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Corneal transplants becoming more common

A cross section of an anatomical model of the eye against a black background; the clear plastic dome of the cornea shows on the left

At one time, replacement parts for the eyes must have seemed unimaginable. Nowadays, if the inner lens of the eye becomes clouded by a cataract, a routine surgery to swap it out with a new artificial lens restores vision.

But what happens if the outer lens of the eye (the cornea) becomes damaged or diseased? You can have that replaced, too. “It’s not as common as cataract surgery, but many people get corneal diseases after age 50 and may need a corneal transplant,” says Dr. Nandini Venkateswaran, a corneal and cataract surgeon at Harvard-affiliated Massachusetts Eye and Ear.

More than 49,000 corneal transplants occurred in 2021 in the US, according to the Eye Bank Association of America.

What is the cornea?

The cornea is a dome of clear tissue at the front of each eye, covering the iris and pupil, that acts as a windshield that protects the delicate eye apparatus behind it, and focuses light onto the retina, which sends signals that the brain turns into images (your vision).

You need this combo of windshield and camera lens to focus and see clearly. But many things can go wrong within the five layers of tissue that make up the cornea. That can make it hard to see and rob you of the ability to read, drive, work, and get through other activities in your day.

How does damage to the cornea occur?

It may stem from a number of causes:

  • Injuries, such as a fall. “Falls are a big reason for people to come in with acute eye trauma. The cornea can be damaged easily if something pokes it,” Dr. Venkateswaran says.
  • Previous eye surgeries. “Especially for adults who’ve had several eye surgeries — such as cataract and glaucoma surgeries — the inner layers of the cornea can become damaged and weakened with age,” she adds.
  • Illness. Problems like severe corneal infections, or genetic conditions such as Fuchs’ endothelial dystrophy, can cause vision loss.

What are the options for treating corneal damage?

Cornea treatment depends on the type of problem you have and the extent of the damage. “It’s a stepwise approach. Sometimes wearing a specialty contact lens or using medications can decrease swelling or scarring in the cornea,” Dr. Venkateswaran says.

When damage can’t be repaired, surgeons can replace one or a few layers of the cornea (a partial-thickness transplant), or the whole thing (a full-thickness transplant).

The vast majority of transplants come from donor corneas that are obtained and processed by eye banks throughout the US. In some instances, such as when repeated transplants fail, an artificial cornea is an option. Recovery after corneal surgery can take up to a year.

How long-lasting are corneal transplants?

There’s always a risk that your body will reject a corneal transplant. It happens about a third of the time for full-thickness transplants. It occurs less often for partial-thickness transplants. Preventing rejection requires a lifetime of eye drops.

Still, transplant longevity varies. “I’ve seen transplants from 50 or 60 years ago and now they’re starting to show wear and tear. Other patients, for a variety of reasons — immune system attacks, intolerance to eye drops, or underlying conditions — may only have a transplant for five to 10 years before they need another,” Dr. Venkateswaran explains.

Preventive eye care can help preserve the cornea

It’s crucial to get regular comprehensive eye exams to make sure your corneas and the rest of your eyes are healthy.

The American Academy of Ophthalmology recommends a comprehensive (dilated) eye exam

  • at age 40
  • every two to four years for people ages 40 to 54
  • every one to three years for people ages 55 to 64
  • every one to two years for people ages 65 and older.

You’ll need an eye exam more often if you have underlying conditions that increase your risk for eye disease, such as diabetes or a family history of corneal disease.

If you have any vision problems, such as eye pain, redness, blurred vision despite new glasses, or failing eyesight, see an eye doctor.

Fortunately, for people who do experience corneal damage, advances in surgical options are encouraging.

“Corneal transplants are a miracle,” Dr. Venkateswaran says. “I have patients whose quality of life was significantly decreased because they couldn’t see through their cloudy windshield. We can give them sight again, and we have the technology and medications to keep the transplant alive.”

About the Author

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Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

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If cannabis becomes a problem: How to manage withdrawal

close-up photo of the hands of a young man rolling a joint

 

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

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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

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Preventing C. diff in and out of the hospital

illustration of the digestive tract with bacteria, virus, and microorganisms with a hand at the lower right holding a magnifying glass

Many people seek medical attention when they have diarrhea, usually when it is severe or is not improving. Doctors like myself ask questions to see what could be causing the problem: Food poisoning? Irritable bowel syndrome? Medication side effects? We also consider that diarrhea may be due to Clostridioides difficile infection (CDI).

