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Loud snoring, grunts, and gasps can be a sign of obstructive sleep apnea, a serious disorder that causes repeated, brief pauses in breathing (apneas) throughout the night. It can leave people drowsy and depressed, and put them at risk for high blood pressure, heart disease, and other health problems.

If this sounds like you or a bed partner, a recent spate of advertisements for a mask-free treatment for the disorder may catch your attention. Known medically as a hypoglossal nerve stimulator, the pacemaker-like device moves the tongue forward during sleep. That helps reopen a collapsed airway — the root cause of obstructive sleep apnea. But how does it compare with other treatments, and who might be a good candidate?

A second-choice therapy for sleep apnea

Marketed under the name Inspire, the device was approved by the FDA in 2014. It’s a second-choice therapy intended only for people who can’t tolerate positive airway pressure (known as PAP or CPAP), according to Dr. Rohit Budhiraja, a pulmonary and sleep specialist at Harvard-affiliated Brigham and Women’s Hospital.

“Sleep apnea causes the muscles in the back of the throat to collapse, which leads to pauses in breathing that wake you up again and again,” he says. PAP, the gold standard therapy for sleep apnea, prevents airway collapse by using a small bedside machine attached to tubing that blows air through a face mask.

This can improve a measurement called the apnea-hypoxia index (AHI) by approximately 90%, lowering it below 5 in most people. The AHI is a score that gauges the severity of sleep apnea. An AHI between 5 and 14 is considered mild; between 15 and 29 is moderate; 30 and higher is severe.

Targeting tongue muscles is less effective

Inspire targets only the muscles of the tongue rather than the entire airway, so it isn’t as effective as PAP. In fact, the company’s stated treatment goal is to lower a person’s AHI by just 50% (or below 20), although some people may do better.

Because PAP is more effective, sleep specialists encourage people to stick with it by trying different strategies. But research suggests a quarter to a third of people have a hard time using PAP (see here and here). When that’s the case, Inspire may be an alternative, says Dr. Budhiraja.

Who might consider hypoglossal nerve stimulation?

In addition to trying PAP without success, you also must

• have moderate to severe sleep apnea (an AHI score of 15 to 65)
• have a body mass index (BMI) of 32 or lower (although some centers allow BMI values as high as 35), which means the device is not right for people in some weight ranges.

If you meet these criteria, you can ask your doctor for a referral to a sleep specialist or an ear, nose, and throat surgeon. The next step is sleep endoscopy. While you are sedated, a doctor passes a small tube with a light and a tiny video camera on one end through a nostril to examine your upper airway. Up to a quarter of people have an airway collapse pattern that can’t be remedied with Inspire, Dr. Budhiraja notes. And, as noted, others have too high an AHI score to try it.

A surgical procedure requiring general anesthesia

The device is implanted during a short, same-day procedure done under general anesthesia. A generator is placed just below the collarbone, a breathing sensor at the side of the chest by the ribs, and a stimulation electrode around the hypoglossal nerve under the tongue.

As with all surgery, possible risks include bleeding and infection. Some people experience tongue weakness, which can cause slightly slurred speech and minor swallowing problems. But this usually resolves within a few days, or for most people, within a few weeks.

The device must be activated a month after surgery at a sleep laboratory. The breathing sensor monitors your breathing and, when necessary, it tells the generator to send a small electrical pulse to the electrode to make the tongue muscles contract. The stimulation moves your tongue forward so you can breathe normally.

How does it feel?

“Some people describe a mild tingling sensation, but most say the feeling is hard to describe,” says Dr. Budhiraja.

At home, you use a small remote control to turn the device on at night and off in the morning. The remote is set to gradually increase the level of stimulation once or twice a week as tolerated until you reach the highest level. You then return to the sleep lab for a study to determine your optimal range. The remote is then programmed to that range.

Some people start noticing a difference in their sleep quality even at the lowest levels of stimulation. Yearly checks are recommended thereafter, and the replaceable battery lasts about 11 years. Medicare and most major insurance plans cover Inspire.

Once it’s working, hypoglossal nerve stimulation is definitely convenient: no maintenance, cleaning, or buying supplies as required with a PAP machine. “But because Inspire is less effective, it’s not considered a replacement for PAP,” says Dr. Budhiraja.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

Acne can be frustrating, especially when it does not go away after your teenage years. Believe it or not, acne can continue to affect adults beyond adolescence, or develop for the very first time in adulthood. This may be particularly distressing for adult women, who are more likely to get acne after the age of 20 compared to men.

What is adult female acne?

Adult female acne can look very similar to teenage acne. While adult acne is commonly thought to affect the jawline and chin, it can appear on any part of the face or trunk. Adult women can have clogged pores, inflamed pus-filled bumps, or deep-seated cysts. Unfortunately, treatment options that worked well in the teenage years may not work as well in adult females with acne, due to triggering factors such as hormonal imbalance, stress, and diet.

