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Thinking about COVID booster shots? Here’s what to know

Vaccination against the virus that causes COVID-19 is the most important lifesaving tool we have in this pandemic. Fortunately, the vaccines authorized in the US have proven remarkably safe and effective. And we’ve known from the start that the strong protection they provide would likely wane over time.

But has protection declined enough to warrant booster shots? Studies published in the last few months by researchers in the UK, Israel, and the US (reviewed here and here) raised this possibility, and Israel and the UK have already started ambitious booster programs.

First things first: Vaccinate everyone

In the US, the CDC and FDA have reviewed the necessity, safety, and effectiveness of boosters for the Pfizer/BioNTech, Moderna, and Johnson & Johnson vaccines. I’ll discuss these recommendations in a moment.

But first, it’s important not to overlook this fact: vaccinating the unvaccinated should be a much bigger priority than giving booster shots to those who’ve received vaccines. That goes for people in the US who have been unable or unwilling to get the vaccine, and people in places throughout the world with limited access to vaccines.

Broadening the pool of people with initial vaccinations would not only save more lives than promoting boosters, but would also reduce COVID-related healthcare disparities between richer and poorer countries. That’s why the World Health Organization (WHO) called for a moratorium on booster doses. Meanwhile, the Biden administration has announced a promise to donate another half billion vaccines to countries with low vaccination rates, bringing the total US commitment to donate 1.1 billion doses. The administration emphasizes that starting a booster program in the US and helping other countries get their citizens vaccinated are not mutually exclusive.

Is there a difference between a booster dose and a third shot?

It’s not trick wording: not all extra vaccine doses are boosters. In August 2021, the FDA approved a third dose of the Pfizer or Moderna vaccine for people who are immunocompromised. This includes people who have HIV and those receiving treatment for cancer that suppresses the immune system. For them, the extra dose is not a booster; it’s considered part of their initial immunization series.

Getting the timing and dose right on vaccine boosters

Ideally, vaccine boosters are given no sooner than necessary, but well before widespread protective immunity declines. The risks of waiting too long are obvious: as immunity wanes, the rates of infection, serious illness, and death may begin to rise.

But there are downsides to providing boosters too early:

  • Side effects might be more common. While studies published to date suggest that boosters are safe, we don’t yet have long-term data.
  • The benefit may be small. It may be better to wait on boosters if most people are still well-protected by their initial vaccinations.
  • Current boosters may not cover future variants. If new variants of concern emerge in the coming months, boosters may be modified to cover them.
  • Waiting longer before a booster might lead to a stronger immune response. As noted by Dr. Anthony Fauci recently: “If you allow the immune response to mature over a period of a few months, you get much more of a bang out of the shot.”

The recommended dose for the Pfizer/BioNTech booster and Johnson & Johnson booster is the same as the initial dose. For the Moderna booster it’s a half-dose, which may reduce the risk of side effects and increase the number of doses available to others.

Recommendations for vaccine boosters

For the Pfizer/BioNTech and Moderna vaccines, a booster is recommended at least six months after the second dose for those who are

  • 65 or older
  • 18 to 64 and at high risk for severe illness from COVID, such as people with chronic lung disease, cancer, or diabetes
  • living or working in a high-exposure setting, such as residents of long-term care facilities, healthcare workers, teachers and day care staff, grocery workers, and prisoners.

No Pfizer/BioNTech and Moderna boosters are recommended for the general population yet. That’s because the initial doses still appear to be providing good protection against severe illness and death for those at lower risk of severe COVID-related illness.

For the Johnson & Johnson vaccine, a booster is recommended for everyone 18 or older two or more months after the first dose. 

Mixing or matching booster shots

The FDA and the CDC have concluded that mixing or matching vaccines when getting a booster dose is safe and effective. Regardless of the initial vaccine you received, any of the three available vaccines may be given as a booster.

Plenty of unknowns

The release of these new recommendations for vaccine boosters raises a number of questions:

  • How convincing is the safety data? Reports to date suggest boosters are safe, but we need more research and real-world data.
  • Will the boosters be modified to protect against emerging variants of concern?
  • Will additional boosters be needed in the future? If so, how often?

There are important gaps in our knowledge of how well vaccine boosters work. We need larger and longer-term studies involving a broad range of participants representing all races and ethnicities and people with compromised immune systems. Look for further information in coming months.

What’s next?

You can expect the FDA and CDC to expand booster recommendations based on continued review and analysis of ongoing research. In the meantime, we should redouble our efforts to vaccinate people who haven’t yet received vaccines. Boosters can play an important role in protecting individuals. But, as CDC director Dr. Rochelle Wallensky notes, “we will not boost our way out of this pandemic.”

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Preventing preeclampsia may be as simple as taking an aspirin

Preeclampsia is a common and dangerous complication of pregnancy that causes high blood pressure and excess protein in urine. Typically, it occurs during the third trimester or very soon after birth, but there may be a simple way to help prevent it.