What is C. diff infection?

CDI is a bacterial infection that can cause severe problems in the gastrointestinal tract, especially the colon. C. diff is responsible for almost half a million infections in the US each year, and it can be a recurring problem: one in six patients with this infection will get it again within two months. Sadly, one in 11 patients over age 65 who is hospitalized for CDI will die within one month of infection due to the severity of illness in CDI. Therefore, CDI is an important public health consideration, and it’s important to get treatment.

Who at risk for C. diff infection?

There are certain risk factors for developing a CDI. These include being hospitalized, having been exposed to antibiotics, or having close contact with someone who has been diagnosed with the infection. If you are immunocompromised (have a weakened immune system), you may be also at higher risk of contracting CDI or of suffering a complication from it.

A major focus of reducing the burden of CDI in the healthcare system is trying to reduce the risk of getting CDI in the hospital. This includes testing for CDI in hospitalized patients who develop new diarrhea, and then isolating those patients into their own rooms.

Prevention also includes washing your hands thoroughly with soap and water. This is a particularly important point because in healthcare settings, alcohol-based sanitizer often is used for convenience when clinicians practice preventive infection control between caring for patients. Alcohol-based sanitizer is not effective against CDI as it is for other types of infection because, unlike other bacteria, C. diff organisms can form resistant spores.

So, to protect yourself in health care settings, you should make sure the people who interact with you — doctors, nurses, medical assistants, etc. — have washed their hands prior to touching you. It can seem rude to ask someone if they have washed their hands. However, all people who work with patients receive training about hand-washing, and sometimes we simply forget in the middle of busy days, so it can be helpful to remind us.

What about CDI transmission outside of medical settings?

What is less understood is when CDI happens outside the hospital. A recent article in Emerging Infectious Diseases reported the presence of CDI in patients who became infected in a way that doctors tend not to think of as often: getting CDI from someone they know without ever being hospitalized or taking antibiotics themselves.

As physicians, we are drilled on the factors previously mentioned — prior use of antibiotics, previous hospitalization — as critical events that may cause CDI. What this research demonstrated is that people without these risk factors developed CDI by being exposed to someone with CDI in the community. It turns out that this is a common way people end up contracting CDI. During my training, we learned that it is important to remind patients newly diagnosed with CDI to be mindful of good hand hygiene, and to avoid as many contacts as possible until their CDI treatments were completed. This new research suggests that focusing on community CDI transmission should be a greater priority.

How is CDI treated?

The first round of CDI treatment is usually antibiotics (ironic, since antibiotics can cause CDI). These include metronidazole, vancomycin (in oral form only), and fidaxomicin. Every few years guidelines are reviewed and updated, but generally, different antibiotic treatment courses are given based on CDI illness severity, whether there is an infection that is failing to clear, or if a new antibiotic needs to be tried.

A promising way to treat CDI, particularly in patients who have not been helped by antibiotic therapy, is to give a fecal microbiota transplant, or FMT. This treatment involves taking a healthy person’s stool donation and administering it during an endoscopy procedure by mouth, during a colonoscopy, or in frozen form by pill. I know — taking someone else’s poop sounds so icky! However, the purpose is to introduce healthy bacteria into a gut that is sick with CDI, and the theory is that these healthy bacteria expand and make the environment harder for the C. diff bacteria to live and cause problems.

What precautions help prevent spread ofCDI?

The rules are simple for reducing your risk of CDI. If you have a weakened immune system, stay away from people who have been diagnosed with CDI. Thoroughly wash your hands with soap and water (not disinfectant) to deal with C. diff spores more effectively. When you are sick, take antibiotics only if they are necessary; doctors often feel pressured to write antibiotic prescriptions for people who have viral illnesses (for which antibiotics do not work).

Evidence is not strong for taking probiotics or eating yogurt to prevent CDI, but these approaches are low-risk ways to introduce healthy bacteria into your gut; this may be reasonable, in part because some in the medical field continue to debate their effectiveness.

Bottom line: if you are having diarrhea that just won’t go away, talk to your doctor to see if you have CDI or if there is something else causing your symptoms.