There are many reasons adult females can get acne. Hormonal disturbances caused by pregnancy, menstrual cycle, menopause, and oral contraceptives can contribute to acne by modifying the production of certain hormones. These hormones stimulate oil production within the skin, promoting the growth of acne-causing bacteria. Stress can increase the production of substances that activate oil glands within the skin of acne patients. Consumption of dairy and high-glycemic foods is also linked to acne. Certain hair or skin products can clog pores and cause comedonal acne (blackheads and whiteheads). A board-certified dermatologist can help determine the appropriate treatment for the type of acne you have.

Consequences of adult acne and scarring

The extent to which acne causes emotional distress varies, and is not related to the severity of the acne or acne scars. Some women with acne may experience disruption in their personal and professional lives as they fear stigmatization in relationships and employment. Adult females may also be more likely to seek treatment for active acne when acne bumps and scarring persist.

Acne scarring can be disfiguring. Permanent changes in skin texture in the form of pits or raised scars may not be easily concealed with makeup. Raised scars may also lead to skin picking and worsening skin texture and pigment.

Acne can also heal with red or dark spots that may not resolve for weeks to months. The dark spots may persist even longer without proper sun protection, especially on darker skin. Having both acne and dark spots may negatively impact one’s quality of life and self-perception.

The emotional toll associated with acne may include an elevated risk of developing depression compared to patients who do not have acne. Clinical studies show that having severe acne can negatively affect quality of life on par with long-term diseases such as arthritis, diabetes, back pain, and asthma. If you have acne, extensive scarring, or dark spots of any severity that are affecting your mental health, you may benefit from earlier intervention with oral medications.

What are options for treatment and support?

Acne is a medical condition, but it only needs to be treated if the acne or marks left behind from it are bothersome to you. Please see a board-certified dermatologist (in person or virtually) for the best available options if you wish to seek treatment.

Your dermatologist may prescribe a combination of topical (skin) and oral treatments. Some of these medications may not be appropriate if you are pregnant or breastfeeding, or carry risks. Ask your dermatologist about hair and skin products that may be irritating, clogging pores, or promoting oil production in the skin, making your acne worse. Also, avoid skin picking to prevent scarring, and try to minimize emotional and physical stressors.

For individuals with dark spots or scarring, consult a board-certified dermatologist to get a personalized treatment geared to your skin concerns. Use a broad-spectrum, tinted sunscreen daily and reapply it every two hours to help prevent acne marks from worsening. If your acne is causing you significant mental distress, ask your doctor about mental health resources. Additionally, seeking treatment for your acne may help you feel better. Consider joining online or in-person support groups in your area.

For more information, visit the American Academy of Dermatology Acne Resource Center.

Follow Dr. Nathan on Twitter @NeeraNathanMD
Follow Dr. Patel on Twitter @PayalPatelMD

About the Authors

Neera Nathan, MD, MSHS, Contributor

Dr. Neera Nathan is a dermatologist and researcher at Massachusetts General Hospital and Lahey Hospital and Medical Center. Her clinical and research interests include dermatologic surgery, cosmetic dermatology, and laser medicine. She is part of the … See Full Bio View all posts by Neera Nathan, MD, MSHS

Payal Patel, MD, Contributor

Dr. Payal Patel is a dermatology research fellow at Massachusetts General Hospital. Her clinical and research interests include autoimmune disease and procedural dermatology. She is part of the Cutaneous Biology Research Center, where she investigates medical … See Full Bio View all posts by Payal Patel, MD

A forest fire in northern California and a mile-long glacier breaking apart appear in your news feed. The stark reminders of climate change are constant, and may cause additional stress to your daily tasks. For example, in surveying your shopping cart filled with wipes, sandwich bags, and packets of baby food, you may question your choices, knowing that the plastic in those items will never break down completely. You may feel guilty about driving the short distance to the store, or you may struggle to stop worrying about how your actions will affect future generations.

What is climate anxiety?

Climate anxiety, or eco-anxiety, is distress related to worries about the effects of climate change. It is not a mental illness. Rather, it is anxiety rooted in uncertainty about the future and alerting us to the dangers of a changing climate. Climate change is a real threat, and therefore it's normal to experience worry and fear about the consequences. Anxiety about the climate is often accompanied by feelings of grief, anger, guilt, and shame, which in turn can affect mood, behavior, and thinking.

How common is climate anxiety?

According to a survey by the American Psychological Association, more than two-thirds of Americans experience some climate anxiety. A study published by The Lancet found that 84% of children and young adults ages 16 to 25 are at least moderately worried about climate change, and 59% are very or extremely worried. This makes sense, as children and young adults will disproportionately suffer the consequences of environmental changes. A 2021 UNICEF report estimates that one billion children will be at "extremely high risk" as a result of climate change. Children and young adults are also particularly vulnerable to the effects of chronic stress, and climate anxiety may affect their risk of developing depression, anxiety, and substance use disorders.

How does climate change affect mental health?

In addition to existential worries and fears about the future, climate change can affect mental health directly (such as through natural disasters or heat) and indirectly (through displacement, migration, and food insecurity). Rising temperatures have been associated with increases in emergency department visits for psychiatric reasons, and may impair cognitive development in children and adolescents. Furthermore, food insecurity is associated with depression, anxiety, and behavioral problems.

