specific receptors that block painful signals from reaching the brain. When these medications are taken for long periods of time, our bodies (as a defense mechanism) try to overcome these blocked signals by activating other pain signals and pathways, a phenomenon known as hypersensitization. These changes reflect the incredible abilities of our brains to form new connections and pathways and alter how the circuits are connected in response to changes, also known as neuroplasticity. A positive example of this would be the rehabilitation process after a stroke: when someone suffers a stroke as a result of a clot or bleed in the brain and becomes unable to use their arm properly, the brain will start forming new connections in an attempt to overcome this deficit, and with proper rehabilitation and training a person may be able to use the arm normally again.

Who is at risk of developing OIH?

Pain perception is a very complex process. Many factors affect how the brain interprets pain signals. Anxiety, depression, genetics, medications, our physical health, and other illnesses can increase or decrease our feeling of pain. Just as pain perception is individual, the level of hyperalgesia is not the same in all patients; some people will experience more hyperalgesia based on their genetics and personal predisposition. Additionally, there is no well-established period of exposure after which OIH occurs, and the exact timing of someone developing OIH varies from patient-to-patient.

What we do know is that people who take opioids regularly are at greater risk of developing OIH. Researchers have looked at many patients who were taking opioids for long periods of time and compared their pain tolerance or pain sensitivity to that of patients who were not taking opioids. Researchers also compared patients’ pain sensitivity before and after starting opioid therapy. In both cases they found that administration of opioids paradoxically increased sensitivity to pain and made pre-existing pain worse, and higher doses of opioids were associated with higher sensitivity to pain.

Recognizing and treating OIH

If you or your doctor aren’t aware of this phenomenon, and you are prescribed more opioids to treat increased pain sensitivity, it can lead to a vicious cycle of increasing the dose of opioids and more pain, as well as an increased risk of overdose. The appropriate approach to treating OIH is to wean slowly from a high dose of opioids, which usually requires time and patience. During this time, it may be appropriate to add non-opioid alternatives to managing pain, such as other medications, injections, behavioral interventions, and physical therapy. You doctor may also recommend avoiding opioids altogether, or taking an “opioid holiday” so your body can recover. Working closely with your healthcare team is very important, as is managing your pain during a weaning period. There are CDC guidelines available to help your doctor safely taper your dose.

Historically, opioids were used to treat pain caused by end-stage advanced cancer, or for acute pain (after surgery, a bone fracture, a serious accident, etc.), and only for a short period of time (a few days), to reduce the risk of side effects. Unfortunately, there has been a drastic increase in the use of opioids in the United States over the last two decades for the treatment of chronic non-cancer pain (back pain, arthritis, etc.), and some people have taken opioids for longer than medically necessary for their type of pain.

While opioids definitely have their place in medical practice, we need to be aware of the serious side effects of these medications, including side effects that may cause more suffering, like OIH, as well as lethal side effects such as overdose. If you think you or a loved one may be experiencing OIH, you should discuss this with you doctor, and work with them to taper your dose and find alternatives to manage your pain safely.


A Comprehensive Review of Opioid-Induced Hyperalgesia. Pain Physician, March/April 2011.

Opioid-induced Hyperalgesia: A Qualitative Systematic Review. Anesthesiology, March 2006.

Opioid Induced Hyperalgesia. Pain Medicine, October 2015.

The post More opioids, more pain: Fueling the fire appeared first on Harvard Health Blog.

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