If you’re pregnant, preeclampsia can cause kidney and liver abnormalities, blood clotting problems, headache, stroke, and even death. It makes it harder to deliver nutrients and oxygen to a growing fetus. And it’s linked to premature birth and low birthweight in babies. Yet a daily low-dose aspirin may help prevent many of these problems, according to a recent statement from the US Preventive Services Task Force (USPSTF).

Who is most likely to develop preeclampsia?

While preeclampsia can happen without any warning, certain risk factors make it more likely to occur:

  • carrying multiples, such as twins or triplets
  • having diabetes
  • being 35 or older
  • having obesity, described as a body mass index (BMI) greater than 30
  • having high blood pressure before pregnancy
  • having kidney disease or an autoimmune disorder.

Preeclampsia also occurs more often in Black people as a result of structural racism, which restricts access to care, and can also be a source of chronic stress from factors like food and housing insecurity that lead to poorer health and well-being.

Overall, preeclampsia affects about one in 25 pregnancies in the United States. It accounts for almost one out of every five medically-induced premature births. Preventing it will save lives.

What does the task force recommend to help prevent preeclampsia?

In the 2021 statement, the USPSTF recommends that doctors prescribe a daily low-dose (81 mg) aspirin for those at high risk for preeclampsia. The aspirin should be started at the end of the first trimester (12 weeks of pregnancy) and continued until the birth.

This supports a previous recommendation from the task force in 2014. And importantly, the statement reflects findings from a recent systematic review of research. The review looked at the role of aspirin in preventing preeclampsia, and whether aspirin can reduce complications among pregnant people, fetuses, and newborns. It also examined the safety of low-dose aspirin in pregnancy.

What did the review tell us?

Thirty-four randomized clinical trials comparing low-dose aspirin and placebo (a sugar pill) were included in the analysis. Most participants in the trials were young and white. Providing low-dose aspirin to those who were at high risk of preeclampsia successfully reduced risk for

  • developing preeclampsia
  • preterm birth (births before 37 weeks of pregnancy)
  • growth restriction (small babies)
  • fetal and newborn death due to preeclampsia.

The review considered whether using aspirin led to more bleeding problems. When comparing the aspirin group and the placebo group, no differences occurred in bleeding problems, such as maternal hemorrhage following a birth, fetal brain bleeding, and the placenta separating from the wall of the uterus too early.

Who should take low-dose aspirin during pregnancy?

Overall, the benefits of taking low-dose aspirin outweigh risks for some pregnant people. Your doctor may recommend it if you

  • have had preeclampsia before
  • already have high blood pressure or diabete
  • are carrying multiples, such as twins or triplets
  • have kidney or autoimmune disease.

It’s important to know that there are moderate risk factors to consider, too. When combined, they can increase the chance of preeclampsia and its complications. Your doctor may recommend low-dose aspirin if you have two or more of these factors:

  • having your first baby
  • having obesity
  • having a mother or sister who had preeclampsia
  • being 35 years old or older
  • having conceived with in-vitro fertilization (IVF)
  • having had a baby before who was small for gestational age
  • having a difficult pregnancy outcome in the past.

Unequal distribution of healthcare, and social and environmental stress, make preeclampsia and its complications more likely to occur in pregnant people who are Black and those who have lower income. Therefore, the task force recommends low-dose aspirin for these pregnant individuals even if they have only one moderate risk factor.

The bottom line

New evidence supports using low-dose aspirin to help prevent preeclampsia, a dangerous and common complication of pregnancy. If you’re pregnant or considering pregnancy, talk with your doctor or midwife about preeclampsia. It’s important to learn the warning signs of possible problems even if you’re not at high risk. Together, you can decide whether low-dose aspirin is a good choice for you.

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What happened to trusting medical experts?

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In all aspects of our lives, we rely on experts, from home repairs to weather forecasting to food safety, and just about everything else that’s part of modern society. There’s just no way to know everything about everything. Yet when it comes to medicine, people seem to be taking their health in their hands in ways they’d never consider if, say, their car brakes needed repairs and they weren’t auto mechanics.

What if your brakes were shot?

Suppose a well-recommended car mechanic tells you your brakes need repair. Hopefully, they explain why this is necessary and review the pros and cons of your options, including no repairs. You certainly could get additional opinions and estimates. But to make a decision, you’d have to accept that a mechanic has specialized knowledge and that their advice is sound. Quite likely, you’d get the brakes fixed rather than risk injury.

Would you berate the mechanic personally because they told you something you didn’t want to hear about your beloved car? Let's hope not. And unless you knew a lot about cars, you probably wouldn’t tinker with the brakes yourself, or take the advice of a neighbor to spray the tires with vegetable oil because a friend of his cousin said it worked for his car. And you wouldn’t take your car to a veterinarian — it just wouldn’t make sense, right?

Yet hundreds of thousands of people in the US are rejecting advice on getting a COVID vaccine from well-respected health authorities like the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA). Healthcare providers have somehow become the target of taunts, hostility, and even death threats for encouraging people to protect themselves and others.