How can you manage climate anxiety?

As uncertainty and a loss of control characterize climate anxiety, the best treatment is to take action. On an individual level, it’s therapeutic to share your worries and fears with trusted friends, a therapist, or by joining a support group. You can also make changes to your lifestyle consistent with your values. This may include deciding to take fewer flights, joining a protest, or increasing public awareness about climate change through advocacy. Joining an organization like The Good Grief Network can help you process feelings related to climate anxiety and connect with others to take meaningful action.

How can you help a younger person?

Climate anxiety disproportionately affects children and youth. To be an ally for a child, adolescent, or younger adult with climate anxiety, you can consider showing your support in the following ways:

• Validate their concerns. “I hear you, and it makes sense that you are worried (or angry) about this issue.”
• Help direct their efforts to advocacy groups. Spend time together researching organizations that they can get involved with.
• Educate yourselves on steps you both can take to minimize your impact on the environment.
• Support your loved one’s decisions to make changes to their lifestyle, especially changes they can witness at home.
• Spend time in nature with your family, or consider planting flowers or trees.

The bottom line

Climate anxiety is rife with uncertainty, but taking action may help you feel in control. Talk with others, join forces, and make lifestyle changes based on your values.

About the Author

Stephanie Collier, MD, MPH, Contributor

Dr. Stephanie Collier is the director of education in the division of geriatric psychiatry at McLean Hospital; consulting psychiatrist for the population health management team at Newton-Wellesley Hospital; and instructor in psychiatry at Harvard Medical School. … See Full Bio View all posts by Stephanie Collier, MD, MPH

 

Proponents of cannabis generally dismiss the idea that there is a cannabis withdrawal syndrome. One routinely hears statements such as, “I smoked weed every day for 30 years and then just walked away from it without any problems. It’s not addictive.” Some cannabis researchers, on the other hand, describe serious withdrawal symptoms that can include aggression, anger, irritability, anxiety, insomnia, anorexia, depression, restlessness, headaches, vomiting, and abdominal pain. Given this long list of withdrawal symptoms, it’s a wonder that anyone tries to reduce or stop using cannabis. Why is there such a disconnect between researchers’ findings and the lived reality of cannabis users?

New research highlights the problems of withdrawal, but provides an incomplete picture

A recent meta-analysis published in JAMA cites the overall prevalence of cannabis withdrawal syndrome as 47% among “individuals with regular or dependent use of cannabinoids.” The authors of the study raise the alarm that “many professionals and members of the general public may not be aware of cannabis withdrawal, potentially leading to confusion about the benefits of cannabis to treat or self-medicate symptoms of anxiety or depressive disorders.” In other words, many patients using medical cannabis to “treat” their symptoms are merely caught up in a cycle of self-treating their cannabis withdrawal. Is it possible that almost half of cannabis consumers are actually experiencing a severe cannabis withdrawal syndrome — to the point that it is successfully masquerading as medicinal use of marijuana — and they don’t know it?

Unfortunately, the study in JAMA doesn’t seem particularly generalizable to actual cannabis users. This study is a meta-analysis: a study which includes many studies that are deemed similar enough to lump together, in order to increase the numerical power of the study and, ideally, the strength of the conclusions. The authors included studies that go all the way back to the mid-1990s — a time when cannabis was illegal in the US, different in potency, and when there was no choice or control over strains or cannabinoid compositions, as there is now. One of the studies in the meta-analysis included “cannabis-dependent inpatients” in a German psychiatric hospital in which 118 patients were being detoxified from cannabis. Another was from 1998 and is titled, “Patterns and correlates of cannabis dependence among long-term users in an Australian rural area.” It is not a great leap to surmise that Australians in the countryside smoking whatever marijuana was available to them illegally in 1998, or patients in a psychiatric hospital, might be substantively different from current American cannabis users.

Medical cannabis use is different from recreational use

Moreover, the JAMA study doesn’t distinguish between medical and recreational cannabis, which are actually quite different in their physiological and cognitive effects, as Harvard researcher Dr. Staci Gruber’s work tells us. Medical cannabis patients, under the guidance of a medical cannabis specialist, are buying legal, regulated cannabis from a licensed dispensary; it might be lower in THC (the psychoactive component that gives you the high) and higher in CBD (a nonintoxicating, more medicinal component), and the cannabis they end up using often results in them ingesting a lower dose of THC.

Cannabis withdrawal symptoms are real

All of this is not to say that there is no such thing as a cannabis withdrawal syndrome. It isn’t life-threatening or medically dangerous, but it certainly does exist. It makes absolute sense that there would be a withdrawal syndrome because, as is the case with many other medicines, if you use cannabis every day, the natural receptors by which cannabis works on the body “down-regulate,” or thin out, in response to chronic external stimulation. When the external chemical is withdrawn after prolonged use, the body is left in the lurch, and forced to rely on natural stores of these chemicals, but it takes time for the natural receptors to grow back to their baseline levels. In the meantime, the brain and the body are hungry for these chemicals, and the result is withdrawal symptoms.

