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HEALTH NATURAL WORKOUT

Prostate cancer: A new type of radiation treatment limits risk of side effects

photo of a radiologist talking to a senior man about to have a scan for prostate cancer

When it comes to limiting side effects from radiation therapy, the name of the game is precision. Doctors want to treat the cancer while avoiding healthy tissues, and fortunately technological advances are making that increasingly possible.

One newer technique called stereotactic body radiotherapy (SBRT) can focus precisely targeted beams of high-dose radiation on a tumor from almost any direction.

The entire course of therapy requires only five individual treatments over two weeks, making SBRT more convenient than earlier low-dose methods that require more visits to the clinic. The treatment relies on specialized types of medical imaging scans that allow doctors to visualize where cancer exists in the body.

Advances in technology

Recently, doctors have begun to integrate SBRT with imaging scans that can visualize a tumor's movements in real time. Simple acts such as breathing, swallowing, or digesting food can shift a tumor's position. But this new technique — which is called magnetic resonance–guided daily adaptive SBRT, or MRg-A-SBRT for short — continually adjusts for those motions, so that doctors can focus more precisely on their targets.

Now, a new study helps to confirm that MRg-A-SBRT has fewer side effects than a related method called CT-SBRT, which uses computed tomography for imaging.

According to the study's lead author, Dr. Jonathan Leeman, a radiation oncologist at Harvard-affiliated Brigham and Women's Hospital in Boston, MRg-A-SBRT offers several advantages over CT-SBRT: one is that doctors using it can adjust treatment plans to account for a tumor's daily motions (this is called adaptive planning). The technology collects multiple MRI images per second during a radiation procedure, thus ensuring accurate real-time targeting. And finally, MRI visualizes the prostate with better resolution.

Analysis of studies

During the new study, Dr. Leeman and his colleagues searched the medical literature for every published clinical trial so far evaluating SBRT for prostate cancer, either with MRI or CT guidance. (This type of study is called a systematic review.)

The team ultimately identified 29 clinical trials that monitored outcomes for a total of over 2,500 patients. Short-term data on side effects was collected for up to three months on average after the procedures were completed.

Leeman's team used statistical methods to pool results from the studies into combined datasets. They found that the MR-SBRT-treated patients had fewer side effects. Specifically, 5% to 33% of men treated with MR-SBRT had genitourinary side effects, compared to between 9% and 47% of men who had the CT-guided treatments. Similarly, the risk of gastrointestinal side effects in the MR-SBRT-treated men ranged from 0% to 8%, compared to between 2% and 23% among men whose treatments were guided by CT.

Conclusions and comments

The authors concluded that "technical advances in precision radiotherapy delivery afforded by MRg-A-SBRT translate to measurable clinical benefit" (i.e., better tolerated treatments). But precisely why the treatments were better tolerated remains unclear. Is it because MR-scanning has better resolution? Did adaptive planning (and real-time targeting) account for the lower risk of side effects, or can that be attributed to some combination of all these factors? Dr. Leeman says that adaptive planning is "likely the main differentiator," but he adds that further studies are needed to confirm where the benefits come from.

To place this important work in perspective, we reached out to the authors of the new paper, as well as Dr. Anthony Zietman and Dr. Nima Aghdam, two Harvard-affiliated radiation oncologists who are also on the editorial board of the Harvard Medical School Annual Report on Prostate Diseases. All these experts feel this new technology has very promising potential.

But both groups cautioned that as with all newly developed innovations, results from additional studies — including clinical trials that are currentlyongoing — will be needed before more widespread uptake of the technology is warranted. Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, says he "agrees with this conservative, yet optimistic assessment."

About the Author

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Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

photo of Marc B. Garnick, MD

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

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HEALTH NATURAL WORKOUT

Chronic stomach pain in children: What’s the most common cause?

A child in a pink shirt and blue jeans with her arms around her stomach, sitting on a bed curled up against her mother; concept is stomach pain

The most common cause of chronic stomach pain in children isn’t anything you can find on a test or cure with a medicine. And that can make it very challenging to diagnose — and treat.

You may not have ever heard of functional abdominal pain. Yet it ranks as the most common cause of stomach pain lasting two months or more in children and teens.

What is functional abdominal pain?

The mind and the body are tightly connected in ways that we are still working to understand, and this is particularly true of the mind and the gastrointestinal tract. Stress — particularly chronic stress, depression, and anxiety — can lead to pain that is very real. Sometimes the pain is the only symptom of stress, especially in children who are high-achieving or tend to hide their emotions.

Sometimes the pain doesn’t start from stress but from an infection or other illness, and stays once the illness is gone or adds additional pain to the illness while it is being treated. Worry about the pain and its possible cause can make things worse. The nervous system of the gut can go into overdrive.

What are common symptoms of functional abdominal pain?

Children with functional abdominal pain can have mild symptoms that just show up occasionally, or they can have more severe symptoms that interfere with daily life. Along with stomachaches, they can have nausea, vomiting, constipation, or diarrhea — or some combination of all of them. They may have a poor appetite or complain of feeling full very quickly.

When should you contact your child’s doctor?

It’s important to check in with your doctor if your child is having chronic stomachaches. They should have a physical examination, and your doctor may want to do some testing, such as blood or stool tests, as there are many medical conditions that can cause chronic stomachaches.

It’s particularly important to call your doctor if your child

  • is losing weight
  • has blood in their stool
  • has severe pain
  • has fever, rashes, sore joints, or other signs of illness.

If your doctor finds that your child’s examination and tests are normal, and they aren’t losing weight, chances are that your child has functional abdominal pain.

