Hypertension guidelines: how much low?

In an era that that ‘evidence-based medicine’ is facing challenges from many fronts, the benefits of blood pressure control have been shown to decrease morbidity and mortality and increase lifespan. The evidence is strong and there is no disagreement among clinicians and researchers.

However, there is considerable uncertainty and debate as to how much reduction is needed in systolic blood pressure among the leading guidelines that look at the same evidence. The JNC 2018, AHA/ACC and now NICE guidelines vary with the recommendations.

The page below gives the summary of guidelines available from JNC 8 (2014), ACC/AHA (2107) and ESC/ESH (2018) 

Guidelines for Management of High Blood Pressure in Adults

In 2014, panel members of the Eighth Joint National Committee published the results of their evidence review and deliberations about the prevention, detection, evaluation, and treatment of high blood pressure.

The 2014 guideline offers recommendations for the management of hypertension in:

  • People older or younger than age 60 years
  • People aged ≥18 years with chronic kidney disease
  • People aged ≥18 years with diabetes
  • Black and nonblack populations

2017 ACC/AHA Hypertension Guideline

In 2017 the ACC/AHA and 9 other specialty organizations published an updated hypertension guideline which, among many changes, redefined elevated blood pressure to lower BP levels, enlarging the population considered potential candidates for monitoring and treatment. Learn more here.

2018 ESC/ESH Guideline

In 2018 the ESC/ESH published a guideline which retains the 140/90 threshold definition of hypertension, including for patients with chronic kidney disease (CKD), and emphasizes lifestyle interventions as primary treatment, with consideration of antihypertensive drug therapy only in adults at very high risk, eg with established CVD. In many other respects, the 2018 guideline is similar to the 2017 ACC/AHA guideline.

JAMA have produced two Podcasts: Battle of the Heart Societies: Who Is Right–the US or Europe–Regarding How to Manage Hypertension? Part I & Parts II. There can be downloaded free of charge from Appstore or Google Playstore.

 

 

How to get back from a disaster stricken mind

පාස්කු ඉරිදා සිදු වූ අමානුෂික ත්‍රස්ත ප්‍රහාරය හේතුවෙන් තුන්සියයකට ආසන්න පිරිසක් මිය ගොස් පන්සියයකට ආසන්න පිරිසක් තුවාල ලැබූහ. මියගියවුන් අතර කුඩා දරුවෝ හතළිස් පහකට ආසන්න පිරිසක් වූහ. තුවාල ලද දරුවන් සංඛ්‍යාවද බොහෝය. නොසිතූ මොහොතක ඇති වූ මේ දැවැන්ත ව්‍යසනය හමුවේ සමාජයේ ලොකු කුඩා කාහටත් දැඩි මානසික කම්පනයක් ඇති වූ බව රහසක් නොවේ. මේ ව්‍යසනයට මුහුණ පෑ එමෙන්ම එය දුටු සමස්තයේ අවසාන බලපෑම ඇති වන්නේ මේ හැම දෙනාගේම මනසටය. මෙයට විසඳුමක් ලෙස සමස්ත සමාජයේ මෙන්ම දරුවන්ගේ මානසික ව්‍යාකූලතා අවම කිරීම උදෙසා කළ යුතු හා කළ හැකි දේ මොනවාදැයි, අපි මනෝ චිකිත්සාව පිළිබඳ මහාචාර්ය අතුල සුමතිපාල මහතා සමඟ කතාබහ කළෙමු. සෞඛ්‍ය හා සමාජ ආරක්ෂණ ක්ෂේත්‍රයේ හසළ අත්දැකීම් ඇති මහාචාර්ය සුමතිපාල අපරටේ සමාජ ව්‍යසනයන් පිළිබඳ පර්යේෂණයන්හි යෙදීමෙන් සම්මානයට පාත්‍රවී ඇති පර්යේෂණ හා සංවර්ධන ආයතනයේ අධ්‍යක්ෂවරයාය. ඔහු එංගලන්තයේ කීල් විශ්වවිද්‍යාලයේ මනෝචිකිත්සාව පිළිබඳ මහාචාර්යවරයෙක් ද වෙයි.

 

Cපාස්කු ඉරිදා සිදු වූ අමානුෂික ත්‍රස්ත ප්‍රහාරය හේතුවෙන් තුන්සියයකට ආසන්න පිරිසක් මිය ගොස් පන්සියයකට ආසන්න පිරිසක් තුවාල ලැබූහ. මියගියවුන් අතර කුඩා දරුවෝ හතළිස් පහකට ආසන්න පිරිසක් වූහ. තුවාල ලද දරුවන් සංඛ්‍යාවද බොහෝය. නොසිතූ මොහොතක ඇති වූ මේ දැවැන්ත ව්‍යසනය හමුවේ සමාජයේ ලොකු කුඩා කාහටත් දැඩි මානසික කම්පනයක් ඇති වූ බව රහසක් නොවේ. මේ ව්‍යසනයට මුහුණ පෑ එමෙන්ම එය දුටු සමස්තයේ අවසාන බලපෑම ඇති වන්නේ මේ හැම දෙනාගේම මනසටය. මෙයට විසඳුමක් ලෙස සමස්ත සමාජයේ මෙන්ම දරුවන්ගේ මානසික ව්‍යාකූලතා අවම කිරීම උදෙසා කළ යුතු හා කළ හැකි දේ මොනවාදැයි, අපි මනෝ චිකිත්සාව පිළිබඳ මහාචාර්ය අතුල සුමතිපාල මහතා සමඟ කතාබහ කළෙමු. සෞඛ්‍ය හා සමාජ ආරක්ෂණ ක්ෂේත්‍රයේ හසළ අත්දැකීම් ඇති මහාචාර්ය සුමතිපාල අපරටේ සමාජ ව්‍යසනයන් පිළිබඳ පර්යේෂණයන්හි යෙදීමෙන් සම්මානයට පාත්‍රවී ඇති පර්යේෂණ හා සංවර්ධන ආයතනයේ අධ්‍යක්ෂවරයාය. ඔහු එංගලන්තයේ කීල් විශ්වවිද්‍යාලයේ මනෝචිකිත්සාව පිළිබඳ මහාචාර්යවරයෙක් ද වෙයි.

මෙම අවාසනාවන්ත සිදු වීම වාර්තා වූ අන්දම ගැන පළමුව කතා කරමු.