Getting support for withdrawal symptoms

Uncomfortable withdrawal symptoms can prevent people who are dependent on or addicted to cannabis from remaining abstinent. The commonly used treatments for cannabis withdrawal are either cognitive behavioral therapy or medication therapy, neither of which has been shown to be particularly effective. Common medications that have been used are dronabinol (which is synthetic THC); nabiximols (which is cannabis in a mucosal spray, so you aren’t actually treating the withdrawal); gabapentin for anxiety (which has a host of side effects); and zolpidem for the sleep disturbance (which also has a list of side effects). Some researchers are looking at CBD, the nonintoxicating component of cannabis, as a treatment for cannabis withdrawal.

Some people get into serious trouble with cannabis, and use it addictively to avoid reality. Others depend on it to an unhealthy degree. Again, the number of people who become addicted or dependent is somewhere between the 0% that cannabis advocates believe and the 100% that cannabis opponents cite. We don’t know the actual number, because the definitions and studies have been plagued with a lack of real-world relevance that many studies about cannabis suffer from, and because the nature of both cannabis use and cannabis itself have been changing rapidly.

How do you know if your cannabis use is a problem?

The standard definition of cannabis use disorder is based on having at least two of 11 criteria, such as: taking more than was intended, spending a lot of time using it, craving it, having problems because of it, using it in high-risk situations, getting into trouble because of it, and having tolerance or withdrawal from discontinuation. As cannabis becomes legalized and more widely accepted, and as we understand that you can be tolerant and have physical or psychological withdrawal from many medicines without necessarily being addicted to them (such as opiates, benzodiazepines, and some antidepressants), I think this definition seems obsolete and overly inclusive.

For example, if one substituted “coffee” for “cannabis,” many of the 160 million Americans who guzzle coffee on a daily basis would have “caffeine use disorder,” as evidenced by the heartburn and insomnia that I see every day as a primary care doctor. Many of the patients that psychiatrists label as having cannabis use disorder believe that they are fruitfully using cannabis to treat their medical conditions — without problems — and recoil at being labeled as having a disorder in the first place. This is perhaps a good indication that the definition doesn’t fit the disease.

Perhaps a simpler, more colloquial definition of cannabis addiction would be more helpful in assessing your use of cannabis: persistent use despite negative consequences. If your cannabis use is harming your health, disrupting your relationships, or interfering with your job performance, it is likely time to quit or cut down drastically, and consult your doctor. As part of this process, you may need to get support or treatment if you experience uncomfortable withdrawal symptoms, which may make it significantly harder to stop using.

About the Author

Peter Grinspoon, MD, Contributor

Dr. Peter Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital; an instructor at Harvard Medical School; and a certified health and wellness coach. He is the author of the forthcoming book Seeing … See Full Bio View all posts by Peter Grinspoon, MD

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States, and rates are rising, particularly in adults ages 20 to 49. Unfortunately, approximately 30% of eligible people in the US still have not been screened for CRC.

Colon cancer may be prevented with screening tests that look for cancer or precancerous growths called colon polyps.

When should you start screening?

The United States Preventative Services Task Force recommends starting screening for CRC at age 45 for average-risk patients. These guidelines reflect the most up-to-date research on when risk for colon cancer begins to increase.

Average-risk patients are those with no personal or family history of colon cancer or a genetic condition that increases the risk of developing CRC. For this reason, it is important for patients to share their family history, including all cancer diagnoses in blood relatives, with their primary care doctor, who can help decide the right time to begin colon cancer screening.

High-risk patients are advised to begin screening before age 45. A primary care physician can help determine when and how a patient who is concerned about their risk level should be screened for CRC. Patients who have a history of CRC or polyps; a first-degree family member with CRC or advanced polyps (those that would have gone on to become CRC if they had not been removed); a family history of certain genetic syndromes; or a history of inflammatory bowel disease (like Crohn’s disease or ulcerative colitis) are some examples of high-risk factors.

What are the options for CRC screening?

Colonoscopy: Colonoscopy is the gold standard of screening tests, and identifies approximately 95% of CRC. It is also the only method that allows a gastroenterologist to both detect and remove potentially precancerous colon polyps. Colonoscopies are considered low-risk procedures, but they do have a small risk of bleeding and perforation that increases in older age groups.

Patients need to clean out their colon prior to the procedure by drinking a colonoscopy prep, which washes stool out of the colon so that it can be properly assessed during the procedure. The prescription instructions for the prep are provided by the gastroenterologist’s office.

In most cases, the procedure will be performed under sedation to ensure the patient is as comfortable as possible. It is important to note that patients are not placed under general anesthesia, but most remain sleepy and comfortable throughout their colonoscopy.

During the colonoscopy, a gastroenterologist will insert a flexible tube with a camera at the end, called a colonoscope, into the rectum. The entire colon is then carefully examined. If no polyps are detected and the preparation (cleanout) of the colon is adequate, a repeat a colonoscopy is suggested in 10 years. If polyps are detected, or the patient’s risk level or symptoms change, this interval will be shorter.