About the Author

photo of Christopher D. Vélez, MD

Christopher D. Vélez, MD, Contributor

Dr. Christopher Vélez is an attending gastroenterologist in the Center for Neurointestinal Health of Massachusetts General Hospital's division of gastroenterology and the MGH department of medicine. He focuses on neurogastroenterology and motility disorders of the esophagus, … See Full Bio View all posts by Christopher D. Vélez, MD

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Adult female acne: Why it happens and the emotional toll

close-up photo of a woman's face showing a serious acne breakout around her eye and down the right side of her face

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

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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 photo of Payal Patel, MD

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

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Can a vegan diet treat rheumatoid arthritis?

A brightly colored selection of plant-based vegan foods, including vegetables, fruit, grains, nuts, seeds, and vegan dips.

I recently learned about a study suggesting a vegan diet is an effective treatment for rheumatoid arthritis.

While that sounded intriguing, another claim made in an interview about the study really caught my attention: the lead author of the study said that physicians should encourage people with rheumatoid arthritis to try changing their eating patterns before turning to medication.

Before turning to medication? Now wait just a minute. That flies in the face of decades of research convincingly demonstrating the importance of early medication treatment of rheumatoid arthritis to prevent permanent joint damage. An increasing number of effective treatments can do just that.

In fact, there’s no convincing evidence that changes in diet can prevent joint damage in rheumatoid arthritis. And that includes this new study.

So, what did this research find? Let’s take a look.

A vegan diet for rheumatoid arthritis

Researchers enrolled 44 people with rheumatoid arthritis in the study. All were women, mostly white and highly educated. They were randomly assigned to one of two groups for 16 weeks:

  • Vegan diet. Participants followed a vegan diet for four weeks, followed by additional food restrictions that eliminated foods the researchers considered to be common arthritis trigger foods. These foods included gluten-containing grains (wheat, barley, and rye), white potatoes, sweet potatoes, chocolate, citrus fruits, nuts, onions, tomatoes, apples, bananas, coffee, alcohol, and table sugar. After week seven, these foods were reintroduced, one at a time. Any reintroduced food that seemed to cause pain or other symptoms of rheumatoid arthritis was eliminated for the rest of the 16-week period.
  • Usual diet plus placebo. These participants followed their usual diet and took a placebo capsule each day for 16 weeks. The capsule contained insignificant doses of omega-3 fatty acids and vitamin E.

After the first 16 weeks, participants took four weeks off, then the groups swapped dietary assignments for an additional 16 weeks.

What did the study find about the vegan diet?

The vegan approach seemed to help lessen arthritis symptoms. Study participants reported improvement while on the vegan diet, but no improvement during the placebo phase.

For example, the average number of swollen joints fell from 7 to 3.3 in the vegan diet group, but actually increased (from 4.7 to 5) in the placebo group. In addition, while on the vegan diet, participants lost an average of 14 pounds, while those on the placebo gained nearly 2 pounds.

What else do we need to consider?

While the findings sound great, the study had significant limitations:

  • Size. Only 44 study subjects enrolled and only 32 completed the study. With such small numbers, it only takes a few to alter the results. Larger studies (with several hundred or more participants) tend to be more reliable.
  • Lack of diversity. This trial did not include men and had mostly white, highly educated participants.
  • No standard diagnosis of rheumatoid arthritis. A physician’s diagnosis was required, but there was no requirement that standard criteria be met.
  • Study duration. A treatment lasting four months may seem like a long time, but for a chronic disease like rheumatoid arthritis that can wax and wane on its own, this is too short a time to make firm conclusions.
  • Self-reported diet. We don’t know how well study subjects stuck to their assigned diets.
  • Medication use. Study subjects took arthritis medications, though no information on specific drugs is offered. Some made dosage adjustments during the trial. While the researchers tried to account for this through a separate analysis, the small number of participants could make that analysis unreliable.
  • Weight loss. Losing weight, rather than eating a vegan diet, might have contributed to symptom improvement.
  • No assessment of joint damage. No x-rays, MRI results, or other assessments of joint damage were provided. That’s important, because we know that people with arthritis can feel better even when joint damage continues to worsen. Steroids and ibuprofen are good examples of treatments that reduce symptoms of rheumatoid arthritis without protecting the joints. Without information about joint damage, it’s impossible to assess the true benefit or risk of relying on a vegan diet to treat rheumatoid arthritis.