සුනාමිය අවස්ථාවේ දී මාධ්‍යයේ හැසිරීම සමඟ සසඳා බලත් දී ඇත්තටම මේ ඛේදවාචකය වාර්තා කරත්දී මාධ්‍ය හැසිරුණු ආකාරය ඉතාම සාධනීයයි. සුනාමිය අවස්ථාවේ දී ගාල්ලේ දරුවන් ගහගෙන ගිය රූපරාමු පෙළ නැවත නැවත පෙන්වූවා. එවැනි තත්වයක් මෙවර අපි දැක්කේ නැහැ.‍

මේ සිදුවීමට වැඩිහිටියන් වගේම දරුවන් සැලකිය යුතු පිරිසක් මුහුණ දුන්නා,

හුඟක් ආපදාවන්වලදී දරුවන් ඒවාට ගොදුරු වෙනවා. මෙතැනදීත් එහෙමයි. ඒත් සමඟම මේ දරුවන් පිළිබඳ සමාජයට අමතකව යනවා. අවුරුද්දත් පහත් අතර දරුවන්ට මරණය පිළිබඳ ලොකු හැඟීමක් නැහැ. නමුත් අවුරුදු පහත් දොළහත් අතර දරුවන්ට මේ ගැන දැනෙනවා වැඩියි. අද දරුවන් අඩුවෙන් හිතන්නෙත් නැහැ. වැඩියෙන් හිතන්නෙත් නැහැ. මේ දේවල් ගැන ඒ අයගේ හිතේ යම් පීඩනයක් ඇති වෙනවා. අවුරුදු දොළහේ සිට ඊට වැඩි වයස්වල අය මේ ගැන සකච්ජා කරනවා වැඩියි. මෙතැනදී අපි දරුවන් ගැන ප්‍රධාන වශයෙන් අවධානය යොමු කළ යුතුයි.

දරුවන්ට චිත්‍ර අඳින්න ඉඩ දෙන්න

මෙයට සෘජුවම මුහණ දුන් දරුවන් සාමාන්‍ය තත්වයට එන්න කාලයක් ගත වෙනවා. යම් යම් වයස් හා සමාජ මට්ටම්වල දරුවන් මෙයට මුහුණ දුන්නා. ඒ අයගේ සිත්තුළ බයක් තිබෙනවා. එතකොට ඒ අයට මෙය හරිම වෙදනාකාරී අත්දැකිමක්.මෙතනදි දෙන්න පුළුවන් ප්‍රතිකාරයක් තමයි දරුවන්ට එම සිදුවිම පිළිබඳ චිත්‍ර ඇදීමට හා විවිධ නිර්මාණ කිරීමට ඉඩ ලබා දිම. ටික දවසක් යන කොට ඔවුන් දුක තුනී කර ගන්නවා. මේ වෙලාවේ රෝහලේ ඉන්න කුඩා ළමයින්ට පවා කරන්න තියෙන්නේ සෙල්ලම් බඩුවක් දෙන එක නැතිනම් චිත්‍රයක් අඳින්න දෙන එක. මොකද දරුවන්ට අපේ වචන දාහකට වැඩිය වැදගත් සෙල්ලම් බඩුවක් දී මනස සුවපත් කරන එක. තුවාල වී ඉන්න දරුවන්ට බොහොම කරුණාවෙන් ආදරයෙන් කතා කිරීම ඉතාම වැදගත්. සමහර ළමයි ගෙදර යන කොට මව් පියන් සහෝදර සහෝදරියන් නැතිවෙලා ඉන්න පුළුවන්. එතකොට එතැන තියෙන අභියෝගය තමයි සමහර දරුවන්ට වචනයෙන් අහන්න බැහැ. දොළහට වැඩිනම් කතා කරයි. සමහර ළමයින්ට රෑට මූත්‍රා යනවා. එයත් ස්වභාවිකයි. බයයි කියන්නේ නැතිව සමහර ළමයි බඩ රිදෙනවා ඔළුව රිදෙනවා කියලා පාසල් නොයා ඉන්න බලනවා. මෙහිදී මවුපියන් පරිස්සමින් කටයුතු කළ යුතුයි. දරුවන් රෝහලට ගෙනිහින් පරීක්ෂණ කරන්නේ නැතුව දරුවන්ගේ මනස ගැන, ඒ තත්ත්වය වැඩිහිටියන් තේරුම් ගැනීම අවශ්‍යයි.

මෙයට මුහුණ දුන් දරුවන්ට හා මෙය මාධ්‍ය මඟින් දුටු දරුවන්ට පාසල් පද්ධතියෙන් දිය හැකි දායකත්වය කුමක්ද?

ඉතා ආරක්ෂිතව දරුවන් පාසල් අරින එක ඇත්තටම කෙරෙන්න ඕන වැඩක්. ළමයි පාසලට ගියහම ඒ අය සාමුහිකව ඉන්නවා. ගෙදර ඉන්කොට ටීවී එකේ පෙන්වන දේවල් සහ දෙම්ව්පියන් සාකච්ජාකරන දේවල් අහගෙන ඉන්නවා. ළමයි මේ දේවල් අහුලා ගන්නවා. එයින් බලපෑමක් ඔවුන්ගේ මනසට එල්ල වෙනවා.

ස්වාභාවික චර්යාවේ වෙනස්කම්

එවිට ඒ අයගේ ස්වභාවික චර්යාවේ වෙනස්කම් ඇති වෙනවා. පාසල් ගියාම අනෙක් ළමයි ඒ ගැන කතා කරයි. අහයි. කමක් නැහැ. ගුරුවරු ඒ අයට විශේෂ අවධානයක් යොමු කළ යුතුයි. බොහොම ආදරයෙන් ළෙන්ගතුකමින් ආදර‍ය සමාජයෙන් ලබා දිය යුතුයි. ඒ දරුවාට තමා ආරක්ෂිතයි කියන හැඟීම ඇති කරන්න ඕන. මගේ අම්ම තාත්ත නැහැ. අහිමිවීම් මට සිදු වුණා. ඒත් මා රැක බලා ගන්න අය ඉන්නවා කියන හැඟීම දෙන්න ඕන. ඒ වගේම මේ දරුවන් ගැන අවධානයෙන් ඉන්න ඕන. මේ අය තමන්ගේ එදිනෙදා දේවල් වලින් ඈත් වෙනවාද? අනෙක් ළමයි වගේ ඉන්නවාද? කියල බලන්න ඕන. දරුවන්ට අපි හිතනවාට වඩා ඔරොත්තු දීමේ හැකියාව වැඩියි.

අද දරුවන් අතරට බෝම්බ කියන වචනය ඇවිත් තිබෙනවා. දරුවන් බෝම්බ සෙල්ලම් කරන්න පටන්ගෙන තිබෙනවා.

මෙය නරක තත්වයක්. මේ දරුවන් සෙල්ලම් කරත්දී බෝම්බ ගැන කියනව නම් මේ දරුවන්ට තරවටු නොකර බෝම්බ කියන්නේ හොඳ දෙයක් නොවන බවත් එය නරක දෙයක් බවත් එය සෙල්ලමකට ගන්න හොඳ දෙයක් නොවන බවත් තේරුම් කර දී බොහොම කල්පනාවෙන් දරුවන් එකමුතුව සාමුහිකව කරන්න පුළුවන් සෙල්ලමකට යොමු කිරීමට මවුපියන් කටයුතු කළ යුතුයි. තුවක්කු, පිස්තෝල, පිහි දරුවන්ට සෙල්මටවත් ලබා නොදිය යුතුයි.

දුක තුනී කරන සුවිශේෂ ක්‍රම

මේ සිදුවීමට මුහුණ දී ජීවත් වන වැඩිහිටියන් හා දරුවන් තවමත් පසුවන්නේ වියෝ දුකින්, දැඩි වේදනාවකින්. එය තුනී කරගන්නට කටයුතු කළ යුත්තේ කෙසේද?

බොහෝ දෙනෙක් මෙයට උපදේශනය අවශ්‍යයි කිව්වත් ලංකාවේ අපේ සමාජයේ යම් විපතකදී හරි ස්වභාවික මරණයක දී හරි ඇතිවන ඒ වියෝ දුක තුනී කර ගන්න භාවිතා කරන සුවිශේෂී ක්‍රමවේදයන් තිබෙනවා. බෞද්ධ සංස්කෘතිය ගත්තම එහි මතක බණ, දානමාන දී ඒ දුක තුනී කරගන්නවා. පල්ලිවලත් එහෙමයි. හැම ආගමකම සංස්කෘතික වශයෙන් අහිමිවූවන් විඳදරාගැනීමේ ක්‍රමවේදයක් තිබෙනවා. අපේ සංස්කෘතිය ඇතුළේ මේ ක්‍රමවේදය ප්‍රබල වෙනවා. ඒ වගේම පාසල් පද්ධතිවල දරුවන්ට පාසල පටන් ගත්තාට පසු ගුරුවරුන්ට කරන්නට පුළුවන් පහුගිය කාලේ තමන්ගේ මතකයේ රැඳුණු දෙයක් අඳින්න හෝ නිර්මාණයක් කරන්න කියන එක. ළමයි අඳියි. විවිධ දේ නිර්මාණය කරයි. එවිට අපිට මුළු ලංකාවේම ඉන්න බහුතරයක් පාසල් දරුවන් අඳින්නේ මේ සිදුවීම නම් ඒ අයගේ මනස තුළ මෙහි බලපෑමක් තියෙනවා කියන එක හඳුනා ගන්න පුළුවන්. නමුත් කාලයක් යන විට එහි බලපෑම අඩුවෙනවා.

මෙහි බලපෑම මනසටයි එල්ල වෙන්නේ.

බය, දුක හා තරහ එතැනදී ඇතිවෙනවා. ඕනෑම කෙනෙකුට නින්ද නොයෑම සුලබයි. බය, අනෙකා ගැන ඇති සැකය, අනාරක්ෂිතභාවය, කලබලවීම, තරහ යෑම්, පශ්චාත්තාපය ( සමහර දරුවන් යන්න බහැ කියත්දිත් බලෙන් මවුපියන් පල්ලි යවලා දරුවන් මියගියවිට තමන් වැරැදිකාරයන් කියා හිතෙන එක) මේ සේරම සාමාන්‍යයෙන් ඕනෑම කෙනකු ගේ මනසේ ඇති වන ප්‍රතික්‍රියා. ඒවා මානසික රෝග නොවෙයි. මෙය කාලයා විසින් තමයි නැති කරන්නේ.

මේ මානසික පීඩනය රෝගයක් විය හැකිද?

නැහැ. මෙම ව්‍යවසනයට මුහුණ දී මැරුණු අය ඉන්නවා. මරණිය තුවාල සිදු වී ඉතිරි වූ අය ඉන්නවා. මේ හැම දෙනාම යම් ව්‍යාකූලතාවයකට පත්වෙලා තිබෙනවා. තව කොටසක් ඉන්නවා සමාජයේ සෘජු ලෙස මෙයට මුහුණ දුන්නේ නැහැ. ගුවන් විදුලි රූපවාහිනී මාධ්‍ය ඔස්සේ දැක්කා. ඇහුවා. ඒ හරහා ව්‍යාකූලත්වයට පත්ව තිබෙනවා. නමුත් මේ එකක්වත් රෝග නෙමෙයි. මේක ස්වභාවික තත්ත්වයක්. එයට කාලය විසින් තමයි විසඳුම් ලබා දෙන්නේ.

මේ සිදුවීම තවත් අයට ප්‍රකෝපකාරී හැගීම් දනවන්නක් වුණා නේද?

මේ අර්බුදයේ බරපතළම තත්ත්වය තමයි ආගම්වාදය හා ජාතිවාදය ඇවිස්සීමට තිබෙන ඉඩකඩ. එය නවත්තන එක තමයි හැමදෙනාගේම වගකීම. මේ ත්‍රස්තවාදී ප්‍රහාරයට අපේ මනසේ ඇතිවන ස්වභාවික ප්‍රතික්‍රියාවේ නරකම පැත්ත තමයි වෛරය , ද්වේෂය, ක්‍රෝධය ඇති වීම. ඒක ස්වභාවික දෙයක් වුණත් එය නරක අතට පාවිච්චිවන එක වළක්වා ගැනීම ප්‍රධානම අභියෝගය වෙනවා. සෑම නායකයකුගේම හා පුරවැසියෙකුගේම වගකීමක් එය. මේ ද්වේෂ සහගත සිතුවිලි එනවා නම් එය තේරුම් ගෙන ඒවා සමාජයට විනාශකාරි අත්දැකීම් නොවන ලෙස කටයුතු කළ යුතුයි.