FIT testing: The fecal immunochemical test (FIT) is a lab test that looks for hidden blood in the stool. Patients use a kit to collect their stool and then use a probe to scrape the stool, which is then placed into a tube and mailed to the lab. FIT testing is repeated every year. A drawback of FIT testing is that it has a false positive rate of approximately 5%. It can effectively rule out CRC with 79% accuracy. FIT testing is noninvasive, convenient, and cost-effective, making it an acceptable alternative to a colonoscopy for many people. If a stool test is positive, a colonoscopy is needed to evaluate the reason for the positive test.

Flexible sigmoidoscopy: A flexible tube with a camera is used to look at the rectum and the lower part of the colon. The advantages of this procedure are that it is faster than a colonoscopy (only 5 to 15 minutes) and requires less aggressive laxative medications. Typically, patients receive a flexible sigmoidoscopy every five years if no polyps are detected. As this test does not examine the whole colon, it cannot detect cancers or polyps in the unexamined portion. At best, it can detect 70% of cancers and polyps. If an abnormality is detected, a follow-up colonoscopy is needed to look at the entire colon.

CT colonography: A CT scan is used to visualize your rectum and entire colon. Just like with a colonoscopy, patients need to take laxative medications the night before to empty the colon. A small tube is placed in the rectum to expand the colon to get clear pictures. This test may be useful for patients who cannot tolerate anesthesia or have other medical conditions that prevent them from having a colonoscopy. A drawback of CT colonography is radiation exposure, and finding unrelated abnormalities outside the colon that can lead to unnecessary tests. While CT colonography is about 88.7% accurate at finding certain polyps, it is less accurate than colonoscopy overall. If the CT colonography result is abnormal, a colonoscopy is required for full evaluation of the colon.

Cologuard: This is a test where patients collect their stool, scrape it with a probe, insert it into a container with preservative, and mail it to the lab. This test looks for atypical DNA, or traces of blood in the collected stool that may be suggestive of precancerous polyps or CRC. Typically, patients repeat the test every three years. If the Cologuard test is positive, a colonoscopy is necessary for further evaluation. However, Cologuard’s accuracy is still limited; 13% of the time the test indicates the patient may have cancer when they do not. In 2019, a study showed that annual FIT testing or colonoscopy may be more effective and less costly than Cologuard. Further research is ongoing to evaluate how accurate (and thus how useful) this test is at detecting CRC.

Which screening option should you choose?

The most important part of colon cancer screening is to have a screening test performed. For most patients, colonoscopy or FIT testing are the most common ways to screen for colon cancer. However, there are other options to consider if you are unable to undergo or are uncomfortable with colonoscopy or FIT testing. Ultimately, this is an important and personalized decision, and a discussion for a patient to have with their healthcare provider, so that the right test can be done at the right time.

About the Authors

Nisa Desai, MD, Contributor

Dr. Nisa Desai is a practicing hospitalist physician at Beth Israel Deaconess Medical Center, and an instructor in medicine at Harvard Medical School. She completed undergraduate education at Northwestern University, followed by medical school at the … See Full Bio View all posts by Nisa Desai, MD

Loren Rabinowitz, MD, Contributor

Dr. Loren Rabinowitz is an instructor in medicine Beth Israel Deaconess Medical Center and Harvard Medical School, and an attending physician in the Inflammatory Bowel Disease Center at BIDMC. Her clinical research is focused on the … See Full Bio View all posts by Loren Rabinowitz, MD

Active surveillance for prostate cancer has its tradeoffs. Available to men with low- and intermediate-risk prostate cancer, the process entails monitoring a man’s tumor with periodic biopsies and prostate-specific antigen (PSA) tests, and treating only when — or if — the disease shows signs of progression.

Active surveillance allows men to avoid (at least for a while) the side effects of invasive therapies such as surgery or radiation, but men often feel anxious wondering about the state of their cancer as they spend more time untreated. Is there a middle path between not treating the cancer at all and aggressive therapies that might have lasting side effects? Emerging evidence suggests the answer might be yes.

During a newly-published phase 2 clinical trial, researchers evaluated whether a drug called enzalutamide might delay cancer progression among men on active surveillance. Enzalutamide interferes with testosterone, a hormone that drives prostate tumors to grow and spread. Unlike other therapies that block synthesis of the hormone, enzalutamide prevents testosterone from interacting with its cellular receptor.

A total of 227 men were enrolled in the study. The investigators randomized half of them to a year of daily enzalutamide treatment plus active surveillance, and the other half to active surveillance only. After approximately two years of follow-up, the investigators compared findings from the two groups.

The results showed benefits from enzalutamide treatment. Specifically, tumor biopsies revealed evidence of cancer progression in 32 of the treated men, compared to 42 men who did not get the drug. The odds of finding no cancer in at least some biopsy samples were 3.5 times higher in the enzalutamide-treated men. And it took six months longer for PSA levels to rise (suggesting the cancer is growing) in the treated men, compared to men who stayed on active surveillance only.

Enzalutamide was generally well tolerated. The most common side effects were fatigue and breast enlargement, both of which are reversible when men go off treatment.