Finally, it’s unclear how a vegan diet would improve rheumatoid arthritis. This raises the possibility that the findings won’t hold up.

Should everyone with rheumatoid arthritis become vegan?

No, there isn’t enough evidence to justify recommending a vegan diet — or any restrictive diet — for everyone with rheumatoid arthritis.

That said, a plant-rich diet is healthy for nearly everyone. As long your diet is nutritionally balanced and palatable to you, I see little harm in adopting an anti-inflammatory diet. But in the case of rheumatoid arthritis, diet should be combined with medicationto prevent joint damage, not used instead of it.

The bottom line

Growing evidence suggests diet can play a role in treating rheumatoid arthritis. But it’s one thing for a person to feel better on a particular diet; it’s quite another to say diet is enough by itself.

For high cholesterol or high blood pressure, dietary changes are the first choice of treatment. But rheumatoid arthritis is different. Disabling joint damage can occur early in the disease, so it’s important to start taking effective medications as soon as possible to prevent this.

We will undoubtedly see more research exploring the impact of diet on rheumatoid arthritis, other forms of arthritis, and other autoimmune disorders. Perhaps we’ll learn that a vegan diet is highly effective and can take the place of medications in some people. But we aren’t there yet.

About the Author

photo of Robert H. Shmerling, MD

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

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Can music improve our health and quality of life?

Music boosts our mood and well-being, and music therapy may help during treatments for certain health conditions.

photo of a music therapy session: senior woman is playing piano and a young man is sitting on the bench next to her

Times are hard. The current political climate, war, impact of global warming, continued inequities due to systemic racism, and ongoing physical and mental health challenges from COVID are taking a toll on our feelings of safety in the world and quality of life. Hopefully, each of us can find moments of ease and temporarily shift our thoughts away from the difficult daily news. For many people, music can play a role in making that shift, even incrementally.

How can music impact our quality of life?

Recently, researchers looked at the impact of music interventions on health-related quality of life, and tried to answer the question about the best way to help make that shift toward release, relaxation, and rehabilitation. This recent systematic review and meta-analysis (a study of studies) showed that the use of music interventions (listening to music, singing, and music therapy) can create significant improvements in mental health, and smaller improvements in physical health–related quality of life. While the researchers found a positive impact on the psychological quality of life, they found no one best intervention or “dose” of music that works best for all people.

Complexities of music

As complex human beings from a wide variety of cultures, with a variety of life experiences and mental and physical health needs, our connection with music is very personal. Our relationship with music can be a very beautiful, vulnerable, and often complicated dance that shifts from moment to moment based on our mood, preferences, social situation, and previous experiences. There are times where music can have a clear and immediate impact on our well-being:

  • easing a transition to sleep with a soothing playlist
  • finding motivation for exercise by listening to upbeat dance music
  • aiding self-expression of emotions by singing
  • connecting to others by attending a live musical performance.

There are other times when a board-certified music therapist can help you build that connection to music, and find the best intervention and “dose” that could positively impact your health and provide a form of healing.

How can music be used as a therapeutic tool?

Music therapy is an established health care profession that uses evidence-based music interventions to address therapeutic health care goals. Music therapy happens between a patient (and possibly their caregivers and/or family) and a board-certified music therapist who has completed an accredited undergraduate or graduate music therapy program.

Music therapists use both active (singing, instrument exploration, songwriting, movement, digital music creation, and more) and receptive (music listening, guided imagery with music, playlist creation, or music conversation and reminiscence) interventions, and create goals to improve health and well-being.

Some of those goals could include decreasing anxiety, shifting your mood, decreasing pain perception during cancer or other medical treatment, increasing expression, finding motivation, and many others. The approach to using music to achieve these kinds of goals — and to improving your quality of life in general — can shift from moment to moment, and a music therapist can help you find what works best for a particular situation.

My top music therapy tools

Listening

This intervention has been studied the most, in almost every scenario. It can be done either on your own or in music therapy. The music can be live or recorded. Listening can be done with intentional focus or as background listening. You can amplify emotions for release. You can use music to quiet the mind. Or you can utilize the “iso principle” and match music to your current energy or mood, and then slowly change feel, tempo, and complexity to help you shift. Music listening can be paired with prompts for relaxation, or to motivate you to exercise, move more, or do a task you’ve been putting off.

Learning or playing an Instrument

Active music-making truly engages your entire brain. This creates the most potential for distraction, pain reduction, cognition, fine and gross motor development, and expression. Some instruments are designed for easier access to free expression or learning.

A steel tongue drum, for example, set up in a pentatonic scale, has a beautiful resonant sound, has no “wrong notes,” and by design allows you to just play! If you want to engage your cognitive brain a bit, try learning the ukulele. The strings are easy to push, beginner chords only need one or two fingers, and there are many great ukulele resources online. Making music with an instrument can be fun and easy.

A board-certified music therapist can help you find the most direct and success-based path to musical expression. Learning how to really master an instrument and read music takes time, patience, and practice.

Singing

This can be an amazing intervention if you have a good connection to your voice and/or have a good music therapy relationship where the therapist can help you build your connection to your instrument. There are physical benefits of singing on lung function and emotional benefits of singing lyrics that speak your truth. Finally, there is the community connection and power of being surround by strong, tight harmonies.

The bottom line

Although there is not one best intervention, magical song, or perfect genre to make all the hard things in life easier, music can be a powerful agent of change.

Need some extra help finding the best music tools for you? Here are some resources for exploring music therapy and finding certified therapists.

American Music Therapy Association
Certified Board of Music Therapists
American Psychological Association: Music as Medicine

About the Author

photo of Lorrie Kubicek, MT-BC

Lorrie Kubicek, MT-BC, Contributor

Lorrie Kubicek is a board-certified music therapist at Massachusetts General Hospital, co-director of The Katherine A. Gallagher Integrative Therapies Program, and program manager of expressive therapies at MGH Cancer Center and Mass General Hospital for Children. … See Full Bio View all posts by Lorrie Kubicek, MT-BC

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Should you be tested for inflammation?

A test tube with yellow top is filled with blood and has a blank label. It is lying sideways on top of other test tubes capped in different colors.

Let’s face it: inflammation has a bad reputation. Much of it is well-deserved. After all, long-term inflammation contributes to chronic illnesses and deaths. If you just relied on headlines for health information, you might think that stamping out inflammation would eliminate cardiovascular disease, cancer, dementia, and perhaps aging itself. Unfortunately, that’s not true.

Still, our understanding of how chronic inflammation can impair health has expanded dramatically in recent years. And with this understanding come three common questions: Could I have inflammation without knowing it? How can I find out if I do? Are there tests for inflammation? Indeed, there are.

Testing for inflammation

A number of well-established tests to detect inflammation are commonly used in medical care. But it’s important to note these tests can’t distinguish between acute inflammation, which might develop with a cold, pneumonia, or an injury, and the more damaging chronic inflammation that may accompany diabetes, obesity, or an autoimmune disease, among other conditions. Understanding the difference between acute and chronic inflammation is important.

These are four of the most common tests for inflammation:

  • Erythrocyte sedimentation rate (sed rate or ESR). This test measures how fast red blood cells settle to the bottom of a vertical tube of blood. When inflammation is present the red blood cells fall faster, as higher amounts of proteins in the blood make those cells clump together. While ranges vary by lab, a normal result is typically 20 mm/hr or less, while a value over 100 mm/hr is quite high.
  • C-reactive protein (CRP). This protein made in the liver tends to rise when inflammation is present. A normal value is less than 3 mg/L. A value over 3 mg/L is often used to identify an increased risk of cardiovascular disease, but bodywide inflammation can make CRP rise to 100 mg/L or more.
  • Ferritin. This is a blood protein that reflects the amount of iron stored in the body. It’s most often ordered to evaluate whether an anemic person is iron-deficient, in which case ferritin levels are low. Or, if there is too much iron in the body, ferritin levels may be high. But ferritin levels also rise when inflammation is present. Normal results vary by lab and tend to be a bit higher in men, but a typical normal range is 20 to 200 mcg/L.
  • Fibrinogen. While this protein is most commonly measured to evaluate the status of the blood clotting system, its levels tend to rise when inflammation is present. A normal fibrinogen level is 200 to 400 mg/dL.

Are tests for inflammation useful?

In certain situations, tests to measure inflammation can be quite helpful.

  • Diagnosing an inflammatory condition. One example of this is a rare condition called giant cell arteritis, in which the ESR is nearly always elevated. If symptoms such as new, severe headache and jaw pain suggest that a person may have this disease, an elevated ESR can increase the suspicion that the disease is present, while a normal ESR argues against this diagnosis.
  • Monitoring an inflammatory condition. When someone has rheumatoid arthritis, for example, ESR or CRP (or both tests) help determine how active the disease is and how well treatment is working.

None of these tests is perfect. Sometimes false negative results occur when inflammation actually is present. False positive results may occur when abnormal test results suggest inflammation even when none is present.

Should you be routinely tested for inflammation?

Currently, tests of inflammation are not a part of routine medical care for all adults, and expert guidelines do not recommend them.

CRP testing to assess cardiac risk is encouraged to help decide whether preventive treatment is appropriate for some people (such as those with a risk of a heart attack that is intermediate — that is, neither high nor low). However, evidence suggests that CRP testing adds relatively little to assessment using standard risk factors, such as a history of hypertension, diabetes, smoking, high cholesterol, and positive family history of heart disease.

So far, only one group I know of recommends routine testing for inflammation for all without a specific reason: companies selling inflammation tests directly to consumers.

Inflammation may be silent — so why not test?

It’s true that chronic inflammation may not cause specific symptoms. But looking for evidence of inflammation through a blood test without any sense of why it might be there is much less helpful than having routine healthcare that screens for common causes of silent inflammation, including

  • excess weight
  • diabetes
  • cardiovascular disease (including heart attacks and stroke)
  • hepatitis C and other chronic infections
  • autoimmune disease.

Standard medical evaluation for most of these conditions does not require testing for inflammation. And your medical team can recommend the right treatments if you do have one of these conditions.

The bottom line

Testing for inflammation has its place in medical evaluation and in monitoring certain health conditions, such as rheumatoid arthritis. But it’s not clearly helpful as a routine test for everyone. A better approach is to adopt healthy habits and get routine medical care that can identify and treat the conditions that contribute to harmful inflammation.

About the Author

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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

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Why are you taking a multivitamin?

For most Americans, a daily multivitamin is an unnecessary habit.

Multivitamins spilling upward out of a bottle against a dark background

Are you among the one in three Americans who gulps down a multivitamin every morning, probably with a sip of water? The truth about this popular habit may be hard to swallow.

“Most people would be better off just drinking a full glass of water and skipping the vitamin,” says Dr. Pieter Cohen, an associate professor of medicine at Harvard Medical School and an internist at Harvard-affiliated Cambridge Health Alliance. In addition to saving money, you’ll have the satisfaction of not succumbing to misleading marketing schemes.

That’s because for the average American adult, a daily multivitamin doesn’t provide any meaningful health benefit, as noted recently by the US Preventive Services Task Force (USPSTF). Their review, which analyzed 84 studies involving nearly 700,000 people, found little or no evidence that taking vitamin and mineral supplements helps prevent cancer and cardiovascular disease that can lead to heart attacks and stroke, nor do they help prevent an early death.

“We have good evidence that for the vast majority of people, taking multivitamins won’t help you,” says Dr. Cohen, an expert in dietary supplement research and regulation.

Who might need a multivitamin or individual supplements?

There are some exceptions, however. Highly restrictive diets and gastrointestinal conditions, or certain weight-loss surgeries that cause poor nutrient absorption, are examples of reasons why a multivitamin or individual vitamins might be recommended. A daily vitamin D supplement may be necessary when a person gets insufficient sun exposure. Your doctor may recommend an iron supplement if you have a low red blood cell count (anemia).

Why is it hard to give up the habit of a daily multivitamin?

Surveys suggest people take vitamins to stay healthy, feel more energetic, or gain peace of mind, according to an editorial that accompanied the USPSTF review. These beliefs stem from a powerful narrative about vitamins being healthy and natural that dates back nearly a century.

“This narrative appeals to many groups in our population, including people who are progressive vegetarians and also to conservatives who are suspicious about science and think that doctors are up to no good,” says Dr. Cohen.

Unproven marketing claims for dietary supplements

Vitamins are very inexpensive to make, so the companies can sink lots of money into advertising, says Dr. Cohen. But because the FDA regulates dietary supplements as food and not as prescription or over-the-counter drugs, the agency only monitors claims regarding the treatment of disease.