For some families, getting this diagnosis sounds like the doctors are saying that it is all in the child’s head. But nothing could be further from the truth. It is very real pain — but it is not being caused by something dangerous, which is very good news.

How can you help a child diagnosed with functional abdominal pain?

There are many ways to help a child who has functional abdominal pain once the diagnosis is made. They include:

  • Understanding and managing stressors in the child’s life, if there are any
  • Medications recommended by your health care team can help with symptoms, such as laxatives for constipation
  • Cognitive behavioral therapy, which is a kind of therapy that teaches strategies for managing pain, as well as managing any stress or sadness that can be contributing
  • Meditation, yoga, and other ways for a child to relax and regulate how they react to their world
  • For some children, a low-FODMAP diet can be helpful
  • Probiotics, peppermint oil preparations, and some other supplements are sometimes used to help soothe and prevent pain.

Most children with functional abdominal pain can receive care from their pediatrician. Regular visits are a good idea, to check in to see how things are going and adjust any treatments. If things aren’t getting better, a referral to a gastroenterologist can be helpful.

Follow me on Twitter @drClaire

About the Author

photo of Claire McCarthy, MD

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

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How to help your child get the sleep they need

photo of a father reading to his daughter as they snuggle in bed

It’s tempting at this time of year to let summer sleep schedules stay in place or let bedtimes slide, especially when parents feel tired out, too. But it’s important that children have a regular routine — and that they are sleeping during the dark hours and awake during the light ones, as our bodies do best that way. That’s true for families who are home-schooling, as well: even when the trip to school is just a walk to the kitchen table, allowing for more sleep than those catching an early bus may get, no child should be spending all morning in bed.

Sleep is crucial for all of us, and this is particularly true for children. Without enough quality sleep, children are more likely to have health and behavioral problems — and difficulty learning.

Here are a few simple things you can do to help your child get the sleep they need.

Have a regular schedule

Our bodies do best when we go to bed and wake up at roughly the same time every day.

  • Children and teens need eight to 10 hours of sleep. Count back 10 hours from when your child needs to get up in the morning. That’s roughly the time they need to be getting ready for bed (for younger children, count back 11 hours).
  • For example, if your teen needs to be up at 7, then they should be getting ready for bed by 9, and in bed by 10 (since most of us don’t fall asleep the moment our head hits the pillow). A younger child should start getting ready (bathing, etc.) by around 8.
  • Understand that teens are biologically wired to fall asleep later and wake up later and will naturally have later bedtimes. Unfortunately, most school districts don’t accommodate to this, so you are often working against biology.
  • While it’s okay to stay up a bit later on weekends, don’t let the bedtime vary by more than an hour or so.

Turn off the screens before bed

The blue light emitted by screens can keep us awake.

  • It’s best if the screens can be off two hours before you want your child asleep. Use that time when they start getting ready for bed as the time that the screens go off.
  • The only real way to achieve this is to get all devices out of the bedroom. (So true!)
  • Teens will fight you on this. If you can, hold firm (and buy them an alarm clock if they say they need their phone for this). At the very least, be sure that the phone is on Do Not Disturb mode overnight.

Have an environment that encourages sleep

  • Quiet things down. If you are watching TV, turn the volume down, and in general try to not make much noise after children go to bed.
  • Consider a white noise machine, or a fan (or air conditioner if you live somewhere warm). There are also white noise apps for those teens who won’t give up their phones.
  • Room-darkening curtains can make a difference for children who tend to wake up at the first light of dawn — or who can’t fall asleep if it’s not fully dark outside.

Know how other factors influence sleep

  • Busy teens often have difficulty getting everything done in time to get enough sleep. Talk with your teen about their daily schedule and look for ways to help them get more shut-eye, such as getting homework done during the school day, or limiting video games or other activities that eat into homework time. Sleep needs to be the priority.
  • Limit caffeine. It’s best not to have any, but certainly nothing from mid-afternoon on.
  • Limit naps! For a tired older child naps may seem like a good idea, but they can interfere with nighttime sleep. Naptime is okay through preschool.
  • Make sure your child gets exercise. It’s not only important for their health, it helps their sleep.
  • Have calming routines before bed (not exercise!).

If your child is having trouble falling asleep, or is waking up at night, talk to your doctor. It’s also important to talk to your doctor if your child is snoring or having other breathing problems at night. Don’t ever ignore a sleep problem; always ask for help.

About the Author

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Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

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HEALTH NATURAL WORKOUT

Is online gambling harming you?

Multicolored neon signs with "Big Bet," "Online Betting," "Free Bet," plus gambling and sports icons like dice, baseketball and football

Online gambling — all those websites and apps that offer casino games, sports betting, poker, fantasy sports, and lotteries — can be exciting and entertaining. It’s an estimated $9.5 billion per year business, and growing. But for millions of Americans, what starts as occasional fun can lead to devastating gambling-related problems.

“You can experience harm from gambling, including addiction, just like you can with alcohol or other drugs,” says Debi LaPlante, director of the Division on Addiction at Harvard-affiliated Cambridge Health Alliance.

Who is being harmed?

In fact, the American Psychiatric Association’s classification of mental health disorders places gambling disorder in the section defining substance-related and addictive disorders, along with problems like opioid use disorder and alcohol use disorder.

In the US, about 1% of adults (two million) are estimated to have a severe gambling problem, and 2% to 3% (four to six million) are thought have a mild or moderate problem.

How can you recognize a possible gambling problem?