In an accompanying editorial, Susan Halabi, a statistician who specializes in prostate cancer at Duke University, described the data as encouraging. But Halabi also sounded a cautionary note. Importantly, differences between the two groups were evident only during the first year of follow-up. By the end of the second year, signs of progression in the treated and untreated groups “tended to be very similar,” she wrote, suggesting that enzalutamide is beneficial only for as long as men stay on the drug. Longer studies lasting a decade or more, Halabi added, may be necessary to determine if early enzalutamide therapy changes the course of the disease, such that the need for more invasive treatments among some men can be delayed or prevented.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org, said the study points to a new way of approaching active surveillance, either with enzalutamide or perhaps other drugs. “An option that further decreases the likelihood that men on active surveillance will need radiation or surgery is important to consider,” he says. “This was a pilot study, and now we need longer-term research.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

This spring, many parts of United States experienced historic heat waves. Now summer is officially underway, and experts are predicting hotter than normal temperatures across most of the country.

Extreme temperatures increase health risks for people with chronic conditions, including heart problems. If you do have a heart condition, here’s how to keep cool and protect yourself when temperatures rise.

How does hot weather affect the heart?

Not only does exposure to high heat increase the risk for heat exhaustion and heat stroke, but it can also place a particular burden on heart health. It stresses the cardiovascular system and makes the heart work harder. This can increase the chance of heart attacks, heart arrhythmias (irregular heartbeat), and heart failure.

According to the Environmental Protection Agency, the interaction of high heat and cardiovascular disease contributes to about a quarter of heat-related deaths.

And the higher the temperature, the greater the threat. A recent study in the journal Circulation looked at cardiovascular death rates over seven years in Kuwait, where daytime temperatures can reach triple digits in the hottest months. The researchers found a link between rising temperatures and the risk of cardiovascular deaths, with most occurring between temperatures of 95° F to 109° F.

“Climate change is giving us more, and unprecedented, heat that can be deadly, especially for people with heart disease,” says Dr. Aaron Bernstein, interim director of the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health.

How does the body shed heat?

Your body is designed to shed extra heat in two major ways, each of which may affect the heart:

Radiation. When the air around you is cooler than your body, you radiate extra heat into the air. This process requires rerouting blood flow so that more of it goes to the skin.

Evaporation. Evaporating sweat helps cool you down by pulling heat away from your skin. When the air is dry, this works well. But when it’s hot and humid, sweat just sits on the skin as your body temperature rises.

When air temperature approaches or exceeds body temperature, especially in high humidity, the heart has to beat faster and pump harder to help your body shed heat. On a hot and humid day, your heart may circulate two to four times as much blood each minute compared with a cool day.

Some medicines meant to help the heart can add to problems on hot days. For example, beta blockers slow the heartbeat and hinder the heart’s ability to circulate blood fast enough for effective heat exchange. Diuretics (water pills) increase urine output and raise the risk of dehydration.

How can you protect yourself and your heart when temperatures rise?

While exposure to high heat and heat waves affects everyone, having existing heart problems raises your risk for heat-related illness and hospitalization. So it’s especially important to try to follow basic strategies for staying cool, including these:

• Monitor weather forecasts for heat advisories and stay inside on those days. If home is too hot, check with your town or city health department for cooling centers and other options to help you stay cool. If you venture outside, evening and early morning are often the coolest times. Rest in the shade whenever possible.
• When outside, try to drink 8 ounces of water every 20 minutes. Set a timer to remind you. “Never wait until you’re thirsty to drink,” says Dr. Bernstein. If you have heart failure, ask your doctor how much fluid you should drink daily, since fluids can build up and cause swelling. If you take diuretics, ask how much you should drink during hot weather.
• Avoid soda or fruit juice and limit alcohol. Soda and fruit juice may slow the passage of water from the digestive system to the bloodstream. While research is limited, some studies have found that excessive alcohol intake may raise risk for heat stroke during scorching weather.
• Protect your skin. Sunburn affects your body’s ability to cool down and increases dehydration. Wear a wide-brimmed hat, wraparound sunglasses, and lightweight, light-colored, loose-fitting clothing. Also, apply plenty of broad-spectrum or UVA/UVB protection sunscreen with SPF 30 or higher to all exposed skin 30 minutes before going out. Reapply every hour.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

Editor’s note: in honor of Pride Month, we’re re-publishing a 2019 post by Dr. Cecil Webster.

Generally speaking, discussing what happens in our bedrooms outside of the bedroom can be anxiety-provoking. Let’s try to make your doctor’s office an exception. Why is this important? People in the LGBTQ+ community contend not only with a full range of health needs, but also with environments that may lead to unique mental and physical health challenges. Whether or not you have come out in general, doing so with your doctor may prove critical in managing your health. Sexual experiences, with their impact on identity, varied emotional significance, and disease risk, are a keystone for helping your doctor understand how to personalize your healthcare.

Admittedly, talking about your intimate sexual experiences or your gender identity may feel uncomfortable. Many LGBTQ+ patients worry that their clinicians may not be knowledgeable about their needs, or that they’ll to have to educate them. Finding a LGBTQ+ adept doctor, preparing ahead of time for your next appointment, and courageously asking tough questions can give you and your health the best shot.