Fear of the proven and an embrace of the unproven

What’s driving this? It seems to be some combination of distrust ("these so-called experts don’t know what they’re talking about"; "they rushed the vaccines just to help the drug companies") and unfounded suspicion ("they’re trying to control us, experiment on us, inject microchips in us"). Some people see recommendations regarding COVID-19 as attacks on American values ("mask and vaccine mandates infringe on my personal freedom").

At the same time, many who dismiss the advice of true experts are embracing unproven and potentially dangerous remedies, such as ivermectin pills and betadine gargles.

How did we get here?

Some reasons we’ve seen erosion in trust placed in public health experts are

  • Politics. COVID-19 quickly became a political issue in the US. For example, trust in the CDC varies markedly by political affiliation, with Democrats giving much higher marks to the CDC, FDA, and NIH than Republicans.
  • Social media. Misinformation spread through social media is rampant, and much of it has been linked to a small number of people.
  • "Pseudo-experts." Even impressive credentials don’t automatically qualify everyone to be experts in a pandemic disease. Recent examples include radiologists, cardiologists, and chiropractors who have made headlines with their controversial views.
  • Personal gain. Some have profited financially, politically, or otherwise by deliberately spreading health disinformation and denouncing expert advice.

Confusing changes in message

Public health messaging about protecting ourselves from COVID-19 also affects trust. For example, recommendations around wearing masks were inconsistent early on, and have continued to change since then.

While some confusing, seemingly contradictory messages were true missteps, most are simply changes in recommendations based on a change in circumstances, such as spiking virus cases or a more easily spread variant causing severe illness, hospitalizations, and deaths.

Particularly in the early months, no one had all the answers. But as we have accumulated information from research and real-world experience, changes in recommendations should not only be expected but embraced. It’s usually a reflection of the close attention experts are paying to changing circumstances.

Doing your own research?

A wait-and-see policy can be risky — and not just when it comes to fixing your car brakes. The virus that causes COVID-19 was only discovered 18 months ago, and vaccines have been in use for less than a year. Yet already we have an enormous amount of data from research and real-world experience from many millions of people.

So, when someone says they want to "wait and see" or "do their own research" rather than accept the advice of their own doctors or public health experts, what exactly does that mean? Are they waiting to see if something bad will happen to those who were vaccinated? How long is long enough?

Unless you’re a cutting-edge virologist, immunologist, epidemiologist, or public health expert, doing your own research isn’t likely to provide more reliable data than studies published in peer-reviewed medical journals that guide the CDC and FDA. Of course, most people "doing their own research" are relying on others who are also not doing actual research, yet they discount the findings and recommendations of true experts.

It’s important to ask questions. But pose them to your doctor. Rely less on people who tell you what you want to hear, and more on those who trained in science and whose careers have been devoted to improving health.

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Caring for an aging parent? Tips for enjoying holiday meals

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The holidays are supposed to be a time of joy and celebration, and the meal is a centerpiece of the occasion. But when you’re a caregiver for an aging parent, the joy can be overshadowed by stress.

Whether you’re observing winter holidays — such as Hanukkah, Christmas, Kwanzaa, or New Year’s Eve — or holidays that fall during another time of year, take steps in advance to ensure that you and your loved one can enjoy the meal together with as little stress as possible. These tips can help.

Consider the dining schedule

Your mom or dad might normally eat at a different time than the planned holiday meal. If the meal times don’t match, give your parent a nutritious snack to stave off hunger, or find out if it’s possible to serve the holiday meal at a time that’s good for your parent. If other festivities are on the docket, consider that timing as well. Your parent likely has a limited amount of energy to spend visiting with others, so allow plenty of time to eat.

Serve your parent easy-to-eat food

Holiday meals often feature special-occasion foods that may be overly rich or hard for your parent to cut, chew, swallow, or keep on a fork or spoon. Talk about this beforehand, if that’s possible. Know which foods your parent should avoid, such as nuts. Serve safer choices in small amounts, and help by cutting up hard-to-eat foods before they come to the table or arrive on a plate.

Another option is serving something simple for your parent to eat that won’t need much supervision and won’t make a mess. Rice or fine pasta with vegetables, pureed beef or fish stew (no bones!), or mashed root vegetables and beans are some examples. If you’re not hosting the holiday event, ask if it’s okay to bring a meal that’s right for your parent.

Remember medicines

If your parent normally takes prescribed drugs at meals, don’t let this holiday be a time to get off schedule. Go over the medication list in advance and set a timer on your phone to remind you of dosing times.

Work in shifts with other guests

Have a conversation ahead of time with other guests who can help. When assisting a parent during a meal, you may not get much of a chance to eat your own food or chat with people at the table. Build in a break by arranging for another guest (perhaps a sibling) to take a turn helping out.

Plan the bathroom break

When you have to go, you have to go. And aging parents, like young children, sometimes need to excuse themselves mid-bite. A bathroom trip before the meal might reduce that risk, but it’s no guarantee. Work out in advance who’s going to assist your parent if nature’s call arrives during the meal.