The Brief Biosocial Gambling Screen from the Cambridge Health Alliance’s Division on Addiction tests for gambling disorder risk by asking three questions:

  • During the past 12 months, have you become restless, irritable, or anxious when trying to stop and/or cut down on gambling?
  • During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?
  • During the past 12 months, did you have such financial trouble due to gambling that you had to get help with living expenses from family, friends, or welfare?

“If you answer yes to any of these questions, you should evaluate your gambling and how it fits into your life, and seek out further assessment,” says LaPlante.

How do you know if you’re engaging in harmless or harmful gambling?

A gambling addiction often occurs gradually. The line between harmless and harmful is often blurred, so people don’t always recognize they have a problem until it becomes severe. Here is what is considered the threshold of low-risk gambling:

  • You gamble no more than 1% of household income.
  • You gamble no more than four days per month.
  • You don’t gamble at more than two types of games.

What does gambling disorder share with other forms of addiction?

Gambling disorder shares certain risk factors with other types of addiction:

  • genetics
  • faulty thought patterns
  • impulse control disorders
  • availability in one’s community
  • poverty.

Like other types of addiction, gambling-related problems can lead to disrupted romantic, social, and work relationships. Feelings of withdrawal when someone tries to cut back are similar, too.

Does online gambling affect the brain?

Gambling games can affect people at the neurobiological level. Many games have features that trick the brain into thinking a loss is actually a win. For example, a slot machine displays celebratory music, sounds, and lights for a $3 return on a $5 bet.

“Research has found that our sympathetic nervous system responds to losses celebrated as wins the same way it responds to actual wins,” says LaPlante. “This is a powerful reinforcer, and just one example of games affecting brains.”

How can you find help for problem gambling?

Finding help for gambling can be challenging because, unlike for other types of addiction, the number of professionals who treat gambling addiction is limited, according to LaPlante. “Also, because of shame and stigma, people are less likely to acknowledge that gambling can become a problem,” she says.

Still, resources such as Gamblers Anonymous, local and national crisis helplines like 1-800-GAMBLER, self-help books such as Your First Step to Change, and local departments of public health are available to connect people to help.

Addiction treatment is not an exact science, and success varies from person to person. Some treatments have shown promise for gambling disorders, such as cognitive behavioral therapy (CBT) and motivational interviewing.

With CBT, people work with a therapist to help identify faulty thoughts and behaviors, such as the feeling one is “due to win” after a string of losses, and then learn tools to reframe those harmful thought patterns and respond to them more appropriately. During motivational interviewing, a person works with a counselor to enhance their motivation to change by together examining their ambivalence about change.

“If the gambling addiction is a symptom of another mental or physical health problem, addressing those issues is essential,” says LaPlante.

What does recovery from a gambling problem look like?

Different people have different ideas about what it means to be recovered from gambling addiction. For some, this means completely cutting gambling out of their life; for others, it means cutting back.

“Ideally, the treatment experience will include plans to prevent lapses that take people away from maintaining their own goals,” says LaPlante.

About the Author

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Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

photo of Howard E. LeWine, MD

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

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HEALTH NATURAL WORKOUT

Heat rash: How to spot it and what to do

A blazing yellow sun with sun rays against a yellow-red background with clouds; concept is heat-related illness

The first two weeks of July were the Earth’s hottest on human record, and people across the country continue to suffer from lingering, suffocating heat waves. The US Centers for Disease Control and Prevention has issued repeated warnings and tips about recognizing and preventing heat-related illnesses, like heat stroke, heat exhaustion, and heat cramps.

But one heat-related illness that people do not always recognize is heat rash.

“Heat rash can indicate that your exposure to excessive heat could lead to other serious heat-related issues, if not addressed,” says Dr. Abigail Waldman, a dermatologist with Harvard-affiliated Brigham and Women’s Hospital. "While heat rash is not dangerous in itself, sustained exposure to high heat can lead to heat exhaustion and heat stroke, so it's important to note any early signs that your body is struggling with the heat.”

What are the signs of heat rash?

Heat rash is also known as miliaria or prickly heat. It is caused when ducts from eccrine sweat glands that lead to the skin's surface are blocked or inflamed.

Eccrine sweat glands help your body maintain a steady temperature. When your internal temperature rises, these glands release water that rises to the surface of your skin through tiny ducts. There, it quickly evaporates, cooling your skin and the blood beneath.

However, sweat ducts may get blocked when you sweat excessively in hot temperatures, particularly if skin folds or tight-fitting clothes hinder their function.

Sweat is then trapped beneath the skin. This triggers inflammation, which leads to the appearance of small, itchy red bumps, similar to tiny pimples or blisters. In people with darker skin tones, these small, itchy bumps may not appear red, but will look slightly darker than surrounding skin.

Where and when is heat rash likely to occur?

Heat rash can appear on the neck, scalp, chest, groin, or elbow creases.

“Heat rash can occur any time the body sweats, so it is common in hot, humid climates, during hospitalizations, from fever, and during exercise,” says Dr. Waldman.

Heat rash also can occur in newborns, as their eccrine sweat glands are not fully developed. In newborns, heat rash looks like very thin blisters or water drops widely distributed on the face, trunk, arms, and legs. Call your pediatrician for advice if you notice a rash like this.

How can you treat heat rash?

Heat rash in adults is easy to treat with home remedies. “The techniques to relieve symptoms also can help prevent heat rash for adults and babies,” says Dr. Waldman.