Finding a skilled clinician who is LGBTQ+ adept

Many large cities have healthcare institutions whose mission centers on care for LGBTQ+ peoples. However, these organizations may prove inaccessible to many for a variety of reasons. Regardless of your location, asking friends, family, or others to recommend a clinician may be a game changer. If your trans friend had a relatively painless experience visiting an area gynecologist, perhaps your Pap smear may go smoothly there as well. If your coworker has a psychiatrist who regularly asks him about his Grindr use, perhaps it may be easier to navigate your gay relationship questions with her.

Word of mouth is often an undervalued method of finding someone skilled and attentive to the needs of LGBTQ+ individuals. Online, many clinicians offer a short bio with their areas of expertise, and there are provider directories featuring trusted clinicians. Further, some doctors regularly write articles and give talks that may offer clues about desired knowledge. A simple Google search of your provider may yield a bounty.

Next, give your doctor or healthcare organization a call. Don’t be shy about requesting someone whose practice matches your specific needs. Your health information is protected, and generally, physicians hold your clinical privacy dear. Keep in mind that not all clinics will know or share whether or not your doctor is, for example, also a lesbian, but they may pair you with someone well suited to your request or point you in the right direction.

Preparing for your appointment

Let’s say you are nervous about coming out to your doctor. A little preparation may ease this burden. Here are some quick tips:

• Let them know you’re nervous at the start of the conversation.
• Be as bold as you can tolerate.
• Write down what you are excited about, nervous about, and/or curious about.
• Go in with a few goals and start with what’s most important.
• Maximize your comfort. If your partner is calming, bring them. If Beyoncé soothes what ails you, bring her along too.
• Lightly correct or update your clinician if they get something wrong.

Ask tough questions, give clear answers

As a psychiatrist who works with kids and adults, I often hear questions like, “I don’t know really how to say this, but I started experimenting with other guys. Does this mean I’m gay?” I may start by asking if you’ve enjoyed it. My colleagues in health care might begin with the same question.

Pleasurable experiences come in all sorts of constellations, and healthy exploration is part of being human. Additionally, clinicians need to assess and address your safety. Many LGBTQ+ people are at higher risk of intimate partner violence. We may ask about your use of condoms, how many partners you’ve had recently, your use of substances during sex, and how these experiences may shift how you see yourself. Give clear answers if possible, but don’t fret if you’re uncertain. Your doctor will not likely provide a label or pry unnecessarily. They may offer constructive information on the use of condoms, reasons to consider using PrEP (which can effectively prevent HIV), and places you can go for more guidance. Physicians enjoy giving personalized information so that you may make informed healthcare decisions.

There is no end to what is on people’s minds. Be bold. Will tucking reduce my sperm count? Maybe. Does binding my breasts come with risk? Likely. Was Shangela robbed of her RuPaul’s Drag Race: All Stars 3 crown? Utterly, but let’s get back to your cholesterol, shall we?

Remember that it is often impossible to squeeze everything into one appointment. Afterward, take time to catch your breath, reflect on what you’ve learned, and come up with more questions for next time. We’re here for that.

About the Author

Cecil R. Webster, Jr., MD, Contributor

Dr. Cecil R. Webster, Jr. is a child, adolescent, and adult psychiatrist in Boston. He is a lecturer in psychiatry at McLean Hospital and Harvard Medical School, and consultant for diversity health outreach programs at the … See Full Bio View all posts by Cecil R. Webster, Jr., MD

Polio is a potentially life-threatening or disabling illness that spreads from person to person. Thanks to vaccination, the United States has been polio-free since 1979, and the spread of this highly contagious disease has been interrupted in most countries. Yet on June 22, the United Kingdom Health Security Agency announced that it had detected poliovirus in a most unexpected place: the sewers of London.

Over the past several months, scientists at the agency repeatedly found poliovirus in London sewer water. The viruses were genetically similar, suggesting that they were the result of limited spread within a family or close-knit community. Just how concerned should all of us be about this news?

Health clues found in wastewater

Sampling of wastewater for genetic material from viruses is a powerful tool used by epidemiologists to track outbreaks of polio and other diseases. Surges in the amount of SARS-CoV-2 RNA in Boston wastewater have been highly predictive of COVID outbreaks. Wastewater may also help to detect the spread of influenza and antibiotic-resistant bacteria.

Poliovirus infection was once a common and dreaded disease. Most people with poliovirus either had no symptoms or mild gastroenteritis (stomach flu). But one in 100 people developed paralysis, or poliomyelitis. In half of the affected patients, this paralysis was permanent.

In the UK, wild poliovirus has been eliminated since 1984. Although great progress has been made in many parts of the world, complete eradication of polio has been elusive. Pakistan and Afghanistan have never been free from wild-type polio, and outbreaks have recently taken place in Malawi and Mozambique, countries which had previously eliminated polio.

The reasons for this backsliding are complex. Some contributing factors are diversion of scarce resources toward the COVID-19 pandemic, backlogs in vaccine manufacturing, anti-vaccine agitation, and violence directed at vaccine workers.