Keep fluids handy

Make sure your parent is staying hydrated and getting enough fluids before, during, and after the meal. Also, keep an extra glass of water handy, and a straw if necessary, in case your parent is having a hard time swallowing food. Note also that moistened food is easier to swallow, so consider adding a little extra sauce to a parent’s meal.

Watch alcohol intake

While alcohol may be offered at the holiday meal, it doesn’t mean it will be safe for your parent. Alcohol consumption can lead to falls in older adults, and can interfere with medications. Ask your parent’s doctor if a little libation is allowed. such as a half-glass of wine. If not, consider offering your parent non-alcoholic beer, wine, or champagne if they’d like it. And mind your own alcohol intake: while you’re acting as a caregiver you’ll need to stay in control.

Arrange your parent’s exit well in advance

Gatherings can be tiring and stressful for older adults, and your parent might be ready to leave before the holiday meal officially concludes, especially if guests linger. Decide on a realistic exit time and let other guests know about it in advance, so everyone can plan accordingly.

If all goes well, you and your parent will both enjoy the holiday meal and wind up feeling the glow of meaningful family connection, sharing, and love — all of which are great for health.

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Skills children need to succeed in life — and getting youngsters started

All parents want their children to be successful in life — and by successful, we mean not just having a good job and a good income, but also being happy. And all parents wonder how they can make that happen.

According to Harvard’s Center on the Developing Child, it’s less about grades and extracurricular activities, and more about a core set of skills that help children navigate life’s challenges as they grow. These skills all fall under what we call executive function skills that we use for self-regulation. Developing strong executive function skills, and finding ways to strengthen those skills, can help people feel successful and happy in life.

What are five important core skills?

  • Planning: being able to make and carry out concrete goals and plans
  • Focus: the ability to concentrate on what’s important at a given time
  • Self-control: controlling how we respond to not just our emotions but stressful situations
  • Awareness: not just noticing the people and situations around us, but also understanding how we fit in
  • Flexibility: the ability to adapt to changing situations.

While these are skills that children (and adults) can and do learn throughout their lifetimes, there are two time periods that are particularly important: early childhood (ages 3 to 5) and adolescence/early adulthood (ages 13 to 26). During these windows of opportunity, learning and using these skills can help set children up for success. In this post, we’ll talk about that first window of early childhood.

The best way to learn any skill is by practicing — and we are all more likely to want to practice something if it is fun and we feel motivated. Here are some ways that parents can help their children learn and strengthen executive function skills.

Planning

It’s natural for parents and caregivers to do the planning for young children, but there are absolutely ways to get them involved, such as:

  • Planning the day’s activities with them, whether it be a school day or a play day. Talk about all the day’s tasks, including meals, dressing, bathing, and other things; help them see it as part of a whole, and something that they can help manage.
  • Cook or bake something together. Put together the shopping list, go shopping, go over the recipe together, and help them understand all the steps.
  • When getting ready for a holiday or a party, include them in thinking about what everyone would like to do and how to do it.

Focus

The explosion of device use has definitely caused all sorts of problems with focus in both children and adults. There is an instant gratification to screens that makes it hard to put them aside and focus on less stimulating tasks. Now, more than ever, it’s important to:

  • Enforce screen-free time, even if they complain (parents need to abide by this too).
  • Have the materials on hand to make or build things. Find projects that will take an hour or two. Do it with them!
  • Read print books out loud together, including chapter books. Having to picture things themselves rather than seeing it on a screen helps children learn to focus.

Self-control

This is one where being mindful of your own reactions to situations is important. How do you react to anger and frustration? Is road rage a problem for you? Remember that children always pay more attention to what we do than what we say. To help your child learn self-control, you can:

  • Talk about feelings, and about strategies for managing strong emotions — like taking a deep breath, stepping away from the situation, screaming into a pillow, etc.
  • Help them understand how their behavior affects others, and why it’s important to be mindful of that (which also teaches awareness).
  • Debrief after tantrums or upsets. What could everyone have done differently?

Awareness

This one can be fun to teach.

  • Go for walks. Visit places together. Listen and watch. Imagine together what people might be doing or thinking.
  • Join community service activities; show children that anyone can make a difference.
  • Have rituals of checking in as a family, like at dinner. Give people a chance to talk about the best and worst parts of their day, and talk about ways you can work better as a family and treat each other well.

Flexibility

We tend to cater to our children and their needs, making our schedules and plans around them. Some of that is pure parenting survival. But ultimately, it’s not always helpful; life has a way of messing up even the most careful plans. Kids need structure, sure, but they also need to be able to adjust to the inevitable curve balls.

  • Don’t always say no to something that might happen during a naptime or mealtime. It’s okay if schedules occasionally vary.
  • Be spontaneous when you can. Go for an unplanned outing, and otherwise make last-minute plans sometimes.
  • When plans change or fall through, be upbeat about it and make the most of it. Be a role model.

In helping your children learn these skills, you might just learn something about yourself — and learn some new skills too.

Follow me on Twitter @drClaire

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Careful! Health news headlines can be deceiving

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Ever read a headline that catches your eye but then found the story itself disappointing? Or worse, did you feel that the dramatic headline was utterly misleading? Yeah, me too.

The impact of a well-crafted headline can be big. We often skim the headlines, then decide whether or not to read on.

Previously, I’ve written about how media coverage of drug research can mislead or confuse. Here I’m zooming in on health headlines, which can be equally deceptive. Watch for these pitfalls.

Overstated study findings

  • Were humans studied? If a study finds that a drug is safe and effective for an important disease, that’s big news. But what if all of the study subjects were mice? Leaving out this important detail from the headline exaggerates the study’s importance.
  • Too much drama. Dramatic terms such as “breakthrough” or “groundbreaking” are common in headlines about medical research. Yet true breakthroughs are quite rare. That’s the nature of science: knowledge tends to accumulate slowly, with each finding building a bit on what came before.
  • Going too far. Headlines often make a leap of faith when summarizing a study’s findings. For example, if researchers identify a new type of cell in the blood that increases when a disease is worsening, they may speculate that treatments to reduce those cells might control the disease. “Researchers discover new approach to treatment!” blares the headline. Sure, that could happen someday (see below), but it’s an overstatement when the study wasn’t even assessing treatment.
  • Overlooking the most important outcome. Rather than examining how a treatment affects heart disease, let’s say, studies may assess how it affects a risk factor for it. A good example is cholesterol. It’s great if a drug lowers cholesterol, but much better if it lowers the rate of cardiovascular disease and deaths. Headlines rarely capture the important difference between a “proxy measure” (such as a risk factor) and the most important outcome (such as rates of death).

Faulty logic

  • A link for illness is not the same as a cause of illness. The distinction between “causation” and an “association” is important. Observational studies can determine whether there is a link (association) between two health issues, such as a link between a symptom (like a headache) and a disease (like stomach ulcers). But that doesn’t mean one actually caused the other. Imagine an observational study that compared thousands of headache sufferers with thousands of people who rarely had headaches. If more people in the frequent headache group also had more stomach ulcers, the headline might boldly declare “Headaches cause ulcers!” A more likely explanation is that people with a lot of headaches are taking aspirin, ibuprofen, and related drugs, which are known causes of ulcers.

Hazy on key details

  • Someday isn’t today. Studies of new drugs or devices may be heralded as life-changing for people or practice-changing for doctors. Yet, a closer look often reveals that the new treatment is years away from reaching the market — or it may never get approved at all.
  • A work in progress. “Preliminary” is the missing word in many headlines. Studies presented at medical conferences but not yet published in a peer-reviewed medical journal offer preliminary insights. This research, while promising at the time, may ultimately be a scientific dead end.
  • Is it a study, a press release, or an ad? It’s hard to tell with some headlines. Press releases or advertisements typically present a positive spin on new findings or treatments. We expect news stories to be more balanced.

One story, many headlines

Here’s a great example of overhyped headlines. A 2021 study presented findings about a pacemaker that treats abnormal heart rhythms for a period of time and then dissolves. Amazing, right? For people who need a pacemaker only temporarily, a dissolving pacemaker could allow them to avoid a surgical procedure to remove it once it was no longer needed.

Three headlines covering this research spun the story this way:

Coming Soon: An Implanted Pacemaker That Dissolves Away After Use

Could people one day get pacemakers that dissolve into the body?

First-ever transient pacemaker harmlessly dissolves in body

But that dissolving pacemaker had never been tried in living humans — an important fact! To test the dissolving pacemaker, the researchers had performed open-heart surgery in rats and dogs, and lab experiments on heart tissue removed from mice, rabbits, and deceased humans.

The first headline demonstrates the pitfall of overpromising on the findings of preliminary research: yes, a dissolving pacemaker might someday be routine in humans, but it’s unlikely to be “coming soon.” And when a headline says “harmlessly dissolves in body,” we might reasonably think this refers to a livinghuman body. Not so.

The bottom line

Why are we constantly bombarded with misleading headlines? A major reason is that headlines attract attention, clicks, reads, subscriptions, and influence essential to media sites. Some writers and editors lean into hype, knowing it attracts more attention. Others may not be trained to read or present medical news carefully enough.

In a world full of misleading health news headlines, here’s my advice: be skeptical. Consider the source and read past the headline before buying in. And if your go-to media often serves up misleading headlines, consider changing channels or crossing that news source off your list.

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Do I have to yell so much?

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You’ve been trying to get your point across, but it’s not getting through. It’s getting you frustrated, maybe a little offended, so you go for a different approach.

You yell.

Now, concert-level volume has its place, like for saying, “There’s a bear behind you” or “Power line down.” But the big question is, how often do those situations come up? The answer is, rarely.

Next question: How often do you reach that intensity? “Too often” is that answer. You know that it doesn’t work. It never feels good. It never makes the situation better. You would just like to stop doing it.

It’s good to have that desire, but you need more to make it happen. What helps is to play detective to uncover your triggers, then set reasonable expectations, because underlying the yelling is stress, something that isn’t disappearing. The question, as Dr. Antonia Chronopoulos, clinical psychologist at Massachusetts General Hospital, asks, is “How do you regulate yourself in a tense situation?”

Start with the basics

Before you can stop, it helps to understand why we yell in the first place.

We could be in a debate and feel like we’re not being heard. We take it as an insult, get frustrated, and the brain’s limbic system sees it as a threat and sets off the fight-or-flight response.

Our blood pressure rises, breathing becomes shallow, and muscles tense up. Since our history factors in, we can start making assumptions. Adrenaline makes everything go faster, and our attention narrows. “When we’re in survival mode, we’re not thinking about creative solutions as effectively,” she says. “The prime directive is to defend, escape, or fight.”

It’s also not a solo act. We’re yelling at someone, and our attempt to control the situation triggers that person, setting off the aforementioned emotional and physiological reactions, and possibly creating a shoutfest (which is anything but festive).

And there’s one more part, which gets overlooked: the flight element. If we decide to not yell and end up holding anger in, the same process is still taking place: the tense muscles, shallow breathing, narrow focus. We might not be making a lot of noise, but we’re far from calm or looking to improve the situation. “It’s almost like a freeze response,” Chronopoulos says.

The goal is to find the middle ground: not fighting, not flighting, and where you can be more in tune with the other person.

How you get there

It’s not impossible to calm down while yelling. You can find a way to break the dynamic with deep breathing, pausing the conversation, and/or walking away from the trigger, but it is difficult. The best course is to practice strategies before you need to call upon them, because fear is a primitive emotion, and once we’re in it, the body becomes hijacked. “You can’t just relax in a heated moment,” she says.

It starts with awareness

Log your behavior over one week, noting what prompted the yelling and rating your anger from zero to 10. Think about everything involved: the people, topics, location, and whether you had eaten or slept well, because self-care affects your ability to handle stress.

When you give your anger a number, it becomes more objective. You can feel the difference between a 1, 4, and 8, and are more able to control something in the early stages. And when you write down your observations, you can see patterns and start thinking about how to prevent trouble spots. It might be carrying food, avoiding certain people, or scheduling a potentially tough interaction for when you’re at your best.

Deep breathing can help

There’s no magic count. People have their own approaches. Chronopoulos suggests to just notice your breathing, or even walk away and count to 10. The result is similar. Your mind is off the stress and onto something practical and concrete. One more exercise is to progressively relax your muscles when you’re calm. You’ll then be better able to distinguish between when your body is at ease and when it’s tense. Chronopoulos calls it “discrimination training.” With this knowledge, you can remind yourself to do something as simple as lower your shoulders or unclench your hands.

Imagery is another tool

Preview your day and play out how you’ll handle the sticky moments. When the real thing happens, it won’t be the first time you’re experiencing it.

In the actual situation, use assertive dialogue over yelling or silently seething. It’s about keeping things in the first person, naming the problem, and avoiding calling out the other person. Clearly say, “When you say X, it really upsets me,” then shift into asking, “What can we do to make this work?” It goes from competition to negotiation. “Our voice can become the tool to resolve the conflict,” she says.

You can aspire to never yelling, but it may still happen

And finally, realize that none of the above is foolproof. You can’t predict every situation or be constantly mindful. You can also have different reactions to the same situation, because each day is different. “We’re never in a static state of mind,” Chronopoulos says. “But by taking these measures, we’re putting ourselves into a position for having more control of our emotions and being able to respond in a way that’s more effective.”

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Gastroparesis: A slow-emptying stomach can cause nausea and vomiting

If you have a daily commute, a backup of traffic or road work may delay you, but you’ll eventually reach your destination. Gastroparesis, a digestive condition, can be imagined as a slowed commute through the stomach. But the delay involved can cause uncomfortable symptoms, and may have other health consequences that can affect nutrition and your quality of life. Although gastroparesis affects millions of people worldwide, many people are much more familiar with other gut problems, such as acid reflux and gallstones, that can cause similar symptoms.

What is gastroparesis?

Gastroparesis is a condition that causes delay in the emptying of the stomach. When you swallow food, it travels through your mouth and into a long tube called the esophagus before entering your stomach. Your stomach serves two separate functions: The first is to relax to accommodate food and liquid until you feel full. The second is to churn the food and liquid into a slurry that then passes into your small intestine to be digested. When either function is disturbed, slower-than-normal emptying occurs.

What are the symptoms of gastroparesis?

Nausea and vomiting are two of the most common symptoms of gastroparesis, most likely stemming from the sluggish emptying of the stomach. Typically, these symptoms occur toward the end of meals or soon after meals are finished. A third common symptom is abdominal pain caused by a combination of motor nerve and sensory nerve dysfunction. When motor nerves aren’t working properly, food and liquid can be detained in the stomach. When sensory nerves aren’t working well, signals between the gut and the brain are not communicated effectively, which can cause pain, nausea, and vomiting.

A growing body of evidence suggests that gastroparesis overlaps with a disorder of gut-brain interaction called functional dyspepsia, which is recurring indigestion that has no apparent cause. Other health problems can cause similar symptoms as gastroparesis, such as gastric outlet obstruction and cyclic vomiting syndrome, or even conditions beyond the gut, such as glandular disorders. So it’s important to discuss any symptoms that are bothering you with your doctor to get the correct diagnosis.

Who is more likely to experience gastroparesis?

Many misconceptions exist about the typical person with gastroparesis. For example, it’s not true that people must have diabetes to have gastroparesis: only 25% of people with gastroparesis have diabetes. Most commonly, no clear cause for gastroparesis can be found among people who have the condition.

Additionally, people are more likely to experience gastroparesis if they

  • take certain medicines, such as opiate pain medications and some medications for diabetes
  • have had surgeries, radiation, or connective tissue disorders that affect the function of the nerves of the gut
  • are female, because women are several times more likely than men to have gastroparesis.

Thus far, there is limited information on health disparities among people with gastroparesis, although one study shows that diabetes is more likely to be the cause of gastroparesis among Black and Hispanic patients than white patients. It’s not yet clear why, although socioeconomic inequities that affect health outcomes may be a factor (as is true for many other conditions).

How is it diagnosed?

Diagnosing gastroparesis and deciding on the best treatment strategy requires a careful patient history, blood tests, imaging tests, and sometimes endoscopy. Usually, people first discuss their symptoms with a primary care doctor who can rule out some possible causes and refer them to a specialist to discuss next steps, such as imaging or endoscopy, if necessary.

A common imaging test used in the US is called a gastric emptying scan, which takes four to five hours. The person having the test eats a standardized meal, such as an egg sandwich, that contains safe levels of medical-grade radiation. At certain intervals, images are taken to see how much of the meal remains in the stomach. During normal digestion, about 90% of the stomach is emptied within four hours and 10% is left behind; more than this amount remaining meets a key criterion for gastroparesis.

It’s worth noting that the exact amount of stomach emptying in four hours may fluctuate and may be influenced by other health factors, such as uncontrolled blood sugar, or certain medications, particularly opiate pain medicines.

How is gastroparesis treated?

The main goal of treatment is to address the symptom that bothers you the most. Depending on your diagnosis and symptoms, treatment might involve one or more of the following:

  • Medications. Erythromycin and metoclopramide speed up emptying the stomach. A newer medicine called prucalopride may have the same effect. Other medications, particularly for people who are finding pain and nausea more problematic, target disordered gut-brain interaction using neuromodulators, such as older forms of antidepressants and neuropathy medications. These medicines may improve sensation of the gastrointestinal tract.
  • Procedures and surgeries. A gastroenterologist may suggest different endoscopy techniques that improve stomach emptying by disrupting a valve between the stomach and the small intestine called the pylorus. One approach, called a per-oral pyloroplasty, does not require surgery. A surgical approach called laparoscopic pyloroplasty reshapes the muscle of the valve between the stomach and small intestine to help the stomach empty more quickly. Less often, surgically implanting a gastric stimulator to help improve the signaling between gut and brain may be considered.

If you have gastroparesis, be sure to discuss all these treatment options to see which one is best for you.

Follow me on Twitter @Chris_Velez_MD

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Why is topical vitamin C important for skin health?

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Topical vitamin C is a science-backed, dermatologist-favorite ingredient that may help slow early skin aging, prevent sun damage, and improve the appearance of wrinkles, dark spots, and acne. Vitamin C is an antioxidant, meaning it fights harmful free radicals (toxins) that come in contact with your skin from external sources like air pollution, or from inside the body as a result of normal processes like your metabolism. Free radicals can damage the skin, and applying topical vitamin C can combat free radicals and may improve the skin’s overall appearance.

Skin benefits of vitamin C

A few clinical studies have demonstrated that vitamin C can improve wrinkles. One study showed that daily use of a vitamin C formulation for at least three months improved the appearance of fine and coarse wrinkles of the face and neck, as well as improved overall skin texture and appearance.

Vitamin C may also help protect the skin from harmful ultraviolet rays when used in combination with a broad-spectrum sunscreen. Clinical studies have shown that combining vitamin C with other topical ingredients, namely ferulic acid and vitamin E, can diminish redness and help protect the skin from long-term damage caused by harmful sun rays.

Further, vitamin C can reduce the appearance of dark spots by blocking the production of pigment in our skin. In clinical trials, the majority of the participants applying topical vitamin C had improvement in their dark spots with very little irritation or side effects, but more studies are needed to confirm the brightening effects of vitamin C.

Additionally, topical vitamin C can help with acne through its anti-inflammatory properties that help control sebum (oil) production within the skin. In clinical trials, twice-daily application of vitamin C reduced acne lesions when compared to placebo. While no serious side effects were reported with vitamin C use in any of these studies, it is important to note that there are only a handful of clinical trials that have studied the effects for vitamin C, and more studies are needed to confirm the findings presented here.

Where to find topical vitamin C and what to look for on the label

Vitamin C can be found in serums or other skincare products. Different formulations of vitamin C can alter its strength and effects in the skin. Consider purchasing vitamin C products from your dermatologist’s office or a verified online retailer, with a clinical formulation that contains an active form of vitamin C (for instance, L-ascorbic acid), has a strength of 10% to 20%, and a pH lower than 3.5, as this combination has been studied in clinical trials. This information can be obtained from the manufacturer’s website under the ingredients section.

Who shouldn’t use Vitamin C products?

Vitamin C has only been studied in adults and is not recommended for children. Always read the ingredient list before purchasing a vitamin C product. If you have sensitivity or a known allergy to any of the ingredients, consider a patch test or consult your doctor before use. If you have acne-prone or oily skin, consider using a formulation that also fights oils, or contains ingredients like salicylic acid that fight breakouts.

How to use topical Vitamin C

During your morning skincare routine

  • use a gentle cleanser
  • apply a few drops of a vitamin C serum to the face and neck
  • apply moisturizer and sunscreen.

You may experience a mild tingling sensation with the use of vitamin C. You may choose to begin applying it every other day, and if tolerated you may apply it daily. It may take up to three months of consistent use to see a noticeable improvement. If you experience substantial discomfort or irritation, please stop using vitamin C and consult with your physician.

Vitamin C does not replace the use of sunscreen or wearing sun-protective clothing. Be sure to use broad-spectrum, tinted sunscreen daily, and limit sun exposure during peak hours.

Follow Dr. Nathan on Twitter @NeeraNathanMD
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Is a common pain reliever safe during pregnancy?

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For years, products containing acetaminophen, such as the pain reliever Tylenol, were largely viewed as safe to take during pregnancy. Hundreds of widely available over-the-counter remedies, including popular cold, cough, and flu products, contain acetaminophen. Not surprisingly, some 65% of women in the US report taking it during pregnancy to relieve a headache or to ease an aching back.

But recently, a group of doctors and scientists issued a consensus statement in Nature Reviews Endocrinology urging increased caution around acetaminophen use in pregnancy. They noted growing evidence of its potential to interfere with fetal development, possibly leaving lingering effects on the brain, reproductive and urinary systems, and genital development. And while the issue they raise is important, it’s worth noting that the concerns come from studies done in animals and human observational studies. These types of studies cannot prove that acetaminophen is the actual cause of any of these problems.

An endocrine disruptor

Acetaminophen is known to be an endocrine disruptor. That means it can interfere with chemicals and hormones involved in healthy growth, possibly throwing it off track.

According to the consensus statement, some research suggests that exposure to acetaminophen during pregnancy — particularly high doses or frequent use — potentially increases risk for early puberty in girls, or male fertility problems such as low sperm count. It is also associated with other issues such as undescended testicles, or a birth defect called hypospadias where the opening in the tip of the penis is not in the right place. It might play a role in attention deficit disorder and negatively affect IQ.

Risks for ill effects are low

If you took acetaminophen during a current or past pregnancy, this might sound pretty scary — especially since you’ve probably always considered this medicine harmless. But while experts agree it’s important to consider potential risks when taking any over-the-counter or prescription medicines during pregnancy, you shouldn’t panic.

“The risk for an individual is low,” says Dr. Kathryn M. Rexrode, chief of the Division of Women’s Health, Department of Medicine at Harvard-affiliated Brigham and Women’s Hospital.

Chances are pretty good that if you took acetaminophen during a pregnancy, your baby likely did not, or will not, suffer any ill effects.

The research on this topic is not conclusive. Some information used to inform the consensus statement was gathered from studies on animals, or human studies with significant limitations. More research is needed to confirm that this medicine is truly causing health problems, and to determine at what doses, and at what points during a pregnancy, exposure to acetaminophen might be most harmful.

Sensible steps if you’re pregnant

Three common-sense steps can help protect you and your baby until more is known on this topic:

  • Avoid acetaminophen during pregnancy when possible. Previously during preconception and pregnancy counseling, Dr. Rexrode had warned patients against using NSAID drugs, such as Advil and Aleve, and suggested taking acetaminophen instead. “Now I also tell people that some concerns have been raised about acetaminophen use during pregnancy, and explain that its use should be limited to situations where it is really needed,” says Dr. Rexrode. In short, always consider whether you really need it before you swallow a pill.
  • Consult with your doctor. Always clear acetaminophen use with your doctor, particularly if you are going to be using the medicine for a long period of time. They might agree that taking it is the best option — or suggest a safer alternative.
  • Minimize use. If you do need to take acetaminophen during pregnancy, take it for the shortest amount of time possible and at the lowest effective dose to reduce fetal exposure. “This advice about the lowest necessary dose for the shortest period of time is generally good counseling for all over-the-counter medication use, especially during pregnancy,” says Dr. Rexrode.

While all of this is good advice for using acetaminophen, there are times when it’s riskier not to take it. For example, if you have a high fever during pregnancy — which can harm your baby — acetaminophen may be needed to bring your fever down. Provided it’s advised by your doctor, the benefits of acetaminophen use in this case outweigh the potential risks.