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Friday, April 19, 2019

Number of babies born in withdrawal from prescription painkillers is on the rise

Atrial fibrillation is a heart rhythm disorder that affects millions of people. It can make you feel lousy. Even worse, it can cause potentially disabling or deadly strokes. A special MRI scan may — I stress the “may” — help identify people with atrial fibrillation who are at high risk of having a stroke. This could help many people with this condition to avoid taking warfarin or other clot-preventing medications for life.

A normal heartbeat starts in a cluster of cells called the pacemaker. It sits in the heart’s upper right chamber (the right atrium). These cells generate a pulse of electricity that flows to the rest of the heart and causes a coordinated heartbeat. In people with atrial fibrillation, electrical signals arise from areas outside of the pacemaker. These signals are fast and irregular. So instead of contracting with a steady rhythm, the right and left atria quiver. This can allow blood to pool in the atria instead of flowing smoothly through the heart and into the body.

When blood pools in the atria, it can form small clots. If one breaks away from inside the heart and gets into circulation, it could lodge in the brain, causing a stroke.

To reduce the risk of stroke, people with atrial fibrillation are often advised to take a blood thinner like warfarin or one of the newer alternatives, dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis). But blood thinners can cause severe and sometimes life-threatening bleeding.

Researchers from Johns Hopkins University School of Medicine wanted to see if imaging could identify people with atrial fibrillation who were at high stroke risk. They performed standard MRI scans of the hearts of 149 men and women with atrial fibrillation, then used special motion-tracking software to evaluate the images. The scans revealed specific changes in the muscles of the left atrium that increased stroke risk in some of the volunteers. These changes were not associated with age or other risk factors for stroke. The results were published online April 27th in the Journal of the American Heart Association.
Calculating stroke risk from atrial fibrillation

It would be great to have a way to identify which individuals with atrial fibrillation are at high risk of stroke and which ones are at low risk. The Hopkins study offers a step in that direction. But it is much too early to include MRI as part of the standard evaluation of people with atrial fibrillation — not to mention that such scans would significantly increase the cost of these evaluations. For now, doctors will continue to use standard tools to help determine stroke risk.

If you have atrial fibrillation, your stroke risk is high if you:

    are age 65 or older, and even higher if you are 75 or older
    have had a stroke or a mini-stroke (transient ischemic attack, or TIA) in the past
    have heart failure
    have blood vessels in any part of the body narrowed by cholesterol-filed plaque (vascular disease)
    have diabetes
    are a woman.

Experts have devised a tool called the CHA2DS2-VASc Score to calculate stroke risk for people with atrial fibrillation. It estimates this risk by taking into account age and sex; the presence or absence of heart failure, high blood pressure, narrowed blood vessels, and diabetes; and whether you’ve had a previous stroke, TIA, or blood clot. A low score indicates that warfarin or other clot-preventing medicine may not be needed.

You can calculate your CHA2DS2-VASc Score online.

Someday, the use of MRI scans or some other technique to image the heart will probably be important in the evaluation of atrial fibrillation. But not any time soon. When prostate cancer spreads from the prostate gland into nearby lymph nodes or bladder tissue, it is called locally advanced prostate cancer. The standard treatment for it is a combination of radiation therapy and hormone therapy. Radiation kills prostate cancer cells. Hormone therapy, formally known as androgen deprivation therapy (ADT), deprives prostate cancer cells of testosterone, which they need in order to grow and spread.

But both types of therapy have their own sets of side effects. So is such a one-two punch really needed? It is. That’s the conclusion drawn from the largest clinical trial of the combination to date.Medicine

Using radiation therapy plus ADT against locally advanced prostate cancer came into favor after studies began showing that men treated with both radiation and ADT lived longer than men treated with radiation alone. In one such study, French researchers divided 415 men with locally advanced prostate cancer into two groups: one group was treated with radiation only, while the other group was treated with radiation and three years of ADT. Ten years later, 60% of the men on the combination treatment were still alive, compared with 40% of those who had been treated with radiation only.

What that and other studies did not investigate was how combination therapy stacks up against ADT alone. An international research team has addressed this question, and the results strongly favor combination therapy.

“Adding radiation to ADT more than halved the risk of dying from locally advanced prostate cancer,” said Malcolm Mason, a professor at Cardiff University in Wales and lead author of the study.

Mason and his colleagues enrolled 1,205 men between the ages of 50 and 80 who were diagnosed with locally advanced prostate cancer between 1995 and 2005. Half of the men were treated with lifelong ADT; the other half were treated with ADT plus a seven-week course of radiation.

After 10 years, 43% of the men treated with ADT alone had died, compared to 34% of the men treated with ADT plus radiation. That translates into a 30% lower risk of death from any cause in the combined treatment group. Deaths specifically from prostate cancer were nearly 50% lower among men who got ADT plus radiation. Mason cites that as the study’s take-away conclusion. The results were published in the Journal of Clinical Oncology.

Side effects were roughly comparable in the two treatment groups, with about one in three men reporting a low sex drive and difficulty getting or keeping an erection. Other side effects included bowel problems, hot flashes, and a frequent urge to urinate, which were all slightly more common in the combined treatment arm.

“This paper is significant because it shows that ADT by itself is not enough for men with locally advanced prostate cancer,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and Editor in Chief of HarvardProstateKnowledge.org. “They also need radiation therapy.”

But Garnick points out that a critical question remains: as part of combination therapy, how long should ADT last? In a separate study, the French researchers showed that three years of ADT was more effective than six months. But ADT can be difficult to tolerate, and some men in the trial’s three-year treatment arm weren’t able to complete it.

“We try to give at least two years of ADT to men with high-risk disease, but it depends on what they can tolerate,” Garnick said. “And as the optimal duration isn’t known, this will require further study.”
 Each year, an alarming number of babies born in the United States spend their first few days withdrawing from drugs, often prescription painkillers their mothers took during their pregnancies. This problem, called neonatal abstinence syndrome (NAS), has increased fourfold since 2004, according to a report published online yesterday in The New England Journal of Medicine.

NAS occurs in many babies whose mothers took a type of medication called an opioid during pregnancy. (Two commonly used opioids are OxyContin and Vicodin.) These drugs easily pass from the mother’s bloodstream to the baby’s. They can be addictive, and are often abused. In effect, NAS is a baby’s withdrawal from opioids.

Babies with NAS are stiffer and more irritable than normal babies. They don’t feed well, and so don’t gain weight well. Some have seizures. With medication and time, babies with NAS get better, but they have to spend time in the hospital. In short, they get a rough start on life that can set them back and possibly have long-term repercussions.

For the new study, researchers from several U.S. medical centers looked at the records of almost 700,000 newborns treated in 299 neonatal intensive care units around the country between 2004 and 2013. During that period, the number of children treated for NAS rose nearly fourfold, from 7 cases per 1,000 babies admitted to neonatal intensive care units to 27 cases per 1,000. Neonatal intensive care unit days needed to treat babies with NAS went up sevenfold. The report was published yesterday to coincide with a presentation of the results at the Pediatric Academic Societies annual meeting in San Diego.

In the study, the leading cause of NAS was mothers taking methadone during pregnancy, which accounted for nearly one-third of cases. Methadone is a medication used to treat drug addiction, especially heroin addiction. The second most common reason for NAS was mothers taking opioid painkillers.
Safer pain options

The number of prescriptions for opioid painkillers has skyrocketed in recent years, as has the number of people addicted to opioids. Some prescriptions for opioids are written for pregnant women. A survey published online in Pediatrics found that 28% of pregnant women with Medicaid in Tennessee received at least one prescription for an opioid pain reliever during their pregnancies.

With so many safe options for pain control, women who are pregnant should use opioids only if these medications are absolutely necessary. Doctors can often recommend other effective options for pain control that are safer for the baby.

Because opioids are so addictive, many people become dependent on them. Pregnant women are no different — some are addicted before they become pregnant, others become addicted during pregnancy. In either case, the health of the baby is at stake.

With opioid addiction on the rise, it’s likely that the number of babies with NAS will continue to climb, too. It’s often difficult for someone in the grip of addiction to make a healthy change. That’s why it’s important that the partners, family members, and friends of pregnant women be aware of this problem. Sometimes they are the best ones to speak up, give support, and make a difference. Studies like this one that draw attention to the youngest, most vulnerable, and totally innocent victims of opioids may also help galvanize us to fight opioid addiction once and for all.

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