  • Cool down. The first step is to get out of the heat and cool and dry your skin. Use a fan or air conditioner, take a cool shower, or apply cool compresses to the affected areas. It's important to know that some people are more vulnerable to heat, and to make plans to help stay safe when temperatures are dangerously high.
  • Prevent irritation. To prevent skin irritation, avoid wearing clothes made from synthetic materials, which can trap heat. (While dry-fit clothing helps to wicks away moisture from the skin, it often can be too tight fitting.) Instead, wear light, loose-fitting cotton clothing that allows airflow over your skin. If a heat rash occurs around your groin area, avoid wearing undergarments until it clears up.
  • Try anti-itch products. Use an over-the-counter topical corticosteroid cream or calamine lotion for itching. However, avoid baby powder, oily or greasy moisturizers, and sunscreen, as they can further block sweat ducts.

Heat rash typically goes away within one to two days once you cool down your body. More severe heat rashes can last a week or longer. See your doctor (or follow up with your pediatrician) if a heat rash has not cleared up after a week. Also seek immediate care if you experience pain, intense itching, or the rash appears infected.

About the Author

photo of Matthew Solan

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

photo of Howard E. LeWine, MD

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

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HEALTH NATURAL WORKOUT

Dealing with thick, discolored toenails

The ball of a foot and five toes with different emotions like a sad, worried, or happy face drawn on in pen; background blurred

Wriggling toes in the sand and wearing sandals are warm weather treats, unless you’d rather keep your toes under wraps due to thickened, yellowish nails. Nail fungal infections (known as onychomycosis) are common, affecting up to 14% of the general population. In advanced cases, nails can become brittle, crumbly, or ragged, or even separate from the nail bed.

While completely curing these fungal infections is difficult, the right treatments can discourage the problem from spreading and make your nails look better.

Do nail fungal infections only affect toenails?

No, fingernails can become infected, too. However, toenails are a more common target because of certain habits, including wearing shoes, so we’ll concentrate on them in this post.

How do people get toenail fungus?

“Feet are more likely to be sweaty and damp, which provides a better environment for the fungi, yeasts, and molds that are naturally present on your skin to flourish,” says Dr. Abigail Waldman, a dermatologist at Harvard-affiliated Brigham and Women’s Hospital.

People also can be exposed to various fungi, known as dermatophytes, by walking barefoot in locker rooms, spas, or near swimming pools, or getting a pedicure at a nail salon, she says. A fungal overgrowth can infect the area between your toes and the skin or your feet, causing athlete’s foot. The fungus can then spread to the toenails.

What makes toenail fungus hard to treat?

While antifungal creams can easily treat skin infections, toenails are another story.

“Nail tissue is harder and thicker, so these medications don’t penetrate very well,” Dr. Waldman explains. That’s also true for antifungal drugs taken as pills. Toenails grow slowly and the tissue isn’t very metabolically active. So although the medication gets into your bloodstream, only small amounts end up in your toenails. That’s why it’s hard to get rid of toenail fungus once it takes hold.

What counts as a cure?

Research reports so-called clinical cure rates between 60% to 80%, but this means only the absence of symptoms — that is, your toenails return to their normal appearance. The fungal infection may still be lurking under your nails, says Dr. Waldman.

In fact, in clinical trials when investigators recheck toenail clippings for any residual fungus after treatments applied to nails, only around 10% to 15% show no detectable fungal spores. As a result, recurrences of toenail fungal infections are fairly common.

Despite this, there’s a reasonable chance that different treatment approaches can improve your symptoms and the appearance of your toenails.

What works for treating toenail fungus?

Here is a rundown of the different treatment options, starting with Dr. Waldman’s go-to first-line suggestion, which uses inexpensive products you may already have in your home.

Home remedies

Soaking your toes to soften your nails before applying a fungus-fighting agent will help the remedy penetrate the nail. For the soak, Dr. Waldman recommends mixing one part white or apple cider vinegar to three parts warm water. Soak your toes for at least 10 minutes (but up to 40 minutes is better). Instead of vinegar, you can use Listerine, which contains thymol, the main compound in the herb thyme. Like vinegar, thymol has antifungal properties.

Then dry your feet well and apply an antifungal substance to all the affected nails. One option is a paste of crushed garlic, but most people will probably find the over-the-counter drugstore products listed below more convenient to use.

Over-the-counter products

The best evidence is for 100% tea tree oil, but another popular option is Vicks VapoRub (which also contains thymol and other essential oils that may fight fungus), Dr. Waldman says. Or you can use one of the various creams sold to treat athlete’s foot on your toenails.

Be sure to apply the product right after soaking. The clinical cure rates for each of these approaches vary between products, and depend on the severity and duration of the infection. But about 60% of people notice improvements after a few months of treatment, Dr. Waldman says.

Drugstores also carry several other toenail treatments, including a treated patch you put on your nails overnight. It contains urea, an acidic substance that improves the look of your nails by making them less brittle and discolored. Another product that promises similar results uses a tiny LED light that you clip onto your toenail after applying a liquid containing polyethylene glycol, which softens nails.

Prescription treatments to put on toenails

These topical products, which are best for milder infections, include amorolfine (Loceryl, others), efinaconazole (Jublia), tavaborole (Kerydin), and ciclopirox (Penlac). They are clear lacquers that you brush on your toenails once daily, usually for months. It may take as long as a year to see results. Clinical cure rates range from 35% to 60%.

Prescription pills

More severe infections may respond better to oral drugs, which include fluconazole (Diflucan), griseofulvin (Grifulvin), itraconazole (Sporanox), and terbinafine (Lamisil). These are taken daily in pill form for three months. While the clinical cure rates are higher (around 80%), these drugs have more side effects, including stomach upset, diarrhea, and (in rare cases) liver damage.

Laser therapy

Lasers penetrate and break down nail tissue, helping to destroy the fungus. There are many different types of lasers and protocols. Clinical cure rates are hard to pin down, but some have been reported as ranging between 60% and 75%.

Advice on toenail clippers, nail polish, new shoes, and more

During and after treatment, Dr. Waldman advises people to use two sets of toenail clippers — one for infected nails and one for noninfected nails — to prevent fungal spread. If you’re embarrassed by the appearance of your toenails, it’s okay to use nail polish for short periods of time, she says.

Once you finish treatment, buying new shoes will help avoid reinfection. “I also always recommend people do a diluted vinegar soak once or twice a week after finishing treatment, which helps prevent any lingering fungus from reinfecting the nail,” says Dr. Waldman.

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

About the Reviewer

photo of Howard E. LeWine, MD

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

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HEALTH NATURAL WORKOUT

Will miscarriage care remain available?

A abstract red heart breaking into many pieces against a dark blue background; concept is miscarriage during a pregnancy

When you first learned the facts about pregnancy — from a parent, perhaps, or a friend — you probably didn’t learn that up to one in three ends in a miscarriage.

What causes miscarriage? How is it treated? And why is appropriate health care for miscarriage under scrutiny — and in some parts of the US, getting harder to find?

What is miscarriage?

Many people who come to us for care are excited and hopeful about building their families. It’s devastating when a hoped-for pregnancy ends early.

Miscarriage is a catch-all term for a pregnancy loss before 20 weeks, counting from the first day of the last menstrual period. Miscarriage happens in as many as one in three pregnancies, although the risk gradually decreases as pregnancy progresses. By 20 weeks, it occurs in fewer than one in 100 pregnancies.

What causes miscarriage?

Usually, there is no obvious or single cause for miscarriage. Some factors raise risk, such as:

  • Pregnancy at older ages. Chromosome abnormalities are a common cause of pregnancy loss. As people age, this risk rises.
  • Autoimmune disorders. While many pregnant people with autoimmune disorders like lupus or Sjogren’s syndrome have successful pregnancies, their risk for pregnancy loss is higher.
  • Certain illnesses. Diabetes or thyroid disease, if poorly controlled, can raise risk.
  • Certain conditions in the uterus. Uterine fibroids, polyps, or malformations may contribute to miscarriage.
  • Previous miscarriages. Having a miscarriage slightly increases risk for miscarriage in the next pregnancy. For instance, if a pregnant person’s risk of miscarriage is one in 10, it may increase to 1.5 in 10 after their first miscarriage, and four in 10 after having three miscarriages.
  • Certain medicines. A developing pregnancy may be harmed by certain medicines. It’s safest to plan pregnancy and receive pre-pregnancy counseling if you have a chronic illness or condition.

How is miscarriage diagnosed?

Before ultrasounds in early pregnancy became widely available, many miscarriages were diagnosed based on symptoms like bleeding and cramping. Now, people may be diagnosed with a miscarriage or early pregnancy loss on a routine ultrasound before they notice any symptoms.

How is miscarriage treated?

Being able to choose the next step in treatment may help emotionally. When there are no complications and the miscarriage occurs during the first trimester (up to 13 weeks of pregnancy), the options are:

Take no action. Passing blood and pregnancy tissue often occurs at home naturally, without need for medications or a procedure. Within a week, 25% to 50% will pass pregnancy tissue; more than 80% of those who experience bleeding as a sign of miscarriage will pass the pregnancy tissue within two weeks.

What to know: This can be a safe option for some people, but not all. For example, heavy bleeding would not be safe for a person who has anemia (lower than normal red blood cell counts).

Take medication. The most effective option uses two medicines: mifepristone is taken first, followed by misoprostol. Using only misoprostol is a less effective option. The two-step combination is 90% successful in helping the body pass pregnancy tissue; taking misoprostol alone is 70% to 80% successful in doing so.

What to know: Bleeding and cramping typically start a few hours after taking misoprostol. If bleeding does not start, or there is pregnancy tissue still left in the uterus, a surgical procedure may be necessary: this happens in about one in 10 people using both medicines and one in four people who use only misoprostol.

Use a procedure. During dilation and curettage (D&C), the cervix is dilated (widened) so that instruments can be inserted into the uterus to remove the pregnancy tissue. This procedure is nearly 99% successful.

What to know: If someone is having life-threatening bleeding or has signs of infection, this is the safest option. This procedure is typically done in an operating room or surgery center. In some instances, it is offered in a doctor’s office.

If you have a miscarriage during the second trimester of pregnancy (after 13 weeks), discuss the safest and best plan with your doctor. Generally, second trimester miscarriages will require a procedure and cannot be managed at home.

Red flags: When to ask for help during a miscarriage

During the first 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

  • heavy bleeding combined with dizziness, lightheadedness, or feeling faint
  • fever above 100.4° F
  • severe abdominal pain not relieved by over-the-counter pain medicine, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Please note: ibuprofen is not recommended during pregnancy, but is safe to take if a miscarriage has been diagnosed.

After 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

  • any symptoms listed above
  • leakage of fluid (possibly your water may have broken)
  • severe abdominal or back pain (similar to contractions).

How is care for miscarriages changing?

Unfortunately, political interference has had significant impact on safe, effective miscarriage care:

  • Some states have banned a procedure used to treat second trimester miscarriage. Called dilation and evacuation (D&E), this removes pregnancy tissue through the cervix without making any incisions. A D&E can be lifesaving in instances when heavy bleeding or infection is complicating a miscarriage.
  • Federal and state lawsuits, or laws banning or seeking to ban mifepristone for abortion care, directly limit access to a safe, effective drug approved for miscarriage care. This could affect miscarriage care nationwide.
  • Many laws and lawsuits that interfere with miscarriage care offer an exception to save the life of a pregnant patient. However, miscarriage complications may develop unexpectedly and worsen quickly, making it hard to ensure that people will receive prompt care in life-threatening situations.
  • States that ban or restrict abortion are less likely to have doctors trained to perform a full range of miscarriage care procedures. What’s more, clinicians in training, such as resident physicians and medical students, may never learn how to perform a potentially lifesaving procedure.

Ultimately, legislation or court rulings that ban or restrict abortion care will decrease the ability of doctors and nurses to provide the highest quality miscarriage care. We can help by asking our lawmakers not to pass laws that prevent people from being able to get reproductive health care, such as restricting medications and procedures for abortion and miscarriage care.

About the Authors

photo of Sara Neill, MD, MPH

Sara Neill, MD, MPH, Contributor

Dr. Sara Neill is a physician-researcher in the department of obstetrics & gynecology at Beth Israel Deaconess Medical Center and Harvard Medical School. She completed a fellowship in complex family planning at Brigham and Women's Hospital, and … See Full Bio View all posts by Sara Neill, MD, MPH photo of Scott Shainker, DO, MS

Scott Shainker, DO, MS, Contributor

Scott Shainker, D.O, M.S., is a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center (BIDMC). He is also a member of the faculty in the Department of Obstetrics, … See Full Bio View all posts by Scott Shainker, DO, MS

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HEALTH NATURAL WORKOUT

Fall shots: Who’s most vulnerable to RSV, COVID, and the flu?

Yellow, red, and greenish autumn leaves with a vaccine syringe and vial posed against a white background; concept is fall vaccines

The fall calendar doesn’t just warn us of impending cold temperatures: It also points toward seasonal upticks in cases of RSV (respiratory syncytial virus), COVID, and influenza. These respiratory viruses were dubbed a “tripledemic” last year. After they collided to overload health care systems across the country, hospitalizations rose in tandem for all three illnesses over the fall and winter months.

Warding off severe cases — which may lead to hospitalization or death — should be top of mind, especially for those who are most vulnerable, a Harvard expert says. And updated versions of all three vaccines are now available to help protect us.

Why do cases of flu, RSV, and COVID typically rise in fall?

“This is typically the time of year we start to see viral infections increase, which has a lot to do with kids going back to school,” says Dr. John Ross, an assistant professor of medicine at Harvard Medical School who is board-certified in infectious diseases.

“Also, we’re starting now to have weather that’s more favorable for viral transmission, particularly lower humidity. Viruses survive better in dry air. And drier air also affects our airways and makes them more vulnerable to being infected.”

Who is eligible for each shot?

Eligibility recommendations vary by age and vulnerability to serious illnesses. Additionally, some shots are designed to help protect specific groups against serious illness.

The CDC recommends these shots for the following groups.

RSV

  • Babies under 8 months and older infants at risk of severe RSV: A new shot, nirsevimab (Beyfortus), provides antibodies that protect against RSV for about five months.
  • If you’re pregnant: One vaccine (Abrysvo) is approved at 32 weeks to 36 weeks of pregnancy. Having this shot during pregnancy protects infants during the first six months of life.
  • If you’re over 60: Two vaccines (Arexvy and Abrysvo) are approved. Ask your health provider if you should consider getting one.

COVID

  • Everyone 6 months and older should consider getting one of the updated COVID boosters, which were approved and authorized for emergency use by the FDA in early September. 
  • Age 5 and older: Regardless of prior vaccination, children and adults are eligible for one dose of an updated mRNA vaccine if it’s been at least two months since their last COVID vaccine, the FDA says.

Flu

  • Everyone 6 months and older should receive a flu vaccine.
  • Different vaccines are approved for different age groups and for people with certain health issues or allergies. Most protect against four strains of flu virus (quadrivalent vaccines) expected to circulate this season.
  • Three vaccines could potentially be more effective for people over 65: Fluzone High-Dose Quadrivalent vaccine; Flublok Quadrivalent Recombinant vaccine; and Fluad Quadrivalent adjuvanted flu vaccine. If these are not available, it’s fine to get any other flu shot approved for your age and health issues or allergies.

Who is likely to benefit most?

Getting the right vaccines can help people avoid missed work or school days and running the risk of making others sick. And the protection offered by these shots is especially important for certain groups.

For all three viruses, the people most vulnerable to severe illness are similar, Dr. Ross says, including

  • adults 65 and older
  • those with compromised immune systems or underlying lung conditions such as COPD and asthma
  • those who are pregnant.

“Certainly with COVID and flu, pregnancy outcomes are worse with those infections,” Dr. Ross says. “I’m not saying that RSV isn’t a risk for pregnant mothers, but there’s not much data. The reason pregnant women are offered RSV vaccination is so the maternal antibodies they produce protect the newborns, because they’re at very high risk for RSV with very bad outcomes.”

Additionally, an even wider range of people are more prone to complications from the flu, according to the CDC. This includes

  • infants under 2
  • people with heart disease, neurologic conditions, blood disorders, endocrine disorders such as diabetes, obesity, kidney disease, liver or metabolic disorders
  • people who have had a stroke.

What else should you know about flu, COVID, and RSV shots?

Beyond broad guidance determining who’s eligible for each type of vaccine, Dr. Ross offers other useful insight that may guide your choices.

When is the best time to get a flu shot?

The CDC recommends getting a flu shot in September or October, and Dr. Ross agrees. “These are usually the months the flu vaccine becomes available and vaccine clinics are easiest to find,” he says. “My personal approach is just to get the vaccine when it’s available, so you don’t forget.”