Another problem is vaccine-derived poliovirus. In the United States and most other countries, injections containing killed viruses are used. While these vaccines are safe, they are less effective than oral vaccines at breaking the chain of polio transmission. Oral vaccines stimulate long-lived immune responses in the lining of the intestines, where polioviruses replicate. Unfortunately, oral vaccines contain weakened but live viruses, which occasionally revert to a more dangerous form. In fact, the poliovirus found in London was a vaccine-derived strain that the infected individual had likely acquired from travel abroad.

Who is at risk for poliovirus stemming from this source?

Vaccine-derived viruses pose little risk to highly vaccinated populations, but they are able to spread in communities with low polio vaccination rates. In some cases, this can even cause paralytic disease. Because of these risks, steps are being taken to gradually phase out the use of oral polio vaccines.

If you’re concerned about polio, the best protection against this disease is vaccination. Children should receive a full series of four shots of inactivated polio vaccine, given at specific intervals, that helps with developing immunity.

Nationwide, rates of childhood polio vaccination in the United States are still high (nearly 93%). However, some infectious disease experts worry that the weakening of vaccine mandates in some areas has created islands of vulnerability in this sea of immunity. Communities in the US with low childhood vaccination rates have been vulnerable to large measles outbreaks in recent years, and might also be vulnerable to polio outbreaks.

With few exceptions, adults who were fully vaccinated as kids do not need booster shots. These exceptions include travel to a country with active polio transmission, laboratory work with poliovirus, or providing health care to polio patients and their close contacts. A single lifetime booster dose of inactivated polio vaccine is adequate for these high-risk scenarios.

About the Author

John Ross, MD, FIDSA, Contributor

Dr. John Ross is an assistant professor of medicine at Harvard Medical School. He is board certified in internal medicine and infectious diseases, and practices hospital medicine at Brigham and Women’s Hospital. He is the author … See Full Bio View all posts by John Ross, MD, FIDSA

It’s an old line: everyone complains about the weather but no one is doing anything about it.

But if you’re a person with bad allergies or asthma, stormy weather can be more than an annoyance; it can be a serious threat to your health. “Thunderstorm asthma” was first reported in the 1980s in England and Australia, and cases continue to crop up. Just after severe thunderstorms passed through Melbourne, Australia in 2016, more than 9,000 people sought urgent medical care for asthma during one notable event. Medical facilities were overwhelmed and at least eight people died. That’s unusual, but if you do have asthma — or seasonal allergies, as it turns out — understanding this trigger can help you stay well.

What is thunderstorm asthma?

The term describes an attack of asthma that starts or worsens after a thunderstorm. It can occur in anyone with asthma, but it most often affects people with seasonal allergic rhinitis, which many people know as hay fever or allergies. Heralded by a runny nose, sneezing, and itchy eyes, seasonal allergies are often worst in the spring, summer, or early fall.

Rain tends to lower pollen counts by cleansing the air, and many people find that rainy weather tends to reduce asthma symptoms triggered by allergies. But thunderstorms can make asthma worse because of a unique sequence of events:

• Cold downdrafts concentrate air particles, such as pollen and mold
• These air particles are swept up into clouds where humidity is high
• In the clouds, wind, humidity, and lightning break up the particles to a size that can readily enter the nose, sinuses, and lungs
• Wind gusts concentrate these small particles so large amounts can be inhaled.

What raises risk for experiencing thunderstorm asthma?

According to a new study in the Journal of Allergy and Clinical Immunology, a whopping 144 out of 228 people with seasonal allergies reported experiencing thunderstorm asthma — that’s 65%! And many of the asthma attacks set off by thunderstorms weren’t mild. Nearly half of people who had an attack sought emergency hospital treatment.

Among people with seasonal allergies, risk factors for experiencing thunderstorm asthma include having

• poorly controlled asthma symptoms (assessed by a standard asthma questionnaire)
• a low score on a rapid exhalation test (a common breathing test for asthma)
• higher levels of a certain antibody (ryegrass pollen-specific IgE)
• higher numbers of certain blood cells (eosinophils, which tend to increase when people have allergic conditions)
• higher levels of exhaled nitric oxide (one measure of lung inflammation among people with asthma).

Not everyone with these risk factors will develop thunderstorm asthma. And even among those who do, asthma attacks won’t necessarily occur with every storm. But it may be useful to know if you’re among those at risk, especially if you live in an area where thunderstorms are common.

The bottom line

Thunderstorm asthma may seem like more of a curiosity than a serious threat to public health. But when it affects a large population area, emergency rooms can become overwhelmed, as happened during the 2016 Melbourne event. A better understanding of when these events are expected could lead to advanced warning systems, enhanced emergency room preparedness, and even preventive treatment.

In the US, 25 million people have asthma and more than 20 million have seasonal allergies. Odds are good that millions have both, which puts large numbers of people at risk for developing thunderstorm asthma.

If you’re among them, the weather forecast may be much more than just a guide on what to wear or whether to bring an umbrella. Knowing thunderstorms are headed your way may serve as an advance warning to double check that you are taking your asthma medicines properly, have a supply of rescue medicine handy, or simply plan to stay indoors until the storm has passed.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD