More intensive treatment of DCIS reduces the risk of invasive breast cancer – Harvard Health Blog


Breast cancer screening with mammography or other tools (such as MRI) has increased the rates of diagnosis of very early breast cancers knowns as DCIS (ductal carcinoma in situ). As opposed to invasive breast cancers, DCIS cancers are confined to the local area and have not spread to deeper tissues or elsewhere in the body. With increased rates of diagnosis, there has been considerable controversy about the true risks of DCIS and the best treatments, with some suggesting that women are being overtreated for a condition that does not substantially increase the long-term risk of death, and others advocating more intensive preventive treatment among women with DCIS.

Long-term outcomes for women with and without DCIS have been limited, until now

A recent study published in The BMJ offers the best data so far on the risks associated with DCIS and the impact of different treatments. In the study, more than 35,000 women diagnosed with DCIS via mammography were followed for up to 20 years to see if they developed invasive breast cancer or died of breast cancer.

Overall, the researchers found that having DCIS more than doubled the risk of developing invasive breast cancer and increased the risk of dying of breast cancer by 70%, compared with the general population. Moreover, the researchers observed that more intensive treatment of DCIS was associated with lower risk of invasive breast cancer. Compared to women who had both breast-conserving surgery (lumpectomy) and radiation therapy, those who had lumpectomy alone had 43% higher rates of breast cancer, and those who had mastectomy had 45% lower rates of breast cancer. A larger DCIS-free margin in the biopsy sample was also associated with lower rates of developing invasive breast cancer. For women with estrogen receptor-positive DCIS, hormone treatment to reduce estrogen levels was associated with lower risk of invasive breast cancer.

The findings from this new study are broadly similar to a US study of more than 100,000 women with DCIS that found an 80% higher risk of dying of breast cancer in women with DCIS than in the general population, although that study couldn’t determine how the DCIS was diagnosed. A Danish study also found that women with DCIS who were treated with mastectomy had lower rates of invasive breast cancer in that breast than those treated with more conservative surgery, with or without radiation therapy.

What does the new research mean for a woman who is diagnosed with DCIS?

This study showed that increased cancer risk persisted for more than 15 years after a diagnosis of DCIS, and that more intensive therapy than lumpectomy alone — whether with mastectomy, radiation therapy, or endocrine therapy — reduced the risk of invasive breast cancer among women with DCIS. The lowest risk of invasive breast cancer was in women who chose mastectomy.

The risk of invasive breast cancer was seen regardless of severity of DCIS. Women who had low- or moderate-grade DCIS, as well as high-grade DCIS, had long-term increased risk.

Women who are recently diagnosed with DCIS should work with their treatment team to weigh the best individual treatment strategies based on their preferences and other health conditions. This new research validates the need to consider the long-term consequences of DCIS when making treatment decisions, and it may prompt doctors and patients to consider more intensive treatments to reduce later risk of invasive breast cancer and risk of dying of breast cancer. While no details on surveillance strategies, such as regular mammograms or other exams, were presented in this study, based on these results, patients with DCIS should continue active surveillance for breast cancer for decades after their diagnosis.



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Alcohol harms the brain in teen years –– before and after that, too – Harvard Health Blog


If we only paid attention to ads, it might seem as though alcohol — a beer or glass of wine, a shot of fiery liquor or sophisticated cocktail — merely served as a way to bring people together and make them happy. Drink responsibly, the ads wink, without ever explaining the toll that frequent or excessive alcohol use exacts, particularly at certain stages in life. Because alcohol doesn’t just get us drunk, impair our judgment, and hurt our liver: it can have many other bad effects on our bodies — including effects on the brain.

In a recent editorial in The BMJ, a trio of scientists pointed out that there are three periods in life when the brain goes through major changes and is particularly vulnerable to the effects of alcohol. Two of those periods are at the beginning and end of life. When pregnant women drink alcohol, it can damage the developing brain of the fetus, leading to physical problems, learning disabilities, and behavioral problems. When people over the age of 65 drink alcohol, it can worsen declines in brain function that happen during aging.

The third period is adolescence. During those years of transition between childhood and adulthood, the brain grows and changes in many important ways that are crucial for that transition to be successful. When teens and young adults drink alcohol, it can interfere with that process of brain development in ways that affect the rest of their lives.

Alcohol use in teens and young adults

According to the Centers for Disease Control and Prevention (CDC), alcohol is the most commonly used substance among young people in the US. Although rates of drinking and binge drinking have been going down over recent decades, national surveys show that among youth and young adults, one in five report drinking alcohol in the past 30 days, and one in 10 report binge drinking. The 2019 Youth Risk Behavioral Survey found that more than a quarter of high school students drank alcohol in the 30 days before they took the survey, and one in seven reported binge drinking in that same time period.

That’s an awful lot of youth who could be changing their brains — and their lives — forever.

Here is what the parents of teens can and should do:

  • Talk to your teens about alcohol and its effects — all of them. Make sure they have the facts.
  • Have strict rules about alcohol use, and consequences if those rules are broken. Yes, it’s normal for teens to experiment, but if you condone going to parties with alcohol, binge drinking, or driving while drinking, it could literally ruin your child’s life — or end it.
  • Get to know the parents of your teen’s friends, and work toward having a shared, community responsibility for keeping everyone safe.
  • Set a good example. Drink responsibly, just as those ads encourage.

For more advice on talking to your teen and strategies for preventing alcohol use and abuse, visit the website of the National Institute on Alcohol Abuse and Alcoholism.

Follow me on Twitter @drClaire



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Exercise matters to health and well-being, regardless of your size – Harvard Health Blog


Unfortunately, the COVID-19 pandemic continues to wreak havoc in our daily lives. Regardless of who you are, your life has been impacted in some way. Stress is mounting, and you may need to find a way to decompress while social distancing. Enter stage left my favorite pastime: exercise!

All right, I know what you are thinking: She’s one of those exercise fanatics who is going to tell me that I need to exercise several hours every day. Well, no. What I am going to tell you is that you can make exercise work for you. It is imperative to find your “soulmate workout” or simple activities you can do. You might think that you need to be a certain size or already in shape to engage in exercise. This is simply not true, nor is it helpful for your health and well-being, since exercise — even small amounts — helps improve blood pressure, heart problems, blood sugar control, and mood. It can help you live longer, too.

So, let’s start with some questions that you may have. How much physical activity does your body need? Is it possible to be active during the middle of the COVID-19 pandemic? How can you make exercise work for you? What if excess weight or painful joints make it hard to be active? And what if you haven’t been active at all? We’ve got the answers for you.

How much exercise do I need?

Before you start counting minutes, understand this: almost anything that gets your body moving counts as exercise, and active minutes add up over your day and week.

Every week, adults should aim for at least 150 minutes of moderate physical activity, or 75 minutes of vigorous physical activity. So depending on the intensity of exercise, that could be 30 minutes (moderate) — or just 15 minutes (vigorous) — five days a week. Experts also recommend muscle-strengthening activities at least twice a week. But even if you can’t reach these goals, some activity is always better than none. Just trying to move around more and sit less will help. Now, let’s break this down a little further.

What is moderate physical activity?

Moderate activity raises your heart rate, makes you break out into a sweat, and allows you to talk but not sing. Here are some examples:

  • walking at a brisk pace
  • water aerobics
  • pushing a lawn mower or a vacuum
  • riding a bicycle on flat ground
  • casual dancing.

What is vigorous physical activity?

Vigorous activity causes a large increase in your heart rate, you breathe very hard, and you are only able to say a few words, not full sentences. Here are some examples:

  • jogging or running
  • playing basketball
  • swimming laps
  • riding a bicycle fast or on hills.

What if I have excess weight or painful joints?

There are several activities that are great for persons of all ages and sizes. Here are a few:

  • walking aerobic videos and workouts available on TV, cable, or through streaming services (more information below)
  • elliptical machine
  • recumbent bicycle
  • water aerobics.

These activities are economical or free, and easy to do. You can always increase or decrease your intensity as you are able.

So how do I get started?

Just do it! However, it is important not to go from doing nothing to thinking you will compete in the Olympics tomorrow. So, listen to your body. If you have not been a regular exerciser, I recommend starting to exercise in 10-minute spurts. Eventually, you can build up to longer sessions as you become more accustomed to exercise. Your goal is to be consistent and to make exercise a part of your life.

What is the minimal amount of exercise I can do to make a big difference in my health?

An analysis of multiple studies using activity trackers with people who were middle-aged or older indicated that just 11 minutes of moderate-to-vigorous exercise a day, combined with less than 8.5 hours of daily sedentary time, reduces risk for dying prematurely. Just 11 minutes, plus a commitment to moving more and sitting less throughout your day! You can make that happen.

What are some tools and resources to help me explore physical activity?

  • If you love walking: Take short walks near your home for free. Or explore walking workouts available online, such as this one with Leslie Sansone. You can do one- to five-mile walks in the comfort of your living room.
  • If you’d like to get some use out of your DVD or video player: Take a look at Collage Video, which has a collection of over 1,200 fitness DVDs available at low cost. They also offer options if you are older or have physical disabilities that do not allow you to walk or move around easily. Your local library may have exercise DVDs or videos, too.
  • If you are looking for a wide assortment of on-demand workouts, such as hip-hop dancing and strength or cardio workouts, available free or as part of a membership or monthly subscription: You can find these options on TV, cable, and streaming channels or fitness organizations online, such as the YMCA 360 and the American Council on Fitness. Or try these flexibility, strength, and balance exercises or short workouts designed for older adults from the National Institute on Aging. Depending on your level of fitness and ability to walk and move around, you might also consider chair workouts.

In addition to these resources, be on the lookout for local on-demand workouts by staying connected to social media outlets such as Twitter or Instagram. Dr. Arghavan Salles and I led the Social Distancing Fitness Challenge during the COVID-19 surge last spring to encourage our patients to be active.

My final thoughts: You can do this! Believe in yourself. You will surprise yourself.

Follow me on Twitter and Instagram @askdrfatima





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Can I take something to prevent colorectal cancer? – Harvard Health Blog


Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. There is compelling evidence that screening to detect CRC early to find and remove precancerous polyps can reduce CRC mortality. However, screening has associated harms, including procedural complications, and inherent limitations. For example, colonoscopy, the most common screening tool in the US, is less effective in preventing cancers of the right, or ascending side, of the colon compared with cancers of the left, or descending side, of the colon.

Moreover, only 60% of US adults recommended for screening actually follow through. Even under the best circumstances, screening is resource-intensive, requiring time, equipment, and a trained doctor to perform the procedure, and cannot be widely implemented in many parts of the world. Thus, alternatives to screening to effectively prevent CRC are a high unmet need.

What are alternatives to screening for prevention of colorectal cancer?

Adherence to healthy lifestyle habits, including maintaining a healthy body weight, keeping physically active, and abstaining from tobacco, can reduce risk of CRC in all individuals. These habits also help prevent other chronic health conditions.

In addition to lifestyle, chemoprevention — the use of agents to inhibit, delay, or intercept and reverse cancer formation — also holds significant promise. The ideal chemopreventive agent, or combination of agents, requires the benefits to outweigh the risks, especially since effective prevention likely requires long-term use. Many different agents have been proposed and studied over the last several decades.

Study suggests aspirin may help prevent colorectal cancer

In an article published in the journal Gut, researchers performed a systematic review, analyzing data from 80 meta-analyses or systematic reviews of interventional and observational studies published between 1980 and 2019, examining use of medications, vitamins, supplements, and dietary factors for prevention of CRC in people of average risk.

The authors found that regular use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve), magnesium, and folate is associated with decreased risk of CRC. In addition, high consumption of fiber, fruits and vegetables, and dairy products also appears to be associated with reduced risk. In contrast, heavy alcohol intake and high red or processed meat consumption is associated with an increased incidence of CRC. There was no evidence of any protective benefit for tea, coffee, garlic, fish, or soy products.

The strongest level of evidence for a protective benefit exists for aspirin, which includes “gold standard” randomized controlled trials showing that regular use of aspirin reduces risk of precancerous adenomatous colon polyps, the precursor to the vast majority of CRC. The level of evidence is low to very low for other protective agents, including NSAIDs, magnesium, and folate.

The limitations of this review include variation in the included study populations, study designs, dosing of the studies’ agent or agents and duration of exposure, and follow-up time. This reflects the inherent challenges of conducting studies of preventive agents for CRC, which require large numbers of participants and long-term follow-up (it takes several years for normal colon tissue to transform into a polyp and then a CRC).

What do I tell my patients?

Despite a low level of supporting evidence, efforts to prevent cancer through dietary interventions, such as eating a high-fiber diet and minimizing intake of red meat, are reasonable to recommend broadly, since they are generally not associated with negative consequences.

However, interventions that involve taking medications generally require a higher standard of evidence, since they are associated with the potential for adverse effects. Among drugs proposed for chemoprevention of CRC, I believe aspirin has perhaps the strongest level of evidence supporting potential effectiveness, a conclusion shared by the review. The studies included in this systematic review led the US Preventive Services Task Force (USPSTF) to recommend low-dose (81 milligrams per day) aspirin for joint prevention of CRC and cardiovascular disease (CVD), for individuals ages 50 to 59 with a 10% 10-year risk for a CVD event. However, the USPSTF cautioned about the potential harms of aspirin, including gastrointestinal bleeding.

I generally recommend aspirin use for prevention of CRC only after a detailed discussion of potential risks and benefits, while acknowledging the lack of broader population-based recommendations or conclusive data supporting use in additional age groups or based on other risk factors.

Follow me on Twitter @AndyChanMD





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3 simple steps to jump-start your heart health this year – Harvard Health Blog


In 2020, the terrible toll of the COVID-19 pandemic largely overshadowed the affliction that remains the leading cause of death in this country: heart disease. In the United States last year, at least twice as many people died from cardiovascular causes as those who died from complications from SARS-CoV-2, the novel coronavirus.

While the challenges from the virus are new, experts have been studying heart disease for decades — and everyone can benefit from that knowledge. “The lifestyle habits that keep your heart healthy may also leave you less vulnerable to serious complications from infections such as COVID-19 and influenza,” says cardiologist Dr. Deepak L. Bhatt, professor of medicine at Harvard Medical School and editor in chief of the Harvard Heart Letter.

So what exactly are those heart-healthy habits? The American Heart Association refers to them as “Life’s Simple 7.” Put simply, they are:

1) Stop smoking

2) Eat better

3) Be active

4) Lose weight

5) Manage your blood pressure

6) Control your cholesterol

7) Reduce your blood sugar

Choosing three steps to jump-start heart health this year

But seven steps may seem like too much to manage, or may even seem overwhelming. So, let’s make it even simpler by focusing on just a few. Of course, not everyone needs to lose weight or lower their blood sugar. And in reality, most Americans don’t smoke, so step one doesn’t apply to very many people.

Unfortunately, that’s not the case for steps two and three. Most people don’t eat enough plant-based foods like vegetables, whole grains, beans, and fruit. And few Americans get the recommended amounts of exercise. That’s at least 150 minutes of moderate-intensity aerobic activity (like brisk walking) each week, plus muscle-strengthening activity (like lifting weights) at least two days each week.

Of course, improving both your diet and your exercise game will help you lose weight (step four). But did you know that eating better and moving more can also help with steps five, six, and seven?

Start with one small change, then add on

In 2021, do your heart a favor by doing these three things.

Make one small change to your diet. Some suggestions: Swap meat with beans in one of your favorite dinner recipes. Eat a slice of whole-grain bread instead of white bread. Try a vegetable you’ve never had before.

Do a heart rate-elevating exercise for 10 minutes. Some suggestions: Take a brisk walk around your neighborhood. Hop on a treadmill or other exercise machine. No machines handy? Do some simple calisthenics, like a combination of jumping jacks, squats, leg raises, and arm circles.

Know your numbers. It’s easy to track these four key values. Step on a scale, then use your weight and height to calculate your body mass index. Measure your blood pressure (many pharmacies have machines). Check your medical records for your latest blood test results, which should include cholesterol and fasting blood sugar values.

Here are the standard targets:

  • body mass index between 18.5 and 25 (see this BMI calculator)
  • blood pressure below 120/80 mm/Hg
  • total cholesterol of less than 200 mg/dL
  • fasting blood sugar (glucose) below 100 mg/dL.

It’s important to note that your individual targets may differ, depending on your age and medical and family history. Talk with your doctor about this, then work together to achieve or maintain these four values in the optimal range for you. This might include taking medications. And in the meantime, start making small tweaks to your diet and exercise routine. Gradually adding more healthful foods and spending more time exercising can really make a difference to your heart and overall health.



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CBD and other medications: Proceed with caution – Harvard Health Blog


Products containing cannabidiol (CBD) seem to be all the rage these days, promising relief from a wide range of maladies, from insomnia and hot flashes to chronic pain and seizures. Some of these claims have merit to them, while some of them are just hype. But it won’t hurt to try, right? Well, not so fast. CBD is a biologically active compound, and as such, it may also have unintended consequences. These include known side effects of CBD, but also unintended interactions with supplements, herbal products, and over-the-counter (OTC) and prescription medications.

Doubling up on side effects

While generally considered safe, CBD may cause drowsiness, lightheadedness, nausea, diarrhea, dry mouth, and, in rare instances, damage to the liver. Taking CBD with other medications that have similar side effects may increase the risk of unwanted symptoms or toxicity. In other words, taking CBD at the same time with OTC or prescription medications and substances that cause sleepiness, such as opioids, benzodiazepines (such as Xanax or Ativan), antipsychotics, antidepressants, antihistamines (such as Benadryl), or alcohol may lead to increased sleepiness, fatigue, and possibly accidental falls and accidents when driving. Increased sedation and tiredness may also happen when using certain herbal supplements, such as kava, melatonin, and St. John’s wort. Taking CBD with stimulants (such as Adderall) may lead to decreased appetite, while taking it with the diabetes drug metformin or certain heartburn drugs (such as Prilosec) may increase the risk of diarrhea.

CBD can alter the effects of other drugs

Many drugs are broken down by enzymes in the liver, and CBD may compete for or interfere with these enzymes, leading to too much or not enough of the drug in the body, called altered concentration. The altered concentration, in turn, may lead to the medication not working, or an increased risk of side effects. Such drug interactions are usually hard to predict but can cause unpleasant and sometimes serious problems.

Researchers from Penn State College of Medicine evaluated existing information on five prescription CBD and delta-9-tetrahydrocannabinol (THC) cannabinoid medications: antinausea medications used during cancer treatment (Marinol, Syndros, Cesamet); a medication used primarily for muscle spasms in multiple sclerosis (Sativex, which is not currently available in the US, but available in other countries); and an antiseizure medication (Epidiolex). Overall, the researchers identified 139 medications that may be affected by cannabinoids. This list was further narrowed to 57 medications, for which altered concentration can be dangerous. The list contains a variety of drugs from heart medications to antibiotics, although not all the drugs on the list may be affected by CBD-only products (some are only affected by THC). Potentially serious drug interactions with CBD included

  • a common blood thinner, warfarin
  • a heart rhythm medication, amiodarone
  • a thyroid medication, levothyroxine
  • several medications for seizure, including clobazam, lamotrigine, and valproate.

The researchers further warned that while the list may be used as a starting point to identify potential drug interactions with marijuana or CBD oil, plant-derived cannabinoid products may deliver highly variable cannabinoid concentrations (unlike the FDA-regulated prescription cannabinoid medications previously mentioned), and may contain many other compounds that can increase the risk of unintended drug interactions.

Does the form of CBD matter?

Absolutely. Inhaled CBD gets into the blood the fastest, reaching high concentration within 30 minutes and increasing the risk of acute side effects. Edibles require longer time to absorb and are less likely to produce a high concentration peak, although they may eventually reach high enough levels to cause an issue or interact with other medications. Topical formulations, such as creams and lotions, may not absorb and get into the blood in sufficient amount to interact with other medications, although there is very little information on how much of CBD gets into the blood eventually. All of this is further complicated by the fact that none of these products are regulated or checked for purity, concentration, or safety.

The bottom line: Talk to your doctor or pharmacist if using or considering CBD

CBD has the potential to interact with many other products, including over-the-counter medications, herbal products, and prescription medications. Some medications should never be taken with CBD; the use of other medications may need to be modified or reduced to prevent serious issues. The consequences of drug interactions also depend on many other factors, including the dose of CBD, the dose of another medication, and a person’s underlying health condition. Older adults are more susceptible to drug interactions because they often take multiple medications, and because of age-related physiological changes that affect how our bodies process medications.

People considering or taking CBD products should always mention their use to their doctor, particularly if they are taking other medications or have underlying medical conditions, such as liver disease, kidney disease, epilepsy, heart issues, a weakened immune system, or are on medications that can weaken the immune system (such as cancer medications). A pharmacist is a great resource to help you learn about a potential interaction with a supplement, an herbal product (many of which have their own drug interactions), or an over-the-counter or prescription medication. Don’t assume that just because something is natural, it is safe and trying it won’t hurt. It very well might.



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Wondering about COVID-19 vaccines if you’re pregnant or breastfeeding? – Harvard Health Blog


Now that COVID-19 vaccines are rolling out, pregnant and breastfeeding people have many questions around risks and benefits. At first, many of those receiving vaccines in US will be healthcare workers, although the circles for vaccine eligibility are widening.

The Centers for Disease Control and Prevention (CDC), the American College of Obstetrics and Gynecology (ACOG), and the Society for Maternal-Fetal Medicine agree that the new mRNA COVID-19 vaccines should be offered to pregnant and breastfeeding individuals who are eligible for vaccination.

Here are answers to some basic questions you may have about getting a COVID-19 vaccine if you’re pregnant or breastfeeding — or are considering a pregnancy. Keep in mind that information is evolving rapidly. Your obstetric provider or medical team can advise you more fully, based on your personal health risks, exposures to the virus that causes COVID-19, and preferences.

What do we know about how COVID-19 affects people who are pregnant?

COVID-19 is potentially dangerous for all people. Although the actual risk of severe illness and death among pregnant individuals is very low, it is higher when compared to nonpregnant individuals from the same age group. Those who are pregnant are at higher risk for being hospitalized in an intensive care unit and requiring a high level of care, including breathing support on a machine, and are at higher risk for dying if this happens.

If you’re pregnant, you may also wonder about risks to the fetus if you get COVID-19. Research suggests that having COVID-19 might increase risk for premature birth, particularly for those with severe illness. So far, studies have not identified any birth defects associated with COVID-19. And while transmission of the virus from mother to baby during pregnancy is possible, it appears to be a rare event. You can read more about pregnancy and COVID-19 here.

What do we know about the safety of newly available mRNA COVID-19 vaccines in people who are pregnant?

The mRNA vaccine trials did not deliberately include pregnant or breastfeeding individuals, so our direct knowledge is currently limited. Some vaccine trial participants inadvertently became pregnant; 18 of these people received the vaccine. Further information may be available in coming months.

When studied during animal tests, the mRNA vaccines did not affect fertility or cause any problems with pregnancy. In humans, we know that other kinds of vaccines generally are safe for use in pregnancy — in fact, many are recommended.

It’s also important to know that

  • The mRNA vaccines do not contain any virus particles.
  • Within hours or days our bodies eliminate mRNA particles used in the vaccine, so these particles are unlikely to reach or cross the placenta.
  • The immunity that a pregnant individual generates from vaccination can cross the placenta, and may help to keep the baby safe after birth.

What about vaccine side effects? One possible short-term side effect of the mRNA vaccine trials (occurring within one to two days of vaccination) is fever. About 1% to 3% of people have experienced fever after the first dose of mRNA vaccine, and about 15% to 17% after the second dose. These fevers are generally low and can be managed with acetaminophen, which is safe to take during pregnancy. Rarely, high, prolonged fevers in pregnancy may lead to birth defects.

For more information about common COVID vaccine side effects, click here.

What to consider about COVID-19 vaccines if you’re pregnant

Eligibility for COVID vaccines varies from state to state. Healthcare workers with direct patient contact are typically in the first phase for vaccines, followed by other people at high risk for getting COVID, such as first responders, essential workers, nursing home residents, people over age 75, and people with certain health conditions.

Assuming the mRNA vaccine is available to you during your pregnancy, you have several options to discuss with your health care provider.

  • Get vaccinated as soon as the vaccine is available to you. You might decide to do this if you have additional risk factors for severe complications from COVID-19 (such as high blood pressure or obesity), and/or multiple potential exposures to COVID-19 from your work, your family, or your community.
  • Wait until after you give birth to get the vaccine. You might choose to do this if pregnancy is your only risk factor for severe disease, and you are able to control your exposures by limiting interactions with people outside of your household and using protective measures (mask-wearing, handwashing, and physical distancing).
  • Consider ways to modify your exposures to COVID-19 and possibly defer getting the vaccine. Most people have some risk factors and some uncontrolled exposures. If this describes you, you still have options. You may decide to modify your exposures if possible and defer vaccination until the second trimester, when the natural risk of miscarriage is lower. Or you may choose to delay vaccination until after the baby is born.
  • Wait for a traditional vaccine similar to the flu shot or Tdap vaccines. These vaccines are in development but are not yet approved in the US. Experts know much more about using these types of vaccines in people who are pregnant. However, depending on your exposures to COVID-19 and your risk for getting seriously ill if you get infected, it may be wisest to have an mRNA vaccine.

If you are considering deferring the vaccine, ask whether vaccination will be available to you at a later date. The answer may vary depending on supplies of the COVID vaccines and vaccination programs where you live.

What to consider about COVID-19 vaccines if you’re breastfeeding

Experts believe it is most likely safe to get an mRNA COVID-19 vaccine if you’re breastfeeding. Although breastfeeding people were not included in the vaccine trials, the mechanism of mRNA vaccines and experience from other vaccines suggest this is true.

It is important to know:

  • There is no virus in the mRNA vaccines. You cannot get COVID, or give your baby COVID, by being vaccinated. The components of the vaccine are not known to harm breastfed infants.
  • When you receive the vaccine, the small mRNA vaccine particles are used up by your muscle cells at the injection site and thus are unlikely to get into breast milk. Any small mRNA particles that reach the breast milk would likely be digested.
  • When a person gets vaccinated while breastfeeding, their immune system develops antibodies that protect against COVID-19. These antibodies can be passed through breast milk to the baby. Newborns of vaccinated mothers who breastfeed can benefit from these antibodies against COVID-19.

What to consider if you’re thinking of becoming pregnant soon or in the future

If you are considering pregnancy soon, accepting the COVID-19 vaccine as soon as it is available to you is a great way to ensure that you — and your pregnancy — are protected.

COVID-19 vaccination is not believed to affect future fertility.

The bottom line

COVID-19 vaccination for people who are pregnant or breastfeeding has potential benefits, and raises some as yet unanswered questions. It helps to become as informed as you can when making your decision, but realize that information may be changing rapidly. We will be learning more about COVID vaccine safety during pregnancy and while breastfeeding from animal studies now underway, and from human studies that are enrolling participants.

Meanwhile, you can stay informed by checking trusted health websites, such as those listed above, and talking with your healthcare providers. Together you can balance the latest data on risks of COVID-19 in pregnancy, the safety of available vaccines, your individual risk factors and exposures, and most importantly, your values and preferences.



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Can gout be prevented? – Harvard Health Blog


To many people, gout seems like a disease of the past. Cartoons from 200 years ago depicted it as a condition afflicting the wealthy (“the disease of kings”), whose gluttonous consumption of food and drink was thought to bring on the attacks of debilitating arthritis.

All these years later, much about gout is still misunderstood. Shame, derision, and the belief that the gout sufferer deserves the condition linger. And rather than being a disease of the past, gout is quite common — and rates are rising. Estimates suggest gout affects nearly 4% of the adult population in the US, an increase from prior decades. And it’s not a disease limited to the well-to-do; it affects people of all economic classes.

The most likely explanations for the rising rates of gout are an aging population and excess weight. Both are major risk factors for the disease. The expanding waistline of the average American probably plays a bigger role than age, since overweight and obesity have increased more rapidly than the average age of Americans in recent decades.

A study of gout suggests ways to avoid it

Even though research has identified some preventable risk factors for gout, the impact of modifying them is uncertain. Now a new study published in JAMA Network Open has found that more than three-quarters of gout cases affecting men might be completely avoidable. And since gout affects men more often than women, this finding is notable.

The researchers analyzed data from nearly 45,000 men who completed detailed surveys about their health, habits, and medications every two years for 25 years. Comparing those who developed gout (nearly 4%) with those who did not, four factors were identified as protective:

  • normal body mass index (BMI), a measure of weight and height (see calculator)
  • no alcohol consumption
  • no use of a diuretic medication (a drug that increases urination, commonly used to treat high blood pressure and other conditions)
  • following a DASH-style diet, a heart-healthy diet originally developed to counter high blood pressure.

The analysis suggested that 69% of all cases of gout in men could be avoided with these four measures. Most of this benefit applied to men who were not obese. Obese men (BMI of 30 or higher) saw little benefit. According to the researchers, this suggests losing excess weight is necessary to reap benefit from the other three protective factors.

As with all research, this study has limitations. For example, the analysis relied heavily on self-reporting, which can be inaccurate. This included information about diet, alcohol consumption, medication use, and even the diagnosis of gout. And it’s possible that other, unmeasured contributors to the risk of gout (such as genetic factors) could have contributed to the findings. The study participants were all male health professionals (dentists, optometrists, osteopaths, pharmacists, podiatrists, and veterinarians), and 91% were white, so the findings may not apply to all persons at risk for gout.

In the real world, is this study a game-changer?

While the findings could be seen as game-changing, we don’t know how much impact they’ll actually have. For example, if every household in the country received this information, how many people would switch to the DASH diet and stick with it? How many people who usually drink alcohol would give it up? And how many overweight and obese individuals would manage to achieve and maintain a normal BMI?

As for diuretic use, doctors often prescribe diuretics, such as hydrochlorothiazide or furosemide, for people with high blood pressure and other health conditions. The risk of future gout is unlikely to alter this. However, there are many alternative medications available to lower blood pressure. So if gout is diagnosed in a person taking a diuretic, switching to a different drug is worth considering.

The bottom line

The idea that a painful and sometimes disabling condition like gout can be prevented without medications is certainly appealing. But knowing how to prevent gout and actually preventing it are two different things. At the very least, this new research adds one more reason to adopt a healthy diet, moderate alcohol intake, and maintain a healthy weight: not only might this improve your health overall, but you may also save yourself from gout.

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Hormonal therapies for advanced prostate cancer linked to a higher risk of falls and fractures – Harvard Health Blog


Falls rank among the top causes of death and injuries among the elderly, and the risk increases significantly in older people being treated for cancer. Now, investigators are reporting that a newer class of drugs for advanced prostate cancer is associated with a significant increase in fall risk.

Called androgen receptor inhibitors, or ARIs, these drugs target testosterone, a hormone that accelerates the growth of prostate tumors. Unlike traditional hormonal treatments that interfere with the body’s ability to make testosterone (known as androgen deprivation therapy, or ADT), ARIs work by preventing testosterone from binding to its receptor on cancer cells. Three ARIs were evaluated in the study — apalutamide, enzalutamide, and darolutamide — and each can limit prostate cancer progression and extend survival. The investigators emphasized that the benefits of using ARIs outweigh the risk of falls and fractures, which are rare even in treated patients.

What the investigators did

To generate the findings, the investigators performed a systematic review of previously published studies comparing ARI treatments with placebo. In all, 11 studies enrolling a combined total of 11,382 men met the criteria for evaluation. The average age of the men was 72, and the ARI treatments lasted between 5.4 and 20.5 months. Men were excluded if they had a prior history of heart disease or seizure disorders.

What they found

Results showed that 525 of 6,536 ARI-treated men (8%) had suffered falls, compared to 221 of 4,846 men (5%) who were given a placebo. Roughly half the falls in both groups resulted in fractures. However, grade-3 fractures causing more severe injuries occurred 1.6 times more frequently in the men taking ARIs. Apalutamide was associated with the highest fall risk (12%), followed by enzalutamide at 8% and darolutamide at 4.2%.

Just why ARIs boost fall risk isn’t known. Apalutamide and enzalutamide both cross the blood-brain barrier (making them useful for treating brain metastases), and may therefore have more central nervous system side effects that include falls. The drugs may weaken men by decreasing skeletal muscle mass and strength. The concurrent use of other drugs, such as benzodiazepines (including valium) or opioids, can also elevate the risk.

To ward against falls in older men, the investigators recommended risk-screening tools used more commonly in noncancer populations. They singled out the Hendrich II Fall Risk Model, which predicts falls based on independent risk factors that include depression, impairments in bladder and bowel function, dizziness, use or cessation of antiepileptic drugs, treatment with benzodiazepines, and poor performance on a “get-up-and-go” test of rising form a seated position. Men who score highly on a screening evaluation will require precautionary interventions. It’s possible that certain bone-health drugs such as denosumab can protect against fracture, but data with these sorts of agents in advanced prostate cancer are limited, so the investigators couldn’t make a strong recommendation either way.

“I welcome this study, since it brings attention to an often overlooked issue in older men, many of whom may be frail and have lost bone density and bone mass as a result of lowered testosterone values resulting from overall treatment,” said 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. “Falls and traumatic fractures are a devastating event for this patient population and studies like this are long overdue. Hopefully with studies like this coming to light, and more data being collected, best practices for fall prevention will be developed and implemented at the point of care.”



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