For example, supplement makers cannot say that their product “lowers heart disease risk.” But their labels are allowed to include phrases such as “promotes a healthy heart” or “supports immunity,” as well as vague promises about improving fatigue and low motivation.

“Supplement manufacturers are allowed to market their products as if they have benefits when no benefit actually exists. It’s enshrined into the law,” says Dr. Cohen. It’s wise to note the legally required disclaimer on each product: “These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”

But even the strong language in this disclaimer — “not intended to diagnose, treat, cure, or prevent” — doesn’t seem to affect how people perceive the marketing claims.

Although multivitamins aren’t helpful, at least they’re not harmful. But the money people spend on them could be better spent on purchasing healthy foods, Dr. Cohen says.

About the Author

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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

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Can an implanted tongue-stimulating device curb your sleep apnea?

Man asleep in bed, snoring, on his side; woman awake and looking at him with one hand cupped over her ear to block noise

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

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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

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Struggling to sleep? Your heart may pay the price

Alarm clock on wood table shows 2:40 am; on dark blue background is crescent moon and fuzzy stars, concept is insomnia

Growing evidence suggests that poor sleep is linked to a host of health problems, including a higher risk of high blood pressure, diabetes, obesity, and heart disease. Now, a recent study on people in midlife finds that having a combination of sleep problems — such as trouble falling asleep, waking up in the wee hours, or sleeping less than six hours a night — may nearly triple a person’s risk of heart disease.

"These new findings highlight the importance of getting sufficient sleep," says sleep specialist Dr. Lawrence Epstein, assistant professor of medicine at Harvard Medical School. Many things can contribute to a sleep shortfall, he adds. Some people simply don’t set aside enough time to sleep. Others have habits that disrupt or interfere with sleep. And some people have a medical condition or a sleep disorder that disrupts the quality or quantity of their sleep.

Who was in the study?

The researchers drew data from 7,483 adults in the Midlife in the United States Study who reported information about their sleep habits and heart disease history. A subset of the participants (663 people) also used a wrist-worn device that recorded their sleep activity (actigraphy). Slightly more than half of participants were women. Three-quarters reported their race as white and 16% as Black. The average age was 53.

Researchers chose to focus on people during midlife, because that’s when adults usually experience diverse and stressful life experiences in both their work and family life. It’s also when clogged heart arteries or atherosclerosis (an early sign of heart disease) and age-related sleep issues start to show up.

How did researchers assess sleep issues?

Sleep health was measured using a composite of multiple aspects of sleep, including

  • regularity (whether participants slept longer on work days versus nonwork days)
  • satisfaction (whether they had trouble falling asleep; woke up in the night or early morning and couldn’t get back to sleep; or felt sleepy during the day)
  • alertness (how often they napped for more than five minutes)
  • efficiency (how long it took them to fall asleep at bedtime)
  • duration (how many hours they typically slept each night).

To assess heart-related problems, researchers asked participants "Have you ever had heart trouble suspected or confirmed by a doctor?" and "Have you ever had a severe pain across the front of your chest lasting half an hour or more?"

A "yes" answer to either question prompted follow-up questions about the diagnosis, which included problems such as angina (chest pain due to lack of blood flow to the heart muscle), heart attack, heart valve disease, an irregular or fast heartbeat, and heart failure.

Poor sleep linked to higher heart risk

The researchers controlled for factors that might affect the results, including a family history of heart disease, smoking, physical activity, as well as sex and race. They found that each additional increase in self-reported sleep problems was linked to a 54% increased risk of heart disease compared to people with normal sleep patterns. However, the increase in risk was much higher — 141% — among people providing both self-reported and wrist-worn device actigraphy data, which together are considered more accurate.

Although women reported more sleep problems, men were more likely to suffer from heart disease. But overall, sex did not affect the correlations between sleep and heart health.

Black participants had more sleep and heart-related problems than white participants, but in general, the relationship between the two issues did not differ by race.

What does this mean for you?

If you have trouble falling or staying asleep, there are many ways to treat these common problems, from simple tweaks to your daily routine to specialized cognitive behavioral therapy that targets sleep issues. These are well worth trying, because getting a good night’s sleep helps in many ways.

"Treating sleep disorders that interfere with sleep can make you feel more alert during the day, improve your quality of life, and reduce the health risks related to poor sleep," says Dr. Epstein.

About the Author

photo of Julie Corliss

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