Will the updated COVID vaccines protect against newer strains of the virus?

The latest mRNA shots by drugmakers Pfizer and Moderna are monovalent, meaning they protect against one variant — XBB.1.5, the most recent to descend from Omicron earlier in 2023. Though that strain is no longer dominant, the boosters should still guard against closely related subvariants that are now circulating, Dr. Ross says. “People can feel comfortable about their protection regardless,” he says.

What else should I know about RSV shots?

The version meant for infants, Beyfortus, isn’t a vaccine at all. It’s a monoclonal antibody product that directly delivers antibodies that protect babies for the duration of a single fall-winter RSV season. These antibodies can prevent RSV or lessen its severity.

Dr. Ross says adults over 60 considering RSV vaccination should be aware of the potential for two rare but potentially serious side effects of the nervous system: the autoimmune conditions Guillain-Barre syndrome and acute disseminated encephalomyelitis, or ADEM. Guillain-Barre can lead to bodywide paralysis, while ADEM can cause weakness and seizures. The risk of these side effects after RSV vaccination in adults is about one in 7,000 — far higher than occurs after flu vaccination, Dr. Ross notes.

“If you’re a totally healthy 60-year-old, I’m not sure it makes sense to get the RSV vaccine,” he says. “It’s a conversation you should have with your doctor.”

How should I schedule shots if I’m getting several vaccines?

Research suggests that it’s safe to get both flu and COVID vaccines at the same time. Reactions (such as muscle aches, fatigue, and headache) are slightly higher when flu vaccine and an mRNA COVID vaccine are combined, according to one study, though these reactions usually are mild and disappear quickly.

“Because RSV vaccines are newer, I don’t think we know much about combining these shots with other vaccines,” says Dr. Ross. Scheduling this vaccine separately is a good idea, although you should talk to your doctor about potential risks and benefits for your situation.

About the Author

photo of Maureen Salamon

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

About the Reviewer

photo of Howard E. LeWine, MD

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

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HEALTH NATURAL WORKOUT

7 organs or glands you may do just fine without

Colorful discs with illustrations of different body parts and organs (appendix, kidneys, eye and more)

 

There was a time when pediatricians routinely recommended tonsil removal, even for healthy children — including me. As far as I can tell, I suffered no ill effects — plus, I got extra ice cream!

That practice is no longer routine. But it does raise an interesting question: Why do we have body parts that can be safely removed? If they’re not needed, why do humans have them in the first place?

One theory is that these nonessential organs and glands once served important roles in the lives of our evolutionary ancestors but now represent anatomic remnants. For example, it was long thought that the appendix helped our predecessors digest food, but over thousands of years became obsolete. And some organs are supremely useful during certain stages of life, but then become expendable.

Seven (mostly) unnecessary body parts

Here are seven removable parts of the body:

Appendix

This organ is about the size of your little finger and hangs from the lower right side of your colon. For reasons that aren’t clear, this part of the intestinal tract sometimes becomes blocked, infected, or inflamed. Aptly enough, the word appendicitis means inflammation of the appendix. While it may settle down with antibiotic treatment, emergency surgical removal (an appendectomy) is often necessary.

Tonsils

A network of lymph nodes throughout the body is part of the immune surveillance system that helps trap dangerous invaders such as bacteria and viruses. Consider your two tonsils as larger, specialized lymph nodes watching out for these intruders. They are located at the back of the throat just to the sides of and behind the uvula, the dangling piece of tissue above them.

Now, removing the tonsils (a tonsillectomy) is only recommended for people with repeated bouts of bacterial throat infections such as strep throat, a condition common in children. Once removed, other lymphoid tissue, including the actual lymph nodes, can take over the job of the tonsils.

Adenoids

Situated in the back of the nose where the nasal passages meet the mouth and throat, adenoids are similar to tonsils. They can also become inflamed, infected, and swollen. So when the tonsils are removed, the adenoids are generally removed at the same time. The combined procedure is called tonsillectomy and adenoidectomy. As is true for the tonsils, other lymphoid tissue takes over when the adenoids are gone.

Gallbladder

The gallbladder sits just under the liver in the upper right part of the abdomen. It stores bile made in the liver and releases it into the digestive tract when needed to help digest fatty foods. The gallbladder may need to be removed (a cholecystectomy) if it becomes inflamed, a condition called cholecystitis. Most often this occurs due to infection or gallstones, which are a hardened collection of bile. In some cases, rest and antibiotics can control gallbladder inflammation so removal can be delayed or even avoided.

Uterus

This remarkable reproductive organ has a single purpose: to support fetal growth until birth. When necessary, the uterus can generally be removed (hysterectomy) without impairing health. Common reasons for removal include painful or excessive menstruation, benign growths called fibroids that cause pain or bleeding, or cancer.

Thymus gland

This small gland sits high in the upper chest behind the breastbone. In a fetus or newborn, it’s quite important in the development and maturation of the immune system. But adults can live well without it. Surgery to remove the thymus (a thymectomy) may be recommended if the thymus becomes cancerous, or if a person develops the autoimmune condition myasthenia gravis.

Spleen

Like adenoids and tonsils, the spleen is made up of lymphoid tissue. It filters the blood, removing infectious organisms, aging blood cells, and other abnormal cells traveling through the bloodstream. But sometimes the spleen becomes overactive and begins removing healthy cells.

For example, idiopathic thrombocytopenic purpura (ITP) may develop when platelets (clotting blood cells that prevent excessive bleeding) are removed from circulation. With few platelets left in the bloodstream, bruising and bleeding may be life-threatening. Although medications can help, removal of the spleen (a splenectomy) may be necessary. Or sometimes trauma to the spleen, especially after sports injuries and car accidents, causes internal bleeding, which may lead to splenectomy.

