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If you have knee pain, telehealth may help

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Just about everyone experiences knee pain at some point in their lives. Most of the time, it follows an injury or strenuous exercise and resolves in a few days, but knee pain can last months or even years, depending on the cause. A new study suggests telehealth programs designed for people with knee osteoarthritis may help ease pain, improve ability to function, and possibly even lead to weight loss.

What is osteoarthritis of the knee?

Osteoarthritis (OA) — the age-related, “wear-and-tear” degeneration of the knee joint — is the number one cause of chronic knee pain, affecting nearly a quarter of people age 40 or older. It’s responsible for most of the 600,000 knee replacements in the US each year, and more than $27 billion in annual healthcare spending.

How is it treated?

No treatment for knee OA is ideal or works in every case. Standard approaches to treatment include pain management, exercise, and loss of excess weight.

For pain, people with knee OA may consider

  • anti-inflammatory drugs that are rubbed on the skin, such as diclofenac gel
  • anti-inflammatory medicines, such as ibuprofen
  • pain relievers, such as acetaminophen
  • injections of corticosteroids.

Opiates, arthroscopic surgery, and other injected treatments are not routinely recommended due to risks, lack of proven benefit, or both. Knee replacement surgery has a high success rate for knee OA, but is generally considered a last resort because it’s major surgery that requires significant recovery time.

Virtual visits can help

Before the COVID-19 pandemic, many people with knee OA regularly saw their healthcare providers to

  • monitor their pain and ability to function
  • consider changes in treatment
  • check for treatment side effects
  • determine if other problems are contributing to symptoms.

It turns out, much of this can be done virtually. The pandemic made it a necessity. And a new study suggests it works.

What did the study on knee osteoarthritis find?

The study demonstrated that telehealth visits are a good way to provide care to people with knee OA. The researchers enrolled nearly 400 participants who had knee OA and were overweight or obese. They were divided into three groups:

  • Group 1 was given access to a website that provided information about OA, including pain medications, exercise, weight loss, and pain management.
  • Group 2 received the same information as group 1, and also engaged in six exercise sessions with a physical therapist by videoconference. These sessions lasted 20 to 45 minutes and included advice about self-management, behavioral counseling, and education about choosing exercise equipment.
  • Group 3 followed the same format as group 2, and also had six consults by videoconference with a dietitian about weight loss, nutrition, and behavioral resources. These sessions also lasted 20 to 45 minutes.

After six months, participants in groups 2 and 3 reported pain relief compared to Group 1. On a pain scale of 1 to 10:

  • group 3 improved more than group 1 by 1.5 points
  • group 2 improved more than group 1 by about 1 point.

People in groups 2 and 3 also had better scores for function compared to group 1. All of these improvements were considered meaningful and held up for at least 12 months.

In addition, those assigned to group 3 lost about 20 pounds over the course of the study, while the other groups’ weights were nearly unchanged. That’s an important finding, because excess weight can worsen osteoarthritis of the knee. Losing excess weight can improve symptoms and help prevent the arthritis from getting worse.

Since there was no comparison with in-person care, it’s impossible to say whether these virtual visits were better, worse, or similar to an office visit. In addition, this study did not report the costs of these virtual sessions, the long-term impact of virtual visits, or whether repeated virtual visits could maintain the improvements people reported.

The bottom line

The pandemic is giving researchers an opportunity to seriously study the potential value and limitations of virtual care on a large scale. If these visits are as good as or better than in-person visits for certain conditions and the costs are no greater, that’s a big deal. A virtual visit can eliminate time spent in travel and the waiting room, and possible parking fees that can make a brief doctor’s visit an expensive undertaking that takes half the day. Virtual care also has the potential to reach patients who otherwise cannot get to their doctor’s office.

Of course, telehealth isn’t equally available to everyone due to language barriers, technical abilities, health insurance plans, or simply not having access to smartphones, computers, or data plans. Some states are letting emergency measures supporting telehealth services expire. And some insurers may resort to pre-pandemic rules about coverage or physician licensing that create uncertainty about the future of telehealth.

This study and others suggest that it may be a mistake to curb telehealth just when it’s catching on. More studies like the one described here may make the case to insurers, regulatory agencies, healthcare providers, and patients that the future of medical care should rely on more, not less, virtual healthcare, and encourage approaches that overcome barriers to its use.

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Paths to parenthood: Receiving an embryo donation

Multicolored doors and glowing lights forming paths through the doors; the concept of different options

Embryo donation — the process by which a family donates their “extra” embryos to a couple or individual — is a viable path to parenthood. In a previous blog post, I addressed some of the reasons why people who consider their families complete after in vitro fertilization (IVF) might choose to donate embryos.

Who, then, is on the receiving end? Often, this option interests people considering adoption, and individuals or couples who need donated eggs or sperm, or both, to achieve pregnancy. If you find yourself in one of these groups, here are some initial questions and issues you might consider as you make your decision.

Embryo donation or adoption: A few points to compare

Pregnancy. The opportunity to experience pregnancy draws some prospective adoptive parents to seek embryo donation. This may be important to you. It may be a life experience you always looked forward to, or hoped to share with a spouse or partner. Or perhaps you are concerned about having someone else carry your baby. For example, prospective adoptive parents often worry that their future child could be affected before birth by a birth mother’s choices around drugs and alcohol, or exposures to unavoidable stresses.

Time frame and cost. The pandemic fueled already significant declines in the number of babies placed for adoption. If you are seeking to adopt a newborn, you are likely to face a wait of two years or more. By contrast, embryos are available, and an embryo transfer often occurs within six months of making the decision to seek donated embryos.

The cost of embryo donation is considerably less than adoption. If you go through an agency there will be a fee, as well as costs related to moving embryos from one clinic to another and (depending on your medical insurance) costs associated with medications and with the embryo transfer. While costs are substantial and vary across the US, fees are much higher for infant adoption than for embryo donation.

Although the short wait and lower costs are attractive when comparing embryo donation to adoption, it is important to know that embryo donation does not always result in a live birth, while adoption — with a reputable agency — will bring a baby into your home.

Your child’s story. All of us want our children to feel good about their origin stories. Adoptive families have long recognized that some adoptees have enduring feelings of loss because their birth parents chose to make an adoption plan. Some people believe embryo donation mitigates these losses because the child is born into the family they will be raised in. However, others see it differently: they feel that embryo donation brings with it a more complicated origin story. How will a child make sense of the fact that they began as an embryo created by people longing for a baby, but an embryologist chose another embryo for transfer, making them “extra”? Might this lead to a greater sense of displacement, and perhaps to feeling like a bit of a science experiment?

Choosing family backgrounds. If you pursue adoption, you’ll weigh in on the race of your child. You may be able to request birth parents who avoided drugs or alcohol during the pregnancy and/or have family histories free of serious physical or mental health problems. You will not be able to narrow your match to people you like or feel are compatible, people who feel familiar, and whose interests and values align with yours.

If you pursue embryo donation, you and the donor family get to choose each other. Before anyone makes a commitment, you can confirm with the donor family that you have a shared perspective of how much contact you want to have, and what each of you believes is in the best interest of the children involved. Decisions tend to feel more collaborative than in adoption, where it may feel like “birth parents get to make all the decisions.”

Embryo donation or egg or sperm donation: A few points to compare

If you are in a position to need sperm or egg donation, or both, you might be comparing this with embryo donation as a path to pregnancy. Below are key points to consider, and some questions that may arise as you sort through your options.

Since pregnancy is your primary goal here, you are probably thinking about which option is likely to work best. With embryo donation, one might say you get a head start, since you begin with healthy embryos. However, the number of embryos you receive will be limited.

You could decide to seek a second donor family if you don’t achieve pregnancy with embryos from the first donor, although this would be a long, discouraging path. By contrast, if you seek donated sperm and eggs separately and begin with a large number of eggs, you may have a larger number of embryos to work with.

Time frame and cost. The good news is that each of these options can be available to you without delay. You can obtain donor sperm from a donor known to you, or from major cryobanks within days of choosing a donor. If you choose frozen eggs, these can be secured quickly also. Donated embryos take longer to locate and arrange for their transfer from one family to another.

Your medical insurance will play a big role in determining the expenses associated with each option. Sperm from a known donor usually is free. With egg and sperm donation from a cryobank, you will owe a fee to the donors. In the case of egg donors, fees can be high. With embryo donation, no fee is paid to the donating family.

Your child’s story. If you opt for embryo donation, your child’s story began with another family planning to have a baby. You may wonder if your child will have feelings of displacement similar to what some adoptees report. Or, carrying and giving birth to your baby may make embryo donation feel fundamentally different from adoption. Double donation — conceiving a child with both donated eggs and sperm — also offers the connection that comes with pregnancy, although you may wonder how your child will make sense of being conceived by two people who never knew each other. A single donation of either egg or sperm offers a genetic connection to one parent, which some feel helps root a child in the family. Yet each of these origin stories is complicated, making it essential that you feel comfortable with the story before you move forward. Long before being able to understand the story, your child can sense that you feel secure in the rightness of your decision.

Decisions like these abound worldwide

If you are taking a serious look at embryo donation and comparing it to other parenthood options available to you, you are not alone. The arrival of IVF in 1978 has led to a series of new paths to parenthood. Each one drew pioneers who took a careful look before moving forward into new and unfamiliar territory. Making the decision with patience, thoughtfulness, and information has enabled them to embrace and celebrate the families that they have built.

For more information

Regulations, rules, and costs of different paths to parenthood vary by state and other factors. These resources may help you track down information you need to make a decision.

Resolve

Parents Via Egg Donation (PVED)

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Seeing red? 4 steps to try before responding

Angry red icons that look furious

Breathe. Count to 10. Take a walk. These strategies have long been advised to help you pause and rethink your reaction when you’re seeing red and an inch away from exploding. Under normal circumstances — maybe a little stress at home or at work — those strategies can be useful. But you may find they’re less effective in the pressure cooker we’ve been living in since the pandemic began. What can you do to avoid reaching your boiling point?

For insight, I turned to psychologist Stuart Ablon, founder and director of Think:Kids in the department of psychiatry at Harvard-affiliated Massachusetts General Hospital. Ablon is an expert at defusing explosive behavior among kids and teens with severe developmental delays in problem solving, flexibility, and tolerance to frustration — the skills that keep us from melting down.

Pandemic stress blocks our coping abilities

Ablon says many adults are struggling with a lack of these skills right now — not because we haven’t developed them, but because pandemic stress is blocking them. “When we humans are chronically stressed, we lose access to the part of our brain that performs skills like flexibility and tolerance,” Ablon says.

Blocked skills can reduce our coping abilities to those of little children, like toddlers who scream when they don’t get their way.

Practice empathy

Ablon says it’s crucial to stay calm or “regulated” when you’re feeling mad or upset, so you can access the skills needed to maintain control. And the best way to remain calm, Ablon says, is by practicing empathy — trying to sense another person’s perspective or point of view.

“Empathy is the most powerful human regulator we have. It’s been proven to de-escalate people in the most challenging of prison settings, and it can also work on an airplane or in line at Starbucks,” Ablon says. “Think about it: when someone listens to you and tries to understand your point of view, it calms you. You can feel your heart rate drop.”

How does empathy help you?

Calming others is great, but how does being empathetic keep you from exploding? It has a domino effect.

  • Trying to understand someone else's point of view may change your mind about how you want to react. It will also give you something important to do, which will keep you focused so you can remain calm.
  • Being calm enables you to access coping skills like problem solving, flexibility, and tolerance to frustration.
  • Accessing your coping skills strengthens your ability to keep your cool.
  • Because you’re calm, you’ll keep someone else from exploding, which in turn helps you continue to stay calm.

Four steps to help you stop seeing red

To practice empathy, Ablon recommends the following steps.

  • Adopt a mindset that people are doing the best they can. “We’re all trying our best to handle what the world is throwing at us, with the skills we’re able to access at that moment. None of us wants to be losing it,” Ablon says. “Think to yourself, ‘This person I’m interacting with isn’t giving me what I want, but this person is doing the best they can right now.’ If you can exude that, you will help regulate them. It’s incredibly contagious — the same way a parent who stays calm can soothe a crying baby, or a kindergarten teacher with supreme calmness can regulate a whole class.”
  • Be curious, not furious. Ablon recommends asking questions without jumping to conclusions, so you can find out where people are coming from. What are their circumstances? What’s driven them to this moment? What do they need?
  • Practice active listening. “One of the most powerful things you can do to regulate someone is to repeat back to them what you’re hearing from them in your own words. It makes them feel heard,” Ablon says. “So ask questions, and when you get information, reflect back what you’ve heard. It’s called active listening.”
  • Offer reassurance. Remind the person you’re talking to that you’re trying to help. “Say, ‘I’m just trying to understand. I know you must have an important reason and I want to hear more. I’m not trying to get you upset. I want to work things out.’ That’s very calming and regulating,” Ablon says.

It may not be easy to remain empathetic in these challenging times. But the more you practice this skill, the more empathetic you’ll become. That can deliver significant results. “If you can stay calm and approach someone kindly and with understanding,” Ablon says, “it will head things off at the pass for both of you.”

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Treatment with abiraterone significantly improves survival in advanced prostate cancer

illustration outline of a hand against a blue background with a blue ribbon on the palm symbolizing prostate cancer research

In December, researchers reported findings from a study showing that the drug abiraterone halves the risk of prostate cancer death among a specific group of patients who previously would not have been treated with it. Currently, abiraterone is approved only for men with prostate cancer that is spreading (metastasizing) in the body. But men enrolled in the study were treated at earlier stages, before their tumors had a chance to spread. Based on the findings, the investigators concluded that abiraterone should considered for treating aggressive prostate cancer that has not yet begun to spread to other sites, but likely will in the future.

Abiraterone was first approved in 2011, specifically for metastatic prostate cancer that no longer responds to chemotherapy or drugs that block testosterone (a hormone that fuels prostate tumor growth). Treatments that block testosterone production in the testicles and other glands are called androgen deprivation therapies, or ADT. Some tumors get around ADT by making their own testosterone, however, and that’s where abiraterone comes into the picture: it prevents cancer cells from making the hormone. Doctors give abiraterone together with prednisolone, a steroid that lessens treatment side effects. More recently, abiraterone’s approval was extended to men who still respond to ADT or have not yet been treated with chemotherapy.

During the newly published study, which is called STAMPEDE, researchers in the UK and Switzerland enrolled 1,974 men with high-risk cancer that was still confined to the prostate and nearby lymph nodes. The STAMPEDE clinical trial is testing multiple treatments for advanced prostate cancer, and this particular study was one of several conducted as part of that broader effort. The men in this case were 68 years old on average, and each of them was assigned to one of three different groups:

  • ADT by itself (the control group, which included 988 men) 
  • ADT in combination with abiraterone and prednisolone (459 men)
  • ADT in combination with abiraterone, prednisolone, and another drug called enzalutamide that is similar to abiraterone (527 men).

ADT in the control group lasted three years, while most of the men receiving combined therapies underwent two years of treatment.

The results

After six years of follow-up, 7% of the 986 men who received abiraterone as part of their treatment had died from prostate cancer. By contrast, 15% of the 988 men given ADT by itself had a prostate cancer death. Moreover, abiraterone significantly lengthened the time it took for metastases to appear.

Based on these findings, the investigators concluded that “patients treated with the combination therapy [that includes abiraterone] are more likely to live longer and die from another cause.” Side effects were more common among abiraterone-treated men, and included hypertension and increased liver enzymes. Adding enzalutamide had no added treatment benefits, making that drug’s use among nonmetastatic cancer patients “unjustified due to additional toxicity and cost,” the investigators wrote.

“This important study adds to the extraordinarily encouraging news regarding treatment advances in advanced and metastatic forms of prostate cancer,” 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. “Giving abiraterone together with prednisolone is now a mainstay in the management of men with prostate cancer that has spread beyond the confines of the prostate gland and lymph nodes. This new study shows that the addition of abiraterone plus prednisolone to traditional ADT can benefit men who have not yet developed metastatic disease but would be likely to do so in the future. The investigators of the STAMPEDE program continue to make practice-changing discoveries that are meaningful and improve survival in this population, and we welcome these results.”