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Recent study shows more complications with alternative prostate biopsy method

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If a screening test for prostate cancer produces an abnormal result, the next step is typically a biopsy. In the United States, this is almost always done by threading a biopsy needle into the prostate through the rectum. By watching on an ultrasound machine, doctors can see where the needle is going. Called a transrectal ultrasound (TRUS) biopsy, this procedure comes with a small but growing risk of infections that are in turn increasingly resistant to current antibiotics.

To minimize infection risk, doctors can also thread the biopsy needle through a patch of skin between the anus and scrotum called the perineum, thus bypassing rectal bacteria. These so-called transperineal (TP) biopsies offer a further advantage in that they provide better access to the tip (or apex) of the prostate, which is where 30% of cancers occur. However, they are also more painful for the patient. Until recently, they were done only in hospital operating rooms under general anesthesia.

Today, technical advances are making it possible for doctors to perform TP biopsies under local anesthesia in their own offices. And with this development, pressure to limit infections by adopting this approach is growing.

During a recent study, Harvard scientists looked at how the two methods compare in terms of cancer detection and complication rates. In all, 260 men were included in the study, each closely matched in terms of age, race, prostate-specific antigen levels, and other diagnostic findings. Half the men got TRUS biopsies and the other half got TP biopsies, and all the procedures were performed at a single medical practice between 2014 and 2020. Per standard clinical protocols, all the men in the TRUS group took prophylactic antibiotics to prepare. By contrast, just 43% of men in the TP group took antibiotics, in accordance with physician preferences.

Results showed minimal differences in the cancer detection rate, which was 62% in the TP group and 74% among men who got TRUS biopsies. But importantly, 15% of men with cancer in the TP group had apex tumors that the TRUS biopsies "may have missed," the study authors wrote.

More complications with the TP approach

As far as complications go, one man in the TRUS group developed an infection that was treated with multiple rounds of oral antibiotics. None of the TP-biopsied men got an infection, but eight of them had other complications: one had urinary blood clots that were treated in the hospital, two were catheterized for acute urinary retention, three were medically evaluated for dizziness, and two had temporary swelling of the scrotum.

Why were the TP noninfectious complication rates higher? That's not entirely clear. For various reasons, doctors wound up taking more prostate samples (called cores) on average from men in the TP group than they did from men in the TRUS group. The authors suggest if an equivalent number of cores had been taken from men in either group, then the complication rates might have been more similar. (In fact, larger comparative studies performed in hospital-based settings show no difference in complication rates when equal numbers of cores are obtained). But doctors in the current study also had more experience with TRUS biopsies, and that might also explain the discrepancy, the authors suggest. And as doctors in general become experienced with the TP method, complication rates might fall.

In an editorial comment, 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, acknowledged positive findings from the study, particularly a reduced need for antibiotics with the TP method, and the discovery of apex tumors TRUS biopsies could have missed. Garnick also highlighted a "steep learning curve" with TP biopsies, and how some of the noninfectious complications required hospital-based care. "The ability to perform TP biopsies in an office setting should enable future comparisons with TRUS to help answer whether this new TP technology has enduring value," he wrote.

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Can blue light-blocking glasses improve your sleep?

Recently, my brother mentioned he was sleeping better since he got new prescription glasses with a blue-light filter. He wears his glasses mostly for reading screens (both computer and smartphone) during the day while at work. So I was intrigued, but a little skeptical: could daytime use of blue light-filtering glasses make a difference in how well he slept? How, when, and why blue light affects us seemed like good questions to pose to an expert before deciding whether those glasses could help me, too.

What is blue light?

Visible light includes a short segment of wavelengths tucked into the electromagnetic radiation spectrum. Together, the wavelengths of visible light captured by our eyes are translated into white light by our brains.

You may remember looking through a prism to bend the wavelengths that make up white light into a rainbow of colors. At one end of this rainbow, blue light shades toward violet. Sunlight has a lot of light at all visible wavelengths.

Measured in nanometers (nm), visible light wavelengths range from 400 to 700 nm. Blue-light wavelengths lie between about 450 and 495 nm. And different slices of blue-light wavelengths have different effects on our bodies, including on sleep and alertness.

How does light affect our bodies?

In addition to helping us see, light also has nonvisual effects on the body, says Dr. Steven Lockley, a neuroscientist at the Division of Sleep and Circadian Disorders at Harvard-affiliated Brigham and Women’s Hospital.

The 24-hour circadian clock in the brain regulates sleep and wake cycles, hormonal activity, eating and digesting, and other important processes within the body. “Special photoreceptors in the eye detect light to control our circadian rhythms,” he says. These cells contain a nonvisual photopigment called melanopsin, which is most sensitive to 480 nm light at the blue-green end of the visible light spectrum. Other visual photoreceptors called cones allow us to see even shorter wavelengths of blue-violet light at around 450 nm.

How can blue light affect sleep?

During the day blue-enriched light is desirable, because it helps synchronize our circadian clocks to a 24-hour day. So, exposure to a regular light-and-dark cycle is vital to achieve and maintain good sleep.

Stimulation from certain wavelengths of blue light helps us stay alert, whether this comes from a natural source like the sun in daytime hours, or from electronic devices that emit blue light. While the stimulation is helpful during the day, at night it can interfere with sleep. Blue-light exposure in the evening — for example, binging a TV series on your laptop right before bed — will stimulate the melanopsin-containing cells and alert the brain, making it think it is daytime. That can make it harder to fall asleep and may affect the quality of your sleep.

Blue-light filtering: Can it help a tired body and tired eyes?

Although a recent systematic review suggested that blue light-blocking glasses may help people with insomnia, Dr. Lockley says there’s not enough detail about the studies to draw that conclusion. Most commercially available blue light-filtering glasses, and special coatings added to prescription lenses, aren’t standardized. So you have no way of knowing which wavelengths are being blocked, and whether this affects only visual function, or important nonvisual functions such as alertness and the circadian clock. Also, the timing, duration, and nature of the nighttime light exposure in the summary of these studies was not clear.

If you want to block stimulating blue light that could interfere with sleep, avoid screen use as much as possible after dusk — especially within two to three hours of bedtime. You can also try using computer software that reduces the amount of blue light emitted. Examples include Night Shift (available on Apple devices) or f.lux, a free download available for all computers and related devices. You should also try to address other issues that affect your sleep.

To help reduce eye strain, a common concern for people who use screens often, the American Academy of Ophthalmology advises taking regular breaks using the 20-20-20 rule. Every 20 minutes, look away from your screen at an object about 20 feet away for about 20 seconds.

You should also get as much daylight exposure as possible in between screen use to provide a strong circadian and alerting stimulus, particularly if you spend most of your time indoors.

As for my brother, he doesn’t watch much television and tends to prefer reading print books in the evenings. He agreed that he might be experiencing a placebo effect from the blue-light filter on his new glasses — or simply that he is sleeping better now that he has the correct prescription, and therefore less eye strain.

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Do weighted blankets help with insomnia?

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Insomnia is a sleep disorder that affects approximately 10% of adults in the United States. It is characterized by difficulty with falling asleep, staying asleep, and/or waking up too early, at least three times per week for a period of three months or more. Contrary to some beliefs that insomnia will get better by itself over time, evidence suggests that it will persist if not actively treated. In one study, 37.5% of patients with insomnia reported that their insomnia was still a problem five years later.

What are common treatment options used for insomnia?

Perhaps the most common nonpharmacological intervention used for insomnia is something called sleep hygiene. It describes a series of good sleep habits to engage in (such as keeping your bedroom quiet at night) and ones to avoid (turning off electronic devices before going to bed).

Unfortunately, as many patients know, sleep hygiene is not a very effective treatment for insomnia when implemented by itself. When sleep hygiene is used as one part of a multimodal approach, such as cognitive behavioral therapy for insomnia, it can be an effective complement to other important strategies. While cognitive behavioral therapy for insomnia is recommended as the gold-standard treatment by the American Academy of Sleep Medicine and the American College of Physicians, finding a clinician with expertise in behavioral sleep medicine can be a challenge — even via telemedicine.

Integrative treatment approaches are popular

Many people are interested in pursuing other treatment options for insomnia that do not involve prescription medications. Increasing evidence suggests that a number of approaches may be beneficial, including mindfulness-based practices and mind-body movement practices like yoga. Some people may use dietary supplements such as valerian, melatonin, chamomile, and cannabis, though evidence is more limited regarding their efficacy. You should always tell your doctor if you are taking any dietary supplements, as these may interact with other prescription medications.

An integrative option for people with insomnia and a psychiatric disorder

Insomnia is a common issue for people with a psychiatric disorder, possibly because of overlapping neurobiology. For example, someone with insomnia is 10 times more likely than someone without insomnia to also have depression. Among patients receiving psychiatric care, compression and weight have been used therapeutically. It has been hypothesized that the calming (and possibly sleep-promoting) effects of such an approach may be similar to what is experienced with acupressure or massage.

A team of researchers at the Karolinska Institute in Stockholm, Sweden conducted a study to determine whether a weighted metal chain blanket could improve insomnia symptoms compared to a light plastic chain blanket. They recruited outpatients with elevated insomnia symptoms who were being treated for one of several mood disorders: major depressive disorder, bipolar disorder, generalized anxiety disorder, or attention deficit hyperactivity disorder (ADHD).

Participants were randomly assigned to receive either a weighted metal chain blanket or a light blanket with plastic chains that were sewn on, which were the same shape and size as the metal chains on the weighted blanket. Those who were provided with a weighted metal chain blanket first tried on an 8-kilogram (17.6 pound) blanket. If this was too heavy, a 6-kilogram (13.2 pound) blanket was then provided. Over a four-week period, their sleep was assessed using surveys and a wrist-based device called an actigraph.

What did the researchers learn?

Participants who used the weighted metal chain blanket reported that their insomnia symptom severity declined significantly, while those who had used the light blanket did not experience such notable improvements. Furthermore, depressive symptoms and anxiety symptoms decreased much more for those who used the weighted blanket than those who used the light blanket. This secondary finding is consistent with other work showing that interventions designed to treat insomnia can have a meaningful impact on mood.

These promising findings are tempered by data showing that there were no significant improvements to key insomnia metrics, such as the amount of time spent awake after falling asleep, when sleep was tracked objectively using the actigraph. Other research conducted in children has also failed to demonstrate that weighted blankets significantly change sleep outcomes when measured using an actigraph.

Should you buy a weighted blanket?

While these findings are intriguing, more research is needed. It is important to note that there is a very real placebo effect for insomnia symptoms. This means that if you are someone who believes a weighted blanket could have a positive effect on your sleep tonight… well, it's quite possible that it will. For healthy adults, weighted blankets are considered safe as long as the individual can lift the blanket off when necessary. Because sleep is such a subjective experience, the cost of a weighted blanket may be money well spent — as long as you don’t forget that there are other options available to treat insomnia, with much more research data to support their effectiveness.

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Preparing for the holidays? Don’t forget rapid tests for COVID-19

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As the holiday season approaches, there’s a lot to keep in mind. Let’s just start with the easy questions: Who’s hosting Thanksgiving? Who’s making the turkey? The stuffing? Dessert?

But as we embark on our second round of holidays during the COVID-19 pandemic, we all have additional questions and decisions to make about how to keep everyone safe:

  • Inside or outside? While outside is safer, it may be too cold where you are to consider dining outdoors.
  • Is it necessary to wear masks or keep a physical distance? That depends on everyone’s vaccination status, recent exposures, and risk tolerance.
  • Must everyone be vaccinated? For many, this one’s a dealbreaker. Some hosts may insist. And some family and friends may come only if everyone is vaccinated.

The role of COVID testing could be changing

We know a lot more about testing for COVID-19 than at this time last year:

  • PCR tests. This is still the most accurate test of current infection. It detects small amounts of genetic material from the virus that causes COVID-19. But it often takes days to get the result back.
  • Rapid tests. This is typically an antigen test. It detects small bits of viral protein using similar technology to that used in pregnancy tests. An advantage of this type of testing is that the results are back in minutes. And while these tests have a higher rate of false negatives than a PCR test, getting a negative result strongly suggests you aren’t contagious. Even if you are infected, a negative result suggests there’s too little virus to infect others, at least at the time of the test. So, rapid COVID tests could be used as a way to screen people just before an activity during which exposure is possible — like Thanksgiving or other holiday gatherings.

One approach is to offer testing for each person as they arrive. It might slow the reunion process down a bit, but only for a few minutes. If a visiting friend or family member tests positive, they should leave along with anyone else they might have already exposed. The next step for them would to be to quarantine while waiting for results from a PCR test.

Cost, availability, and other limits of rapid testing before gatherings

While rapid testing may be a useful way to reduce your risk as holiday gatherings approach, it’s not perfect. Cost per test is high, generally $10 to $40 in the US. That’s especially hard for people with limited resources and those at higher risk for infection and complications from COVID-19. Rapid tests may be hard to find, too, although the Biden administration has vowed to address lack of availability by pledging several billion dollars to expand rapid testing. The health department in your community may be able to help you find test sites.

The FDA has given emergency use authorization to nearly 40 different tests, and research suggests that different brands vary widely in their accuracy. Currently, there are no specific recommendations from experts about which rapid test is best.

Additionally:

  • Results only apply to the time that the test is performed. You could have a negative test today despite being infected and a positive test tomorrow. These false-negative results may occur because it’s so early in the infection that there isn’t much viral protein present. Or it could be because of how the sample was obtained — maybe the swab wasn’t inserted deeply enough into the nose or wasn’t twirled around for long enough. Repeated testing can be helpful to address the concern of false-negative results; in fact, some tests specifically recommend repeat testing within a few days.
  • False-positive results may occur. A test may indicate infection when no such infection is present. It’s what happened on a now-infamous episode of The View. Two hosts quickly exited the set during a live broadcast because their COVID tests were positive. Soon after, their results were declared incorrect after further testing was done. Although false-positive results should be quite rare, manufacturing problems may make them more likely. In fact, some tests have been recalled because of an unexpectedly high rate of false-positive results.
  • Be prepared to download an app and follow instructions carefully. Rapid tests for COVID-19 typically require you to download an app and connect your phone or computer to the testing device through the app. Then you need to use a swab to collect a sample from inside your nose, apply the swab to the chemicals from the kit, and wait 15 minutes or so for your device to tell you the result. It’s not a particularly intuitive or consumer-friendly process. Many people may find it challenging.

The bottom line

Despite its limitations, rapid testing for COVID-19 is a strategy worth considering for holiday gatherings or group activities during which exposure to the virus is possible. Ideally, simplified rapid testing will become readily available at low (or no) cost soon. So, think about putting rapid COVID testing on your holiday to-do list, and consider offering tests to guests before you sit down for the turkey. It doesn’t take long, and the turkey probably won’t be ready on time anyway.