එතැනදී පාසල් පද්ධතියට ගුරුවරයාට විශාල වගකීමක් තිබෙනවා. මොකද තරුණ දරුවන් ආවේගශීලියි. යුද්ධය නිමා වෙන කොට අවුරුදු 10 දරුවට අද අවුරුදු 20ක්. එයාට මතක නැහැ. මේවා යුද්ධයෙන් පසුව ඉපදුණු ළමයටත් එහෙමමයි. ඒ අයට අපිට වගේ පරණ අත්දැකිම් නැහැ. ඒ අයට මේ අලුත් අත්දැකීමත් එක්ක ද්වේෂ සහගත හැඟීම් එන්න පුළුවන්. තරහ යන්න පුළුවන්. එතනදී රජයක් වශයෙනුත් සමාජයක් වශයෙනුත් ප්‍රධාන වගකීම තමයි අනර්තකාරී ක්‍රියාවන්ට නැඹුරුවීම‍ට ඉඩ ඇති තරුණ පරපුර එයින් මුදා ගැනීමට සුවිශේෂී වැඩපිළිවෙළක් සැකසීම. නැතිනම් අන්තවාදීන් විසින් ජාතිවාදීන් විසින් මෙය පාවිච්චි කරන්න පුළුවන්. එය පරාජය කිරීමයි වැදගත්. මෙතනදී ජාතික ආරක්ෂාව ඉහළ තලයකට ගෙන ඒම තමයි ප්‍රධාන කොන්දේසිය වන්නේ. මේ ව්‍යයසනය තුළ සුළු ප්‍රතිශතයකට දීර්ඝකාලිනව මානසික රෝගී තත්වයන් ඇති වෙන්න පුළුවන්. අපදා නිසි ලෙස කළමණාකරණය කිරිමයි මෙතනදී වැදගත් වෙන්නේ.

සැකය අනර්ථකාරී නොවිය යුතුයි

අද හුඟදෙනෙක් අතර සැකය පැතිරිලා තිබෙනවා. සැකයෙන් බැලීම ස්වභාවිකයි. විශේෂයෙන්ම තරුණ දරුවන්. මෙතනදී වැඩිහිටියන්ගේ වගකීම තමයි ඒ තත්වය හඳුනාගෙන ඒ ගැන විවෘතව කතාබහ කිරීම. සැකය අපේ භාවිතාවේදී අනර්ථකාරී විදිහට පාවිච්චි නොකළ යුතුයි. ඒ අයට හිතාමතා වෙනස්කම් නොකළයුතුයි. කොන් නොකළ යුතුයි. පාසලකදීනම් ගුරුවරු මේ කණ්ඩායම් දෙකටම තේරුම් කර දෙන්න ඕන මෙහෙම දෙයක් සිද්ධ වුණත් ඔය දරුවන් මේවාට සම්බන්ධ නැහැ. ඒත් තව කෙනෙක් ඔබ දිහා සැකෙන් බලන්න පුළුවන්. ඒ කට කළඹ වෙන්න එපා කියලා. සැකය දුරුවන ලෙස කටයුතු කරන්න කියලා. ඒ වගේමසාමාන්‍ය මිනිසුන් ඉතාම ඉක්මණින් එදිනෙදා ජීවිතයට අනුගතවීම මේ ත්‍රස්තවාදීන්ට කරන්න පුළුවන් ලොකුම අභියෝගය. මොකද ඒ අයගේ අභිප්‍රාය මේ තත්ත්වය නැති කිරිම වන නිසයි. අපි සමාජයක් ලෙස බයෙන් සැකෙන් නෙමෙයි කල්පනාවෙන් ජීවත්වීමයි ඉතාම වැදගත්.

අද අලුත් තාක්ෂණයත් එක්ක සමහර දරුවන් තුන්වැනි තට්ටුවේ ඉඳන් අම්මට එස්එම් එස් කරනවා තේ එක එවන්න කියලා. ඒ විදිහට අපේ ස්වභාවික ගනුදෙනු, කතාබහ, එකට වාඩිවෙලා කන බොන එක සීග්‍රයෙන් නැතිවෙලා ගිහින්. එනිසා තමයි අද දරුවන් කරනදේ මවුපියන් දන්නේ නැති තත්ත්වයට පත්වෙලා තිබෙන්නේ. මේ ත්ත්වයෙන් අපි මිදිය යුතුයි.

Grief and Bereavement in Adults

Grief is the response to bereavement, which is the situation in which a loved one has died [1]. Natural acute grief reactions are often painful and impairing with emotional and somatic distress, but should not be diagnosed as a mental disorder. However, bereavement is a stressor that can precipitate or worsen mental disorders (eg, unipolar major depression). In addition, complications (maladaptive thoughts, feelings, or behaviors) may occur, such that acute grief becomes intense, prolonged, and debilitating. This condition is called complicated grief, which is viewed as a unique and recognizable disorder that requires specific treatment. Ref -[UpToDate

TERMINOLOGY

The terms bereavement, grief (acute and integrated), complicated grief, and mourning describe different aspects of experiencing the death of a loved one [1-4]:

Bereavement – The situation in which someone who is close dies (rather than the reaction to that loss). (See ‘Bereavement’ below.)

Grief – Grief is the natural response (including thoughts, feelings, behaviors, and physiologic reactions) to bereavement. Although grief can occur in response to other meaningful (non-bereavement) losses, this topic focuses primarily upon grief in response to the death of a loved one.

The pattern and intensity of grief varies over time as bereaved individuals adapt to the loss. The experience of grief is influenced by cultural and religious rituals that vary widely, and is unique to each person and each loss. Acute grief can be intense and disruptive but is eventually integrated. Progress from acute to integrated grief is often erratic and hard to discern as it is happening. (See ‘Typical acute grief’ below.)

Complicated grief – Complicated grief is a form of acute grief that is unusually prolonged, intense, and disabling; troubling thoughts, dysfunctional behaviors, dysregulated emotions, and/or serious psychosocial problems impede adaptation to the loss. The syndrome of complicated grief is a unique and recognizable condition that can be differentiated from other mental disorders. Other terms that have been used to describe complicated grief include chronic grief, complex grief, pathological grief, persistent complex bereavement disorder, prolonged grief disorder, traumatic grief, and unresolved grief. (See “Complicated grief in adults: Epidemiology, clinical features, assessment, and diagnosis”.)

Mourning – Mourning is the process of adapting to a loss and integrating grief. Adaptation entails accepting the finality and consequences of the loss, revising the internalized relationship with deceased, and re-envisioning the future such that there is a possibility for happiness in a world without the deceased. When mourning is successful, the painful and disruptive experience of acute grief is transformed into an experience of integrated grief that is bittersweet and in the background. Like grief, mourning is influenced by cultural and religious rituals that vary widely.

 

TYPICAL ACUTE GRIEF

The hallmark of acute grief is the intense focus on thoughts and memories of the deceased person, accompanied by sadness and yearning.

This topic focuses upon grief in response to the death of a loved one. Nevertheless, grief can occur in response to other meaningful (non-bereavement) losses, including an interpersonal loss (eg, separation from a loved one through divorce) or loss of a pet, job, property, or community. In a study of survivors of a natural disaster who showed signs of unusually prolonged, intense, and disabling grief (ie, complicated grief), the large majority of survivors suffered non-bereavement losses [115].

Presentation — Mourners focus their attention, emotions, thoughts, and behavior upon the deceased person and what has been lost. However, the painful feelings and memories are commonly intermingled with periods of respite and positive feelings, thoughts, and reminiscing [3,116]. These positive experiences during bereavement reflect resilience and foretell better outcomes [13,117].

Acute grief symptoms vary across individuals and differ in the same person after different losses. Symptoms also vary over time and are influenced by social, religious, and cultural norms [3,4,14]. The features, intensity, and duration of grief are also influenced by age, health, religious and ethnic identity, coping style, attachment style, available social support and material resources, situation and circumstances of the death (see ‘Type of loss’ above), and the experience of prior losses [4].

MANAGEMENT

General approach — If possible, clinicians should summon families prior to an expected death. If this is not possible and the patient dies, the clinician should promptly call immediate family members who are not present at the bedside in order to inform them, express condolences, answer questions, and offer them the option of viewing the body.

Individuals with acute grief may present seeking relief from symptoms such as intense sadness or disrupted sleep; assessment should rule out conditions that may be triggered or exacerbated by bereavement:

Suicidal ideation and behavior

Complicated grief

Other mental disorders, such as major depression, posttraumatic stress disorder (PTSD), insomnia disorder, and anxiety disorders

Primary care clinicians who are not comfortable diagnosing and treating mental disorders should refer patients to mental health clinicians.

Information about mental disorders that may be precipitated by acute grief, and information about the differential diagnosis of acute grief, is discussed separately. (See “Grief and bereavement in adults: Clinical features”.)

Interventions — Acute grief typically does not require treatment [5]. Most bereaved individuals are resilient and acute grief is transformed and integrated during a natural adaptive process that typically unfolds with the support and encouragement of close family and friends, as well as clergy [1]. Grief work (confronting painful emotions) on its own does not appear to facilitate adjustment to bereavement [6,7], and bereaved individuals who experience little distress, even when they suppress their emotions, have been shown to have a benign course [8]. In addition, embarking on an uncovering or personality-targeted psychotherapy may derail the natural healing process and is potentially harmful [1,4,5,9-12]. Guidelines from the World Health Organization for bereaved individuals who do not have mental disorders recommend that structured psychological interventions should not be routinely offered [13,14].

Bereavement is the situation in which a loved one has died, and grief is the distress that occurs in response to bereavement. Acute grief can be intense and disruptive, but usually is integrated over time. Complicated grief is a form of acute grief that is abnormally prolonged, intense, and disabling; as such, complicated grief is a unique and recognizable mental disorder. (See ‘Terminology’ above.)

Reactions to bereavement can vary depending upon the type of lost relationship. The intensity of acute grief is generally greater in parents who lose a child than it is for bereaved spouses, which in turn is greater than the grief of adult children who lose a parent. The intensity and course of acute grief is also influenced by the circumstances of the death, including the age of the deceased, and whether the loss is sudden or violent, or the result of a chronic or terminal illness. (See ‘Type of loss’ above.)

Bereavement is associated with an increased risk of mortality, general medical illnesses (eg, cardiovascular disease), and mental disorders (eg, unipolar or bipolar major depression, anxiety disorders, and posttraumatic stress disorder [PTSD]), as well as suicidal ideation and behavior that is independent of psychopathology. Some bereaved individuals develop complicated grief, which may account for most of the increased risk for each of these negative health outcomes. (See ‘Adverse general medical outcomes’ above and ‘Associated psychopathology’ above.)

Although diagnosing major depression in the context of bereavement is controversial, bereavement does not preclude the diagnosis. The rationale for diagnosing major depression in bereaved individuals is based upon the best available evidence, which indicates that bereavement-related major depression and major depression not related to bereavement are comparable with regard to risk factors, symptoms, impaired functioning, comorbidities, course of illness, and response to treatment. (See ‘Major depression’ above.)

There is no single way to grieve and adapt to a loss. The specific pattern of grief symptoms as well as the process of adaptation is unique to each specific loss situation, influenced by individual factors as well as social, religious, and cultural norms. Nevertheless, the symptoms of typical acute grief are usually related to either separation from the deceased (eg, yearning for and seeking proximity to the deceased, loneliness, and crying) or to stress and trauma (disbelief, shock and numbness). (See ‘Presentation’ above.)

The course of typical acute grief does not follow a specific series of stages that occur in a fixed order; rather, the trajectory of adaptation is erratic and specific to each loss. However, grief is time-limited and integrated such that painful emotions and insistent thoughts diminish in frequency, intensity and duration. Adaptation to the loss is usually well underway within 6 to 12 months. Grief becomes more subdued but generally does not resolve completely; the deceased person is not forgotten and is still missed, and the intensity of grief may flare during anniversaries of the death, holidays, or periods of heightened stress. (See ‘Course’ above.)

Typical acute grief is not a mental disorder and should not be diagnosed or treated as such. Nevertheless, grief includes symptoms that overlap with those of common mental disorders. The differential diagnosis of acute grief includes complicated grief, major depression, and PTSD. (See ‘Differential diagnosis’ above.)

Gene editing and Designer ‘CRISPR’ babies

 

Gene editing or genome editing is the technique used to replace or cutting pieces of DNA [Ref]. Using a component known as  CRISPR to precisely pinpoint the sequence of DNA in the gene, an enzyme called Cas9 is used to cut through the part identified. It can also replace a removed part by another sequence of DNA. This technique can be used to replace a faculty gene or change a gene to make it behave differently. Gene editing can have very good effects like altering a disease gene or modifying a diseased gene to behave normally. However gene editing can also produce some questionable effects such as altering a physical function or a characteristic – e.g. eye colour gene can be altered to produce blue eyes and this can make the way for designer  babies.

Gene-edited humans would one day be born but the scientific world was not prepared as there was a number of issues to be fully investigated and ethical issues deliberated.

He Jiankui, a scientist from China, had secretly launched the first attempt to create children with edited genes. He edited human embryos using CRISPR to remove a single gene. He claimed that twin girls—named Lula and Lala—had been born and that they would be immune to HIV because of how he’d altered their genomes.

Changing the genes in an embryo means changing genes in every cell. If the method succeeds, the baby will have alterations that will be inherited by all of the child’s progeny. And that, scientists agree, is a serious undertaking that must be done with great deliberation and only to treat a serious disease for which there are no other options — if it is to be done at all [Ref]

What Jiankui did was to disable a perfectly normal gene, CCR₅. While people who are born with both copies of CCR₅ disabled are resistant to H.I.V., they are more susceptible to West Nile virus and Japanese encephalitis. More worrying, Crispr often inadvertently alters genes other than the one being targeted, and there are also circumstances, called mosaicism, where some cells contain the edited gene and others do not.

“Should such epic scientific misadventures proceed, a technology with enormous promise for prevention and treatment of disease will be overshadowed by justifiable public outrage, fear, and disgust,” said Dr. Francis Collins, director of the National Institutes of Health.

Some worry that this is the first step toward using gene editing to create people with extreme intelligence, beauty or athletic ability. But that, for now, is not possible. Such traits are thought to be affected by possibly hundreds of genes acting in concert, and affected in turn by the environment. The biggest ethical concerns for now are with rogue scientists enticing couples who do not realize the risks to babies that might result from the experiments. And when those children grow up, the altered genes will be passed on to their children, and to their children’s children, for generations to come.


The promise and perils of synthetic biology – Economist (Unedited)

To understand them well, look to the past

https://www.economist.com/leaders/2019/04/04/the-promise-and-perils-of-synthetic-biology

For the past four billion years or so the only way for life on Earth to produce a sequence of dna—a gene—was by copying a sequence it already had to hand. Sometimes the gene would be damaged or scrambled, the copying imperfect or undertaken repeatedly. From that raw material arose the glories of natural selection. But beneath it all, gene begat gene.

That is no longer true. Now genes can be written from scratch and edited repeatedly, like text in a word processor. The ability to engineer living things which this provides represents a fundamental change in the way humans interact with the planet’s life. It permits the manufacture of all manner of things which used to be hard, even impossible, to make: pharmaceuticals, fuels, fabrics, foods and fragrances can all be built molecule by molecule. What cells do and what they can become is engineerable, too. Immune cells can be told to follow doctors’ orders; stem cells better coaxed to turn into new tissues; fertilised eggs programmed to grow into creatures quite unlike their parents.

The earliest stages of such “synthetic biology” are already changing many industrial processes, transforming medicine and beginning to reach into the consumer world (see Technology Quarterly). Progress may be slow, but with the help of new tools and a big dollop of machine learning, biological manufacturing could eventually yield truly cornucopian technologies. Buildings may be grown from synthetic wood or coral. Mammoths produced from engineered elephant cells may yet stride across Siberia.

The scale of the potential changes seems hard to imagine. But look back through history, and humanity’s relations with the living world have seen three great transformations: the exploitation of fossil fuels, the globalisation of the world’s ecosystems after the European conquest of the Americas, and the domestication of crops and animals at the dawn of agriculture. All brought prosperity and progress, but with damaging side-effects. Synthetic biology promises similar transformation. To harness the promise and minimise the peril, it pays to learn the lessons of the past.

The new biology calls all in doubt

Start with the most recent of these previous shifts. Fossil fuels have enabled humans to drive remarkable economic expansion in the present using biological productivity from ages past, stored away in coal and oil. But much wilderness has been lost, and carbon atoms which last saw the atmosphere hundreds of millions of years ago have strengthened the planet’s greenhouse effect to a degree that may prove catastrophic. Here, synthetic biology can do good. It is already being used to replace some products made from petrochemicals; in time it could replace some fuels, too. This week Burger King introduced into some of its restaurants a beefless Whopper that gets its meatiness from an engineered plant protein; such innovations could greatly ease a shift to less environmentally taxing diets. They could also be used to do more with less. Plants and their soil microbes could produce their own fertilisers and pesticides, ruminants less greenhouse gas—though to ensure that synthetic biology yields such laudable environmental goals will take public policy as well as the cues of the market.

The second example of biological change sweeping the world is the Columbian exchange, in which the 16th century’s newly global network of trade shuffled together the creatures of the New World and the Old. Horses, cattle and cotton were introduced to the Americas; maize, potatoes, chilli and tobacco to Europe, Africa and Asia. The ecosystems in which humans live became globalised as never before, providing more productive agriculture all round, richer diets for many. But there were also disastrous consequences. Measles, smallpox and other pathogens ran through the New World like a forest fire, claiming tens of millions of lives. The Europeans weaponised this catastrophe, conquering lands depleted and disordered by disease.

Synthetic biology could create such weapons by design: pathogens designed to weaken, to incapacitate or to kill, and perhaps also to limit themselves to particular types of target. There is real cause for concern here—but not for immediate alarm. For such weaponisation would, like the rest of cutting-edge synthetic biology, take highly skilled teams with significant resources. And armies already have lots of ways to flatten cities and kill people in large numbers. When it comes to mass destruction, a disease is a poor substitute for a nuke. What’s more, today’s synthetic-biology community lives up to ideals of openness and public service better than many older fields. Maintained and nurtured, that culture should serve as a powerful immune system against rogue elements.

The earliest biological transformation—domestication—produced what was hitherto the biggest change in how humans lived their lives. Haphazardly, then purposefully, humans bred cereals to be more bountiful, livestock to be more docile, dogs more obedient and cats more companionable (the last a partial success, at best). This allowed new densities of settlement and new forms of social organisation: the market, the city, the state. Humans domesticated themselves as well as their crops and animals, creating space for the drudgery of subsistence agriculture and oppressive political hierarchies.

Synthetic biology will have a similar cascading effect, transforming humans’ relationships with each other and, potentially, their own biological nature. The ability to reprogram the embryo is, rightly, the site of most of today’s ethical concerns. In future, they may extend further; what should one make of people with the upper-body strength of gorillas, or minds impervious to sorrow? How humans may choose to change themselves biologically is hard to say; that some choices will be controversial is not.

Which leads to the main way in which this transformation differs from the three that came before. Their significance was discovered only in retrospect. This time, there will be foresight. It will not be perfect: there will certainly be unanticipated effects. But synthetic biology will be driven by the pursuit of goals, both anticipated and desired. It will challenge the human capacity for wisdom and foresight. It might defeat it. But carefully nurtured, it might also help expand it.

This article appeared in the Leaders section of the print edition under the headline”Redesigning life”

Meet ‘Symptom Checkers’ – Isabel and Babylon

People increasingly search the Internet regarding their health issues and a Google search may be the commonest in most instances. Even doctors ‘Google’ for a diagnosis [Ref].

Recently there has been a proliferation of more sophisticated programs called ‘symptom checkers‘ that attempt to more effectively provide a potential diagnosis for patients and direct them to the appropriate care setting. Many healthcare institutions provide symptom checkers such as  WebMD, Mayo Clinic,  HealthLine.

 

Isabel and Balylon are two different applications that use different programming techniques to provide people with their symptom evaluation.

Isabel uses the orthodox text-searching. Babylon uses a ‘Chatbot‘ – newer machine learning techniques that are part of AI. (You can even build a Chatbot to book a flight in under 7 minutes using IBM Watson!). However, you cannot build something like Isabel that easily. Its often debated what’s the best but the answer is it depends.

Isabel is also a tool that is used by medical experts when diagnoses are difficult and when one has to even think about rare diseases. Babylon does not offer this kind of professional facilities.

Technological Transformation

Technology has enabled bionics and artificial intelligence, each of which can have important applications in health care. As we continue to substitute body parts with machinery, however, we might wonder, “What makes us human?” This drawing interrogates the relationship between humanity and embodiment, specifically in neck and facial musculature and brain structures.

This image represents humankind’s union with technology. It shows the brain turning into a collection of integrated computer circuits and the neck muscles evolving into mechanization-ready cables, pumps, and wires. In artificial intelligence (AI), boundaries distinguishing life and technology are challenged. We wonder, “Is it possible for machines to think? Are our own brains just complex organizations of biological microchips?” Medical students are well positioned to appreciate how intimately technology is becoming part of human life. From wheelchairs and artificial limbs to new antibiotics and imaging, innovations are constantly growing in number and playing larger roles in our existence. If science unlocks the origins of thought, therapies for patients with neurocognitive or psychiatric problems could be enabled. Progress in AI will generate the need in medicine to explore ontological and ethical relationships among brains, minds, selves, and healing.

Elisabeth Miller – AMA Journal of Ethics – LINK

How Should Clinicians Engage With Online Health Information?

From the ‘AMA Journal of Ethics – Illuminating the Art of Medicine’

Many adults, physicians, and medical students search the internet for health information. Open access has many benefits, but the variable quality of internet health information—ranging from evidence based to false—raises ethical concerns. Using Wikipedia as a case study, this article argues that everyone engaging with internet health information has ethical responsibilities. Those hosting and writing for health websites should ensure that information is evidence based, accurate, up to date, and readable and be transparent about conflicts of interest. Health care professionals, including medical students, have both ethical responsibilities to help patients avoid false or misleading health information and practical opportunities to improve the quality of internet health information. All users of such information—professionals and patients alike—should develop critical appraisal skills and apply them to internet health information to distinguish the good from the junk.

The full article – LINK

Screening and General Health Checks in adults – the latest from Cochrane

Screening and prevention

‘Screening is a way of finding out if people are at higher risk of a health problem so that early treatment can be offered or information given to help them make informed decisions. Screening is a way of identifying apparently healthy people who may have an increased risk of a particular condition. The (NHS UK) offers a range of screening tests to different sections of the population.

The aim is to offer screening to the people who are most likely to benefit from it. For example, some screening tests are only offered to newborn babies, while others such as breast screening and abdominal aortic aneurysm screening are only offered to older people.’ [Ref NHS UK] This will give a very good understanding of what screening is and what are the screening tests that are recommended by the NHS-UK. This may be somewhat different from what the MoH recommends for Sri Lankan citizens. (I will try and get a link to the recommended screening programs by the Ministry). 

‘Very importantly, screening is not for people with symptoms. If you have any symptoms, go to your doctor.’

 

‘Prevention is better than cure’ makes intuitive sense. Yet there is evidence that some preventive activities are not effective, some are actually harmful. It has been said ‘all screening programs do some harm; some do good as well’. Screening of asymptomatic patients may lead to overdiagnosis, causing needless anxiety, appointments, tests, drugs and even operations, and may leave the patient less healthy as a consequence. Therefore, it is crucial that evidence clearly demonstrates that benefits outweigh those harms for each preventive activity. [Ref – RACGP Red book]

You can download the 9th ed Redbook

 

Screening test by the private sector

There are many screening tests offered by private sector laboratories and health care institutions. The UK government advice before you go for a test will be important and extremely helpful if you are planning to do so. “Private companies offer a wide range of health checks, from simple blood tests and physical examinations to full body scans and screening for serious conditions like aneurysms or heart failure. Some of the tests offered by private companies are not recommended by the UK NSC because it is not clear that the benefits outweigh the harms. If you’re thinking about paying for any of these checks, it’s worth asking the following questions first.’ Read the full instructions- LINK


LINK

General health checks for reducing illness and mortality

What is the aim of this review?

The aim of this Cochrane Review was to find out if general health checks reduce illness and deaths. This is an update of a previous Cochrane Review.

Key messages

Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.

What was studied in the review?

General health checks involve multiple tests in a person who does not feel ill. The purpose is to find the disease early, prevent the disease from developing, or provide reassurance. Health checks are a common element of health care in some countries. Experience from screening programmes for individual diseases have shown that the benefits may be smaller than expected and the harms greater. We identified and analyzed all randomized trials that compared invitations for one or more health checks for the general public with no invitations. We analyzed the effect on illness and the risk of death, as well as other outcomes that reflect illness, for example, hospitalization and absence from work.

What are the main results of the review?

We found 17 randomized trials that had compared a group of adults offered general health checks to a group not offered health checks.

Fifteen trials reported results and included 251,891 participants. Eleven of these trials had studied the risk of death, and included 233,298 participants and assessed 21,535 deaths. This is an unusually large amount of data in healthcare research, which allowed us to draw our main conclusions with a high degree of certainty. Health checks have little or no effect on the risk of death from any cause (high‐certainty evidence), or on the risk of death from cancer (high‐certainty evidence), and probably have little or no effect on the risk of death from cardiovascular causes (moderate‐certainty evidence). Likewise, health checks have little or no effect on heart disease (high‐certainty evidence) and probably have little or no effect on stroke (moderate‐certainty evidence).

We propose that one reason for the apparent lack of effect may be that primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons. Also, those at high risk of developing disease may not attend general health checks when invited or may not follow suggested tests and treatments.

How up to date is the review?

The review authors searched for studies published up to 31 January 2018.

Authors’ conclusions

Implications for practice

Our results do not support the use of general health checks aimed at a general population. On the other hand, they do not imply either that physicians should stop clinically motivated testing and preventive activities, as such activities may be an important reason why an effect of general health checks has not been shown. Public healthcare initiatives to systematically offer general health checks and offers from private suppliers of general health checks are not supported by the best available evidence.

Implications for research

We see no reason to do more trials of general health checks, as it seems futile based on a large amount of available data and the fact that the results of previous trials have now been confirmed by a recent large trial. Further research in health checks should be limited to studying the effect of one component at a time and should include harmful effects. We also suggest that surrogate outcomes such as changes in risk factors are not used for assessing benefits since they do not capture harmful effects and since their relation to meaningful outcomes is usually in doubt. The required large randomized trials with long follow‐up are expensive but not nearly as expensive as the implementation of ineffective or harmful screening programmes. We suggest more focus on the effects of structural interventions to reduce disease, for example, higher taxes on tobacco and alcohol, or restricting corporate advertising for harmful products.

2019 – 03 – 17

Phishing – stealing legitimate user credentials

Phishing is a form of fraud in which an attacker masquerades as a reputable entity or person in email or other communication channels. The attacker uses phishing emails to distribute malicious links or attachments that can perform a variety of functions, including the extraction of login credentials or account information from victims. One common explanation for the term is that phishing is a homophone of fishing, and is so named because phishing scams use lures to catch unsuspecting victims, or fish. [LINK]

Phishing attacks typically rely on social networking techniques applied to email or other electronic communication methods, including direct messages sent over social networks, SMS text messages and other instant messaging modes.

Although many phishing emails are poorly written and clearly fake, cybercriminal groups increasingly use the same techniques professional marketers use to identify the most effective types of messages — the phishing hooks that get the highest open or click-through rate and the Facebook posts that generate the most likes. Phishing campaigns are often built around major events, holidays and anniversaries, or take advantage of breaking news stories, both true and fictitious.

phishing email Typically, a victim receives a message that appears to have been sent by a known contact or organization. The attack is carried out either through a malicious file attachment that contains phishing software, or through links connecting to malicious websites. In either case, the objective is to install malware on the user’s device or direct the victim to a malicious website set up to trick them into divulging personal and financial information, such as passwords, account IDs or credit card details.

 

 

Phishing defense begins with educating users to identify phishing messages, but there are other tactics that can cut down on successful attacks.

A gateway email filter can trap many mass-targeted phishing emails and reduce the number of phishing emails that reach users’ inboxes. Enterprise mail servers should make use of at least one email authentication standard to verify that inbound email is verified. These include the Sender Policy Framework (SPF) protocol, which can help reduce unsolicited email (spam); the DomainKeys Identified Mail (DKIM) protocol, which enables users to block all messages except for those that have been cryptographically signed; and the Domain-based Message Authentication, Reporting and Conformance (DMARC) protocol, which specifies that both SPF and DKIM be in use for inbound email, and which also provides a framework for using those protocols to block unsolicited email — including phishing email — more effectively.

Phishing attacks aimed at stealing legitimate user credentials have been used in the past 24 months to compromise 45% of UK organisations, 49% of France,  44% of the Netherlands. Ireland performed significantly better, with just 25% according research organisation. This information is from 2017 and the figures may be different now.

Adam Bradley from Sophos said criminals are adept at using social engineering to exploit human weakness, so while well-trained employees are an excellent deterrent, even the best user can slip up. Phishing is one of the most common routes of entry for cyber criminals. “As organisations grow, their risk of becoming a victim also increases as they become more lucrative targets and provide hackers with more potential points of failure.

Organisations should block malicious links, attachments and imposters before they reach users’ inboxes, said Bradley, and use the latest cyber security tools to stop ransomware and other advanced threats from running on devices even if a user clicks a malicious link or opens an infected attachment.

 

What we learned in 2018 in Health & Medicine according to the NYT

Developments in medicine and health that we’re still thinking about at year’s end. It’s not easy to say that any particular development in health or medicine was the most important in a given year [Ref – NYT]. But if we had to choose some highlights, we’d opt for these unforgettable events and findings.

 

 

 

From left, Douglas A. Warner III, Memorial Sloan Kettering’s board chairman; Dr. José Baselga, its former chief medical officer; and Dr. Craig B. Thompson, its chief executive, at its charity ball in New York last year. Credit Rebecca Smeyne for The New York Times

‘Dr. José Baselga, a towering figure in the cancer world, resigned from his post at Memorial Sloan Kettering Cancer Center in New York in September. An investigation by The Times and ProPublica had found that he failed to disclose millions of dollars in payments from health care companies in dozens of research articles. But Dr. Baselga wasn’t the only medical researcher who failed to make such disclosures, a problem that is aggravated by confusing advice from medical journals and a failure to adequately vet the contributors to their pages.’

  • Alcohol and heart health – We learned how public health research can be compromised by private interests.

In June, the National Institutes of Health shut down a study of the effects of moderate drinking on heart attacks and stroke, following an investigation by The Times. The researchers who proposed the study sought funding from beer and liquor companies, and suggested that the results would support a daily drink as a healthy choice. The N.I.H.’s director, Dr. Francis Collins, said the trial seemed to be “set up in a way that would maximize the chances of showing a positive effect of alcohol.”

  • Teenagers and e-cigarettes -We learned that vaping among young people is a growing national problem.

E-cigarettes may help some people quit smoking, but the soaring use of Juul and other vaping devices by teenagers has motivated the Food and Drug Administration to place new limits on the sales of e-cigarette flavors. Schools are grappling with students furtively vaping, as teenagers who may never have smoked a cigarette find themselves struggling to shake a new addiction to nicotine.

Dayton, Ohio, had one of the highest opioid overdose death rates in the nation. Now, it may be at the leading edge of a waning phase of the epidemic. While the data are preliminary, a variety of factors contributed to the reduction in deaths: Medicaid expansion paying for treatment; dwindling availability of one particular drug; greater use of naloxone, which can reverse overdoses; a large network of recovery support groups; and, law enforcement and public health workers improving their coordination.

People with hemophilia, the inability to form blood clots, spend their lives menaced by the prospect of uncontrolled bleeding into a muscle or joint, or even the brain. Experimental gene therapy treatments have rid a few patients — for now, at least — of the condition. It does not yet amount to a cure, and the treatment is imperfect. But some who received the treatments are finding themselves uneasily adjusting to a life with new freedoms.

  • Where a sore throat becomes a death sentence – We learned untreated strep throat leads to heart failure in poor countries.

In the United States and other rich countries, cheap antibiotics cure children with strep throat easily. But in poor countries, strep can result in rheumatic heart disease and a long, slow death sentence. In Rwanda, doctors from a group called Team Heart visit once a year to perform heart valve-replacement surgery for 16 people. But there are thousands more people who need the procedure in a country that has no heart surgeons.

In the winter of 2017-2018, 80,000 Americans died from the flu. It was the highest number in over a decade, and included 180 young children and teenagers. Some hospitals had to bring out their “surge tents” to treat the overflow of patients. While no flu vaccine is perfect at this time, the shots are particularly effective with children, and the secretary of health and human services, Alex M. Azar II, compared getting vaccinated with wearing your seatbelt. You already do that, don’t you?

Everywhere in the United States, hospitals are merging. Instead of creating savings that get passed on to consumers, an analysis found that in some regions, the opposite occurred. From 2010 through 2013, the price of an average hospital stay soared, with prices in most areas going up between 11 percent and 54 percent. What’s happening to the average cost of private hospital stay?