People who lack a spleen are more prone to certain infections, so if removal isn’t urgent, a number of vaccinations are recommended before splenectomy.

The bottom line

I’ve heard it said that at least half of all body parts are unnecessary. That’s a myth. But as with most myths, there is some truth to it: there are indeed many body parts that can be safely removed. That said, it’s generally best to avoid unnecessary surgery and keep the parts you were born with if you can.

Sure, you can survive and thrive despite having your appendix removed. But it’s worth keeping in mind that our understanding about so-called spare parts may change over time. The appendix is a good example: researchers have discovered that the appendix may play a role in immune development and stores “good bacteria” to repopulate the gut in case of future illness. And there is evidence that removing the thymus may slightly increase the risk of cancer, autoimmune disorders, and death.

Someday we may discover important functions for other body parts we now consider expendable. And maybe then I’ll wish I had my tonsils back.

About the Author

photo of Robert H. Shmerling, MD

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, 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

Categories
HEALTH NATURAL WORKOUT

What color is your tongue? What’s healthy, what’s not?

A woman with brown hair, brown eyes, and a blue shirt is reflected in a mirrow as she sticks out her tongue

If the eyes are the windows to the soul, then consider the tongue a sort of check-engine light for the body. The tongue’s appearance gives doctors an idea about certain aspects of your health, and its color is an important clue.

What should your tongue look like?

The tongue should have a rounded, symmetrical shape. It’s generally light pink, though it may have a little purple or brown pigmentation in African, Asian, and Mediterranean populations. It can also have a hint of white coating.

“The coating comes from a tough protein called keratin, which helps keep your tongue from being scratched when you eat,” says Dr. Tien Jiang, a prosthodontist in the Department of Oral Health Policy and Epidemiology at the Harvard School of Dental Medicine.

Up close, you might be able to see that your tongue is covered in tiny bumps (papillae) that serve several purposes:

  • They sense temperature and touch.
  • They contain taste buds that enable you to detect if food is sweet, salty, sour, bitter, or savory.
  • They create friction to help you form a little ball of food (bolus) that you can swallow.

Can diet affect tongue color?

Yes. Sometimes diet may be partly to blame for a shift away from your usual tongue tone. That’s because the papillae can absorb the colors and residues of foods and drinks you consume. For example, that blue popsicle or candy you ate as a kid probably turned your tongue an exciting shade of azure. Coffee, tea, and many types of foods, such as curried dishes with lots of yellow turmeric, can also leave their marks.

Discoloration is usually just temporary, however. Drinking plenty of water and maintaining good oral hygiene will wash away food and dyes that cling to the tongue.

A dark or bright tongue, white patches, and other causes for concern

Some tongue colors and appearances are signs of health issues. Check with your doctor if you notice any of the following:

  • A brown or black tongue signals a condition called “black hairy tongue.” This occurs when papillae get too long. These tiny bumps don’t usually get much chance to grow because they are shed regularly with all the activity in your mouth. If they do grow, they can trap bacteria and a mix of food colors, leading to the brown or black tinge. Risk factors include taking antibiotics or antihistamines, smoking, dry mouth, drinking excessive amounts of coffee or black tea, or poor oral hygiene.
  • Thick white patches or white sores on the tongue probably mean you have an overgrowth of yeast in the mouth (thrush). Thrush can be triggered by conditions such as diabetes or HIV, side effects of antibiotics or cancer treatment, wearing dentures, smoking, dry mouth, or using steroid inhalers. In rare cases, white patches or sores are symptoms of oral cancer.
  • If your tongue has painful red or yellow sores, you might be dealing with canker sores (irritated tissues), thrush (which can sometimes appear as red patches), or (in rare cases) oral cancer.
  • A bright red tongue can indicate that you have a vitamin B12 deficiency or an infection called scarlet fever — a Streptococcus bacteria infection in the throat (strep throat) accompanied by a red body rash. If you have bright red patches that don’t hurt and seem to migrate from one place on the tongue to another, you might have a harmless, incurable condition called “geographic tongue.”

Should you brush your tongue or use a tongue scraper?

Good oral hygiene requires that you floss your teeth at least once a day and brush them at least twice a day. Take a few seconds to use the brush on your tongue.

“Stick out your tongue and swipe your toothbrush from the back of your tongue to the front: one swipe down the middle, one swipe down the left side, and one swipe down the right side. That helps remove bacteria and debris that collect in papillae,” Dr. Jiang says.

Some people swear by using a tongue scraper to clean the tongue. Dr. Jiang isn’t a fan, but doesn’t have a problem with someone using the tool, which is pulled forward on the tongue in a similar fashion to brushing the tongue. “The data about tongue scraper effectiveness are mixed,” she says. “It just comes down to what you’re willing to do daily to keep your tongue, teeth, mouth, and gums as healthy as possible.”

Worried about your tongue? What to do

If you’re worried about anything wrong with your tongue — especially if you also have a fever, a very sore throat, sores that won’t go away, or other new symptoms — call your primary care doctor or dentist.

Your doctor or dentist can

  • assess your condition
  • prescribe or suggest treatments to relieve discomfort, such as medicated mouthwashes or warm-water rinses
  • urge you to stay hydrated and step up your oral hygiene.

If necessary, your doctor can refer you to a specialist for further evaluation.

About the Author

photo of Heidi Godman

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

About the Reviewer

photo of Howard E. LeWine, MD

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD