Destinationcharente

Prostate cancer can progress over long durations, and if a man’s tumor has features that predict slow growth, he can opt for active surveillance instead of immediate treatment. Men on active surveillance get routine PSA blood tests and prostate biopsies, and are treated only if the cancer advances or shows evidence of increasing activity. But when the time comes for treatment, up to a third of men still decide against it. Now, a new study finds that for some of these men, treatment can be safely delayed.

Researchers from the University of California, San Francisco identified 531 men whose cancers progressed while they were on active surveillance. All the men were diagnosed initially with Grade Group 1 prostate cancer, which is the bottom rung on a classification scheme that ranks cancers from low to high risk of aggressive spread. Within 25 months, on average, the men’s biopsy samples showed they had progressed to higher-risk grade groups that are typically treated.

In all, 192 men wound up having surgery to remove the prostate within six months of their tumor upgrade. But 125 men waited up to five years before having the operation, and 214 men decided against being treated at all.

Outcomes and observations

When the researchers compared long-term outcomes among the men who got surgery within six months and those who waited longer for their operation, they found little difference between them. Forty-five men from both groups combined had their cancer return within three years after surgery. But the percentage who avoided a cancer recurrence was similar in both groups: 80% of the men in the early-surgery group were still cancer-free three years later, compared to 87% of the men who put the surgery off for up to five years.

Furthermore, prostate tissues observed by a pathologist immediately after surgery showed similar rates of adverse biological features that predict worse outcomes later. Tumors from about half the men from either group had this type of adverse pathology. Based on these results, the authors concluded that “a subset of patients with biopsy progression can safely continue on active surveillance.”

The trick is to predict who those patients are in advance. Unfortunately, genetic testing provided few insights into which men might progress faster than others. The authors emphasized that further studies are needed to determine how genetic tests might help with making treatment decisions for men on active surveillance. In an editorial comment, Dr. Christopher Morash from the University of Ottawa cautioned that the three-year follow-up is not very long, and that differences between the early- and late-surgery groups may emerge in the coming years.

"This is an important study that continues to provide support for active surveillance not only in men with Grade Group 1 cancers, but also for those who over time progress to Grade Group 2, which in the past has been an impetus to initiate treatment," says Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org. "New findings emerging from the field of biomarkers and genomics should hopefully continue to add to our knowledge about even more precision in selecting men who can and cannot safely defer=”defer” treatments, even in the face of progression."

About the Author

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

As a cisgender woman with long hair and a closet full of dresses, I can count on one hand the number of times I’ve been misgendered by being called “he” or “sir.” Cisgender means I was assigned female at birth and identify as a woman. For people who are transgender and/or nonbinary (TNB), with a different gender identity than their assigned sex at birth, being misgendered may be a daily occurrence.

Why does misgendering matter?

Imagine a scenario in which you are called the wrong pronoun or honorific — for example Mr., Ms., or Mrs. — multiple times a day. It might happen in person, over the phone, or via email. Each time it happens, you must decide whether it is worth it to correct that person or easier to let it go. Imagine that you are repeatedly confronted with this experience and the decision of whether or not to correct it throughout the day — every day. As we know from research, and as I’ve also heard from the TNB people I know, this is both exhausting and demoralizing. When people are misgendered, they feel invalidated and unseen. When this happens daily, it becomes a burden that can negatively impact their mental health and their ability to function in the world.

If you are a cisgender person, you can lighten this burden for TNB people by using the right names, pronouns, and honorifics to refer to them, apologizing when you misgender someone, and correcting other people when they misgender someone.

How do you use the correct name, pronouns, and honorifics?

It’s simple: follow the person’s lead, or ask them. The name, pronouns, and honorifics that a person chooses to use for themselves communicate to others how they want to be seen and acknowledged. Using the correct terms for someone is a sign of respect and recognition that you see them as they see themselves.

If you knew someone previously as one gender and now they use a different name, pronouns, or honorifics, it can be hard to remember to use the right terms, especially if the person is gender-fluid and changes their pronouns more often. It can also be challenging to adjust to using gender-neutral pronouns like they and them, neopronouns like ze and zir, and unfamiliar honorifics, such as Mx (pronounced “mix”). But using the right terms is critically important for supporting and respecting TNB people.

A few tips and tools

• Try not to make assumptions about a person’s name, pronouns, or honorifics based on how they look. The only way to know for sure what terms a person uses is to ask them in private (“What pronouns do you use?”). Asking someone in front of other people may unintentionally put them on the spot to disclose their identity to new people. You can ask anyone — cisgender or TNB — their name, pronouns, or honorifics.
• Once you know what terms a person uses, the best way to make sure that you use the correct ones is to practice (this tool can help). Practice when they are in the room and when they are not in the room. Practice before you know you will see someone. Practice with others in your life: your cisgender friends, your spouse, your pet, your child. In our household, my wife and I try to use gender-neutral pronouns to refer to our preschooler’s toys and dolls so that we can practice using them ourselves. We even change the pronouns of characters in books that we read as another way to practice.
• Another tip for remembering to use the correct name, pronouns, and honorifics is to pause before you speak. When we are stressed or busy, we are more likely to misgender people. Try to pause for a beat before you speak to make sure you are using the right terms to refer to someone. Similarly, reread emails before you send them to make sure you are not misgendering someone.
• Be patient as you learn to use new terms and pronouns. It gets easier with practice and may become second nature over time.

How to apologize for misgendering someone

Misgendering will happen. What’s most important is how you handle it when it does. The best way to handle misgendering someone who is present is to apologize and try harder next time (“I’m sorry, I meant [correct name/pronoun/honorific]”). Keep your apology brief so that it doesn’t become about you and your mistake.

If you are corrected by someone else, try not to be defensive. Instead, simply respond with a thank you and a correction (“Oh, thank you — I’ll email [correct name/pronoun] about that”). This is an important step, even if the misgendered person is not present, so you can practice and so others can learn from your example. Any time you misgender someone, practice so you can do better next time.

How to correct misgendering when you hear or see it

As a cisgender colleague and supervisor to numerous TNB people, many of whom are nonbinary and use they/them pronouns, I often find myself in situations where I need to correct misgendering. I might say something like “I noticed you used she to refer to that person. Just to let you know, they use they/them pronouns.” Or I might write a note in a Zoom chat or in an email, “Just a friendly reminder that this person uses they/them pronouns.” Stepping forward this way lessens the burden of correcting misgendering for TNB people. It also models to others that a correction can be done in a friendly way, and is important for respecting and including TNB people.

How to use gender-neutral language and normalize pronouns

One way to avoid misgendering is to use gender neutral language. Here are some examples:

• Instead of “boys and girls” or “ladies and gentlemen,” say “everyone.”
• Instead of “fireman” or “policeman,” say “firefighter” or “police officer.”
• Instead of “hey guys,” say “hey everyone” or “hey all.”

Try to pay attention to your language and find ways to switch to gender-neutral terms.

You can be mindful of your own pronouns and help other people be mindful by normalizing displays of pronouns. Here are some ways that I make my own pronouns (she/her) visible to others:

• I list my pronouns in my email signature, in my Zoom name, and on the title page of presentations.
• I wear a pronoun pin at work.
• I introduce myself with my pronouns.

These actions signal to others that I am thinking about pronouns,  and am aware that people may use different pronouns than might be expected from their appearance.

You may still make mistakes, but it’s important to keep practicing and trying to use the right terms! By using the correct names, pronouns, and honorifics to refer to people, apologizing when you misgender someone, and correcting other people when they misgender, you can support and respect the TNB people around you. This helps create a more inclusive world for everyone.

About the Author

Sabra L. Katz-Wise, PhD, Contributor

Sabra L. Katz-Wise, PhD (she/her) is an assistant professor in adolescent/young adult medicine at Boston Children’s Hospital, in pediatrics at Harvard Medical School, and in social and behavioral sciences at the Harvard T.H. Chan School of … See Full Bio View all posts by Sabra L. Katz-Wise, PhD

Active surveillance for prostate cancer has its tradeoffs. Available to men with low- and intermediate-risk prostate cancer, the process entails monitoring a man’s tumor with periodic biopsies and prostate-specific antigen (PSA) tests, and treating only when — or if — the disease shows signs of progression.

Active surveillance allows men to avoid (at least for a while) the side effects of invasive therapies such as surgery or radiation, but men often feel anxious wondering about the state of their cancer as they spend more time untreated. Is there a middle path between not treating the cancer at all and aggressive therapies that might have lasting side effects? Emerging evidence suggests the answer might be yes.

During a newly-published phase 2 clinical trial, researchers evaluated whether a drug called enzalutamide might delay cancer progression among men on active surveillance. Enzalutamide interferes with testosterone, a hormone that drives prostate tumors to grow and spread. Unlike other therapies that block synthesis of the hormone, enzalutamide prevents testosterone from interacting with its cellular receptor.

A total of 227 men were enrolled in the study. The investigators randomized half of them to a year of daily enzalutamide treatment plus active surveillance, and the other half to active surveillance only. After approximately two years of follow-up, the investigators compared findings from the two groups.

The results showed benefits from enzalutamide treatment. Specifically, tumor biopsies revealed evidence of cancer progression in 32 of the treated men, compared to 42 men who did not get the drug. The odds of finding no cancer in at least some biopsy samples were 3.5 times higher in the enzalutamide-treated men. And it took six months longer for PSA levels to rise (suggesting the cancer is growing) in the treated men, compared to men who stayed on active surveillance only.

Enzalutamide was generally well tolerated. The most common side effects were fatigue and breast enlargement, both of which are reversible when men go off treatment.

In an accompanying editorial, Susan Halabi, a statistician who specializes in prostate cancer at Duke University, described the data as encouraging. But Halabi also sounded a cautionary note. Importantly, differences between the two groups were evident only during the first year of follow-up. By the end of the second year, signs of progression in the treated and untreated groups “tended to be very similar,” she wrote, suggesting that enzalutamide is beneficial only for as long as men stay on the drug. Longer studies lasting a decade or more, Halabi added, may be necessary to determine if early enzalutamide therapy changes the course of the disease, such that the need for more invasive treatments among some men can be delayed or prevented.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org, said the study points to a new way of approaching active surveillance, either with enzalutamide or perhaps other drugs. “An option that further decreases the likelihood that men on active surveillance will need radiation or surgery is important to consider,” he says. “This was a pilot study, and now we need longer-term research.”

About the Author

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

If you’re in your 80s or 70s and you’ve noticed that you’re having some memory loss, it might be reasonable to be concerned that you could be developing Alzheimer’s disease or another form of dementia. But what if you’re in your 60s, 50s, or 40s… surely those ages would be too young for Alzheimer’s disease or dementia, right?

About 10% of Alzheimer’s disease is young onset, starting before age 65

Not necessarily. Of the more that 55 million people living with dementia worldwide, approximately 60% to 70% of them have Alzheimer’s disease. And of those 33 to 38.5 million people with Alzheimer’s disease, memory loss or other symptoms began before age 65 in 10% of them. Alzheimer’s is, in fact, the most common cause of young onset dementia. A recent study from the Netherlands found that of those with a known classification of their young onset dementia, 55% had Alzheimer’s disease, 11% vascular dementia, 3% frontotemporal dementia, 3% Parkinson’s disease dementia, 2% dementia with Lewy bodies, and 2% primary progressive aphasia.

Young onset dementia is uncommon

To be clear, young onset dementia (by definition starting prior to age 65, and sometimes called early onset dementia) is uncommon. One study in Norway found that young onset dementia occurred in 163 out of every 100,000 individuals; that’s in less than 0.5% of the population. So, if you’re younger than 65 and you’ve noticed some trouble with your memory, you have a 99.5% chance of there being a cause other than dementia. (Whew!)

There are a few exceptions to this statement. Because they have an extra copy of the chromosome that carries the gene for the amyloid found in Alzheimer’s plaques, more than half of people with Down syndrome develop Alzheimer’s disease, typically in their 40s and 50s. Other genetic abnormalities that run in families can also cause Alzheimer’s disease to start in people’s 50s, 40s, or even 30s — but you would know if you are at risk because one of your parents would have had young onset Alzheimer’s disease.

How does young onset Alzheimer’s disease differ from late onset disease?

The first thing that should be clearly stated is that, just as no two people are the same, no two individuals with Alzheimer’s disease show the same symptoms, even if the disease started at the same age. Nevertheless, there are some differences between young onset and late onset Alzheimer’s disease.

People with typical, late onset Alzheimer’s disease starting at age 65 or older show the combination of changes in thinking and memory due to Alzheimer’s disease plus those changes that are part of normal aging. The parts of the brain that change the most in normal aging are the frontal lobes. The frontal lobes are responsible for many different cognitive functions, including working memory — the ability to keep information in one’s head and manipulate it — and insight into the problems that one is having.

This means that, in relation to cognitive function, people with young onset Alzheimer’s disease may show relatively isolated problems with their episodic memory — the ability to form new memories to remember the recent episodes of their lives. People with late onset Alzheimer’s disease show problems with episodic memory, working memory, and insight. So, you would imagine that life is tougher for those with late onset Alzheimer’s disease, right?

Depression and anxiety are more common in young onset Alzheimer’s disease

People with late onset Alzheimer’s disease do show more impairment, on average, in their cognition and daily function than those with young onset Alzheimer’s disease, at least when the disease starts. However, because their insight is also impaired, those with late onset disease don’t notice these difficulties that much. Most of my patients with late onset Alzheimer’s disease will tell me either that their memory problems are quite mild, or that they don’t have any memory problems at all!

By contrast, because they have more insight, patients with young onset Alzheimer’s disease are often depressed about their situation and anxious about the future, a finding that was recently confirmed by a group of researchers in Canada. And as if having Alzheimer’s disease at a young age wasn’t enough to cause depression and anxiety, recent evidence suggests that in those with young onset Alzheimer’s disease, the pathology progresses more quickly.

Another tragic aspect of young onset Alzheimer’s disease is that, by affecting individuals in the prime of life, it tends to disrupt families more than late onset disease. Teenage and young adult children are no longer able to look to their parent for guidance. Individuals who may be caring for children in the home now need to care for their spouse as well — perhaps in addition to caring for an aging parent and working a full-time job.

What should you do if you’re younger than 65 and having memory problems?

As I’ve discussed, if you’re younger than 65 and you’re having memory problems, it’s very unlikely to be Alzheimer’s disease. But if it is, there are resources available from the National Institute on Aging that can help.

What else could be causing memory problems at a young age? The most common cause of memory problems below age 65 is poor sleep. Other causes of young onset memory problems include perimenopause, medication side effects, depression, anxiety, illegal drugs, alcohol, cannabis, head injuries, vitamin deficiencies, thyroid disorders, chemotherapy, strokes, and other neurological disorders.

Here are some things that everyone at any age can do to improve their memory and reduce their risk of dementia:

• Perform aerobic exercise.
• Eat Mediterranean-style meals.
• Avoid alcohol, cannabis, and drugs.
• Sleep well.
• Participate in social activities.
• Pursue novel, cognitively stimulating activities, listen to music, practice mindfulness, and keep a positive mental attitude.

About the Author

Andrew E. Budson, MD, Contributor

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the … See Full Bio View all posts by Andrew E. Budson, MD

A new study shows something we’ve always figured was true: our health and habits as children and teens affect our health as adults. And not just our health, but how long we live.

What did the study measure and find?

The International Childhood Cardiovascular Cohorts Consortium Outcomes Study has been collecting data on almost 40,000 people from the United States, Finland, and Australia. They started enrolling them as children in the 1970s through the 1990s, and have been following them ever since.

The researchers have been looking at the effects of five risk factors:

• body mass index, or BMI, a calculation that shows if a person is within a healthy weight range
• systolic blood pressure, which is the top number in a blood pressure reading and is a measure of how much pressure is exerted on the arteries when the heart beats
• total cholesterol value, a measure of how much of the waxy substance is in your blood. While cholesterol is important for doing things like building cells and hormones, having too much of it can lead to heart disease and stroke.
• triglyceride level, a measure of how much of this fatty substance is in the blood. As with cholesterol, too much of it increases the risk of heart disease and stroke.
• smoking in youth.

From 2015 to 2019, the researchers followed up on all of these people, who were 46 on average, which is not very old. They found that almost 800 of them had had cardiovascular events (like a heart attack or stroke), of which more than 300 were fatal.

When the researchers matched outcomes to values for the five factors, they found that they were indeed risk factors:

• People who had higher than normal values for all of the risk factors had almost triple the risk of cardiovascular disease.
• Smoking was the biggest risk factor, followed by BMI, systolic blood pressure, triglycerides, and cholesterol.
• You didn’t need to have all five factors to be at risk; for example, people who were obese as children were more than three times more likely to have cardiovascular disease — and those whose blood pressure was either high or close to high had double the risk.

None of this is a surprise, but seeing it so clearly should be a wake-up call, especially to parents.

What can parents do to help steer a course toward healthy adulthood?

Parents can take these four important steps:

1. Know if your child is at risk. Understandably, many parents don’t pay close attention to the numbers at their child’s checkup, or the results of blood tests. But those numbers are important.

• Make sure you know your child’s BMI — and if it is healthy or not. In adults, we say that a BMI of 19 to 25 is healthy. In children and teens, it’s a bit more complicated; we look at the BMI percentile based on age and gender. If the percentile is between 85 and 95, the child is overweight; if it’s over 95, the child is obese. The Centers for Disease Control and Prevention has a calculator you can use to get the BMI and percentile.
• Know your child’s blood pressure — and whether it is healthy or not. Again, this depends on age, gender, and height. Sadly, many pediatricians miss abnormal blood pressures because numbers that seem normal can be unhealthy for some children, so it’s important to ask your doctor to be sure. Your child’s blood pressure should be measured at every checkup starting at age 3.
• Ask about checking your child’s cholesterol and triglyceride levels. This is generally done in adolescence, but may be done earlier if a child is overweight, or if there is a family history of elevated levels. If you or a close family member has high cholesterol or triglycerides, make sure your child’s pediatrician is aware.
• Ask your child about smoking (and other substance use). Don’t assume you know.

2. Take what you learn — and this study — seriously. An “it’s just baby fat” or “they have plenty of time to get healthy” approach can be dangerous.

• If your child has an elevated BMI, blood pressure, cholesterol level, or triglyceride level, talk with your doctor about what you can do — and do it. 
• No matter what your child’s numbers are, make sure they have a healthy diet, rich in fruits, vegetables, whole grains, healthy fats, and lean protein. Limit added sugar (especially in beverages), processed foods, and unhealthy fats.
• Same goes for exercise: children should be exercising for an hour a day. That doesn’t have to be a team sport, if your child is not a team sports kind of person (or your life doesn’t lend itself to team sports); active play, going for walks, doing exercise videos, or even just dancing in the living room is fine.

3. Talk to your kids about not smoking. Start early — well before adolescence, when peer pressure becomes powerful. Make sure they know the facts, and help them learn and practice ways to say no.
4. See your doctor regularly. Children should see their doctor at least yearly, and if your child has one of the five risk factors, they will need more frequent visits. Make these visits a priority — your child’s life might literally depend on it.

Follow me on Twitter @drClaire

About the Author

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

“The horse has left the barn.”

Those six words, said by my husband’s oncologist, changed our lives forever, although the sense of impending loss had begun weeks earlier with a blood test. There would be more tests, exams, and visits to specialists. As George and I waited for a definitive diagnosis, we bargained with ourselves and with the universe. When we finally met with the cancer treatment team to review all the tests, George’s 6-foot 2-inch frame struggled to fit into the space at the small table, where we strained to follow the conversation. Hearing the word metastatic — meaning cancer had spread throughout his body — was like fingernails on a blackboard.

But there’s no real way to prepare for grief, an inescapable feature of the human condition. Its stress following the death of a loved one can lead to physical illness: cardiovascular diseases, broken-heart-syndrome (takotsubo cardiomyopathy), cancers, and ulcers. Emotional distress often sparks physical distress known as somatic symptoms. How each person navigates grieving varies. Comfort takes different forms for different people. While my journey is individual, my story touches on universal themes, particularly for those grieving in the time of COVID-19.

Anticipatory grief strikes first

George’s diagnosis was advanced metastatic prostate cancer, spread to lymph nodes and bone. There would be no surgery. No radiation. No chemotherapy. Only palliative care.

Some days George wanted to talk only with me. Other days he wanted to talk with those who were “in the same boat.” He saw himself as washed up on the shores of a new, unknown continent. I felt washed up with him. The National Cancer Institute describes these feelings as anticipatory grief, a reaction that anticipates impending loss.

In time, we returned to everyday routines. Sometimes we laughed and didn’t think about his illness. George even conceived of and hosted an annual party for his best friends — men who would be his pallbearers — and their partners. The “pallbearer party,” as it came to be known, was a wonderfully raucous event. Grown men laughed until they cried. Each year, by the end of the night, I knew the tears were for anticipated loss.

George lived another 11 years, more than twice what was expected. But anticipating his loss did not cushion my broken heart.

Acute grief following a death

George died in May 2020, at the beginning of the COVID-19 lockdown. Despite the pallbearers’ dress rehearsals, there was no funeral, no gathering of loved ones. Nothing to soothe my overwhelming pain.

In those first few weeks, time seemed stretched thin, moments repeating themselves like musical notes on a scratched record. I felt untethered, unmoored, adrift. My sides ached from crying; my knees were unsteady. I don’t recall eating.

At the funeral home, when I saw George in a casket, the large room seemed bright from lights hitting the shiny wood floor. Later, I realized the room was much smaller and dimmer than I remembered, its floor not shiny but covered by oriental rugs. Burgundy drapes kept out the sun. As I took in the scene, so different from my recollection, my chest heaved and spasmed.

Such physical reactions and perceptions are common in acute grief. The death of a loved one is accompanied by waves of physical distress that can include muscle aches, shortness of breath, queasy stomach, and trouble sleeping. Food may have no taste, and some experience visual hallucinations. The grief-stricken may not believe their loved one is dead.

Grief in the time of COVID-19

Restrictions to help prevent the spread of COVID-19 disrupted social rituals that connect us during grief. In The Atlantic, Ed Yong describes this absence of much-needed support as the “final pandemic betrayal.”

Although my husband died of cancer, not COVID, I experienced the loss of comforting rituals and the sense that my grief was never truly acknowledged. Experts call this disenfranchised grief. Some predict that prolonged grief disorder driven by this pandemic may reach rates seen only in survivors of natural disasters and wars.

Grief is proof of love

Losing loved ones is not easily incorporated into our life story, though it becomes part of it. The finality and acceptance of a monumental loss takes time. In The Year of Magical Thinking, Joan Didion captures the sudden tragic death of her husband: “John was talking and then he wasn’t.” Life changes in an instant. Yet it takes time to untangle and embrace all that it means.

My life must now be reconfigured and re-envisioned without George. Letting go of grief happens haltingly. Gradually, I noticed that more of my memories of George were happy ones, slowly crowding out the all-consuming early intensity of grief. With time I began to re-engage with the world.

Just as George had, I found I wanted to talk with others in the same boat. A bereavement group helped. I began to exercise more. That helped too. When our dogs died, I got a new puppy. Above all, I learned to be kind to myself.

If you, too, are struggling with loss, experts advise some basics: try to eat, sleep, and exercise regularly; consider a bereavement group or seek out others experiencing grief; stay open to new possibilities — new hobbies, people, and opportunities. Talk to a professional if, after months, you are preoccupied with thoughts of your loved one or find no meaning in life without them. These may be signs that your grief is stalled or prolonged. Effective treatment can help.

Every “first” without George — the first birthday, first wedding anniversary, first anniversary of his death — awakened the early days of intense grief. Still, the experience of living through each made me realize I could survive. I think George would be pleased.

Additional resources

Grief and Loss, CDC

NIH News in Health: Coping with Grief, National Institutes of Health

The Center for Prolonged Grief, Columbia University

About the Author

Martha E. Shenton, PhD, Contributor

Dr. Martha Shenton is professor of psychiatry and radiology at Harvard Medical School, and director of the Psychiatry Neuroimaging Laboratory at Brigham and Women’s Hospital in Boston. She and her team have pioneered in developing neuroimaging … See Full Bio View all posts by Martha E. Shenton, PhD

It’s an old line: everyone complains about the weather but no one is doing anything about it.

But if you’re a person with bad allergies or asthma, stormy weather can be more than an annoyance; it can be a serious threat to your health. “Thunderstorm asthma” was first reported in the 1980s in England and Australia, and cases continue to crop up. Just after severe thunderstorms passed through Melbourne, Australia in 2016, more than 9,000 people sought urgent medical care for asthma during one notable event. Medical facilities were overwhelmed and at least eight people died. That’s unusual, but if you do have asthma — or seasonal allergies, as it turns out — understanding this trigger can help you stay well.

What is thunderstorm asthma?

The term describes an attack of asthma that starts or worsens after a thunderstorm. It can occur in anyone with asthma, but it most often affects people with seasonal allergic rhinitis, which many people know as hay fever or allergies. Heralded by a runny nose, sneezing, and itchy eyes, seasonal allergies are often worst in the spring, summer, or early fall.

Rain tends to lower pollen counts by cleansing the air, and many people find that rainy weather tends to reduce asthma symptoms triggered by allergies. But thunderstorms can make asthma worse because of a unique sequence of events:

• Cold downdrafts concentrate air particles, such as pollen and mold
• These air particles are swept up into clouds where humidity is high
• In the clouds, wind, humidity, and lightning break up the particles to a size that can readily enter the nose, sinuses, and lungs
• Wind gusts concentrate these small particles so large amounts can be inhaled.

What raises risk for experiencing thunderstorm asthma?

According to a new study in the Journal of Allergy and Clinical Immunology, a whopping 144 out of 228 people with seasonal allergies reported experiencing thunderstorm asthma — that’s 65%! And many of the asthma attacks set off by thunderstorms weren’t mild. Nearly half of people who had an attack sought emergency hospital treatment.

Among people with seasonal allergies, risk factors for experiencing thunderstorm asthma include having

• poorly controlled asthma symptoms (assessed by a standard asthma questionnaire)
• a low score on a rapid exhalation test (a common breathing test for asthma)
• higher levels of a certain antibody (ryegrass pollen-specific IgE)
• higher numbers of certain blood cells (eosinophils, which tend to increase when people have allergic conditions)
• higher levels of exhaled nitric oxide (one measure of lung inflammation among people with asthma).

Not everyone with these risk factors will develop thunderstorm asthma. And even among those who do, asthma attacks won’t necessarily occur with every storm. But it may be useful to know if you’re among those at risk, especially if you live in an area where thunderstorms are common.

The bottom line

Thunderstorm asthma may seem like more of a curiosity than a serious threat to public health. But when it affects a large population area, emergency rooms can become overwhelmed, as happened during the 2016 Melbourne event. A better understanding of when these events are expected could lead to advanced warning systems, enhanced emergency room preparedness, and even preventive treatment.

In the US, 25 million people have asthma and more than 20 million have seasonal allergies. Odds are good that millions have both, which puts large numbers of people at risk for developing thunderstorm asthma.

If you’re among them, the weather forecast may be much more than just a guide on what to wear or whether to bring an umbrella. Knowing thunderstorms are headed your way may serve as an advance warning to double check that you are taking your asthma medicines properly, have a supply of rescue medicine handy, or simply plan to stay indoors until the storm has passed.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, 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

By now, you’ve probably heard that there is a monkeypox outbreak traveling around the globe. Cases have spread far and wide, including in the US, Canada, Europe, and Australia. It’s the largest outbreak ever recorded outside of western and central Africa, where monkeypox is common.

But controlling this outbreak demands preventive measures, such as avoiding close contact with people who have the illness and vaccination. One method of vaccination, called ring vaccination, has worked well in the past to contain smallpox and Ebola outbreaks. It may be effective for monkeypox as well.

How can monkeypox be contained?

According to the Centers for Disease Control and Prevention (CDC) and the World Health Organization, monkeypox is unlikely to become a pandemic. At this time, the threat to the general public is not high. The focus is on identifying possible cases and containing the outbreak as soon as possible.

Three important steps can help stop this outbreak:

1. Recognize early symptoms

• Usually, early symptoms are flulike, including fever, fatigue, headache, and enlarged lymph nodes.
• A rash appears a few days later, changing over a week or two from small flat spots to tiny blisters similar to chickenpox, then to larger, pus-filled blisters.
• The rash often starts on the face and then appears on the palms, arms, legs, and other parts of the body. If monkeypox is spread by sexual contact, the rash may show up first on or near the genitals.

2. Take steps to stop the spread

• Monkeypox spreads through respiratory droplets or by contact with fluid from skin sores.
•  Anyone who has been diagnosed with monkeypox, or who suspects they might have it, should avoid close contact with others. Once the sores scab over, the infected person is no longer contagious.
• Health care workers and other caregivers should wear standard infection control gear, including gloves and a mask.
• In the current outbreak, many cases began with sores in the genital and rectal areas among men who have sex with men, so doctors suspect sexual contact spread the infection. As a result, experts are encouraging abstinence when monkeypox is suspected or confirmed.

3. Use vaccination to help break the chain

• Monkeypox is closely related to smallpox. People who received a smallpox vaccine in the past may have some protection from monkeypox. (The US smallpox vaccination program was discontinued in 1972, and smallpox was declared eradicated worldwide in 1980.)
• Stockpiled smallpox vaccinations and newer vaccines that can be used for monkeypox or smallpox are also available.

Ring vaccination

Monkeypox differs from the virus that causes COVID-19. People with monkeypox usually have symptoms when they’re contagious, and the number of infected persons is usually limited.

This means it’s possible to vaccinate a “ring” of people around them rather than vaccinating an entire population. This selective approach is called ring vaccination.

Ring vaccination has been used successfully to contain smallpox and Ebola outbreaks. It may come in handy for monkeypox as well. Here’s how it works:

• As soon as a case of monkeypox is suspected or confirmed, the patient and their close contacts are interviewed to identify possible exposures.
• Vaccination is offered to all close contacts.
• Vaccination is also offered to those who had close contact with the infected person’s contacts.

Ideally, people should be vaccinated within four days of exposure.

This approach requires widespread awareness of monkeypox, rapid isolation of suspected cases, and an efficient contact tracing system. And of course, vaccines must be available whenever and wherever new cases arise.

Are the vaccines used for monkeypox effective?

According to the CDC, the smallpox vaccine is 85% effective against monkeypox.

While a newer vaccine (JYNNEOS) directed against monkeypox and smallpox has only been tested for effectiveness in animals, it is also expected to be highly effective in humans.

Of course, vaccinations can only work if people are willing to receive them. We’ll learn more about this as more people are offered the option for vaccination.

Are the vaccines used for monkeypox safe?

As with most vaccines, the most common side effects include

• sore or itchy arm at the site of the injection
• mild allergic reactions
• mild fever or fatigue.

Fortunately, more severe side effects, such as significant allergic reactions, are rare.

The bottom line

In light of the current monkeypox outbreak, you may soon be hearing more about ring vaccination. Then again, if appropriate measures are taken to prevent its spread, this outbreak may soon be over. Either way, this won’t be the last time an unusual virus shows up seemingly out of the blue in unexpected places. Climate change, shrinking animal habitats, rising global animal trade, and increasing international travel mean that it’s only a matter of time before this happens again.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, 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

This spring, many parts of United States experienced historic heat waves. Now summer is officially underway, and experts are predicting hotter than normal temperatures across most of the country.

Extreme temperatures increase health risks for people with chronic conditions, including heart problems. If you do have a heart condition, here’s how to keep cool and protect yourself when temperatures rise.

How does hot weather affect the heart?

Not only does exposure to high heat increase the risk for heat exhaustion and heat stroke, but it can also place a particular burden on heart health. It stresses the cardiovascular system and makes the heart work harder. This can increase the chance of heart attacks, heart arrhythmias (irregular heartbeat), and heart failure.

According to the Environmental Protection Agency, the interaction of high heat and cardiovascular disease contributes to about a quarter of heat-related deaths.

And the higher the temperature, the greater the threat. A recent study in the journal Circulation looked at cardiovascular death rates over seven years in Kuwait, where daytime temperatures can reach triple digits in the hottest months. The researchers found a link between rising temperatures and the risk of cardiovascular deaths, with most occurring between temperatures of 95° F to 109° F.

“Climate change is giving us more, and unprecedented, heat that can be deadly, especially for people with heart disease,” says Dr. Aaron Bernstein, interim director of the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health.

How does the body shed heat?

Your body is designed to shed extra heat in two major ways, each of which may affect the heart:

Radiation. When the air around you is cooler than your body, you radiate extra heat into the air. This process requires rerouting blood flow so that more of it goes to the skin.

Evaporation. Evaporating sweat helps cool you down by pulling heat away from your skin. When the air is dry, this works well. But when it’s hot and humid, sweat just sits on the skin as your body temperature rises.

When air temperature approaches or exceeds body temperature, especially in high humidity, the heart has to beat faster and pump harder to help your body shed heat. On a hot and humid day, your heart may circulate two to four times as much blood each minute compared with a cool day.

Some medicines meant to help the heart can add to problems on hot days. For example, beta blockers slow the heartbeat and hinder the heart’s ability to circulate blood fast enough for effective heat exchange. Diuretics (water pills) increase urine output and raise the risk of dehydration.

How can you protect yourself and your heart when temperatures rise?

While exposure to high heat and heat waves affects everyone, having existing heart problems raises your risk for heat-related illness and hospitalization. So it’s especially important to try to follow basic strategies for staying cool, including these:

• Monitor weather forecasts for heat advisories and stay inside on those days. If home is too hot, check with your town or city health department for cooling centers and other options to help you stay cool. If you venture outside, evening and early morning are often the coolest times. Rest in the shade whenever possible.
• When outside, try to drink 8 ounces of water every 20 minutes. Set a timer to remind you. “Never wait until you’re thirsty to drink,” says Dr. Bernstein. If you have heart failure, ask your doctor how much fluid you should drink daily, since fluids can build up and cause swelling. If you take diuretics, ask how much you should drink during hot weather.
• Avoid soda or fruit juice and limit alcohol. Soda and fruit juice may slow the passage of water from the digestive system to the bloodstream. While research is limited, some studies have found that excessive alcohol intake may raise risk for heat stroke during scorching weather.
• Protect your skin. Sunburn affects your body’s ability to cool down and increases dehydration. Wear a wide-brimmed hat, wraparound sunglasses, and lightweight, light-colored, loose-fitting clothing. Also, apply plenty of broad-spectrum or UVA/UVB protection sunscreen with SPF 30 or higher to all exposed skin 30 minutes before going out. Reapply every hour.

About the Author

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

Here we are, well into year three of the COVID-19 pandemic, and now we’re having an outbreak of monkeypox? Is this a new virus? How worried should we be? While new information will continue to come in, here are answers to several common questions.

What is monkeypox?

Monkeypox is an infection caused by a virus in the same family as smallpox. It causes a similar (though usually less severe) illness and is most common in central and western Africa. It was first discovered in research monkeys more than half a century ago. Certain squirrels and rats found in Africa are among other animals that harbor this virus.

Currently, an outbreak is spreading fast outside of Africa. The virus has been reported in at least a dozen countries, including the US, Canada, Israel, and in Europe. As of this writing, Reuters reports more than 100 confirmed or suspected cases, making this the largest known outbreak outside of Africa. So far, no deaths have been reported.

Naturally, news about an unfamiliar virus spreading quickly internationally reminds us of the start of the COVID-19 pandemic. But monkeypox is not new — it was first discovered in 1958 — and several features make it likely to be far less dangerous.

What are the symptoms of monkeypox?

The early symptoms of monkeypox are flulike, and include

• fever
• fatigue
• headache
• enlarged lymph nodes.

The rash that appears a few days later is unique. It often starts on the face and then appears on the palms, arms, legs, and other parts of the body. Some recent cases began with a rash on the genitals. Over a week or two, the rash changes from small, flat spots to tiny blisters (vesicles) similar to chickenpox, and then to larger, pus-filled blisters. These can take several weeks to scab over. Once that happens, the person is no longer contagious.

Although the disease is usually mild, complications can include pneumonia, vision loss due to eye infection, and sepsis, a life-threatening infection.

How does a person get monkeypox?

Typically, this illness occurs in people who have had contact with infected animals. It may follow a bite or scratch, or consuming undercooked animal meat.

The virus can spread between people in three ways:

• inhaling respiratory droplets
• directly touching an infected person
• less often, through indirect contact such as handling an infected person’s clothing.

The respiratory route involves large droplets that don’t linger in the air or travel far. As a result, person-to-person spread typically requires prolonged, intimate contact.

Is monkeypox a sexually transmitted illness?

Monkeypox is not considered a sexually transmitted illness (STI) because it can be spread through any physical contact, not just through sexual contact. Some of the recent cases have occurred among men who have sex with men. That pattern hasn’t been reported before.

Can monkeypox be treated?

Yes. Although there are no specific, FDA-approved treatments for monkeypox, several antiviral medicines may be effective. Examples are cidofovir, brincidofovir, and tecovirimat.

Can monkeypox be prevented?

Vaccination can help prevent this illness:

• Smallpox vaccination, which was routine in the US until the 1970s, may be up to 85% effective against monkeypox.. The US government has stockpiled doses of smallpox vaccine that could be used in the event of a widespread outbreak.
• Additionally, the FDA approved a vaccine (called JYNNEOS) in 2019 for people over 18 who are at high risk for smallpox or monkeypox. The makers of this vaccine are ramping up production as this outbreak unfolds.

If you are caring for someone who has monkeypox, taking these steps may help protect you from the virus: wear a mask and gloves; regularly wash your hands; and practice physical distancing when possible. Ideally, a caregiver should be previously vaccinated against smallpox.

How sick are most people who get monkeypox?

Monkeypox is usually a mild illness that gets better on its own over a number of weeks.

Researchers have found that the West African strain of monkeypox is responsible for the current outbreak. That’s good news, because the death rate from this strain is much lower than the Congo Basin strain (about 1% to 3% versus 10%). More severe illness may occur in children, pregnant people, or people with immune suppression.

What else is unusual about this outbreak?

Many of those who are sick have not traveled to or from places where this virus is usually found, and have had no known contact with infected animals. In addition, there seems to be more person-to-person spread than in past outbreaks.

Is there any good news about monkeypox?

Yes. Monkeypox usually is contagious after symptoms begin, which can help limit its spread. One reason COVID-19 spread so rapidly was that people could spread it before they knew they had it.

Outbreaks occur sporadically, and tend to be relatively small because the virus does not spread easily between people. The last US outbreak was in 2003; according to the CDC, nearly 50 people in the Midwest became ill after contact with pet prairie dogs that had been boarded near animals imported from Ghana.

Perhaps the best news is this: unlike SARS-CoV2, the virus that causes COVID-19, monkeypox is unlikely to cause a pandemic. It doesn’t spread as easily, and by the time a person is contagious they usually know they’re sick.

How worried should we be?

The growing numbers of cases in multiple countries suggest community spread is underway. More cases will probably be detected in the coming days and weeks.

It’s still early in the outbreak and there are many unanswered questions, including:

• Has the monkeypox virus mutated to allow easier spread? Early research is reassuring.
• Who is most at risk?
• Will illness be more severe than in past outbreaks?
• Will existing antiviral drugs and vaccines be effective against this virus?
• What measures can we take to contain this outbreak?

So, monkeypox is no joke and researchers are hard at work to answer these questions. Stay tuned as we learn more. And let your doctor know if you have an unexplained rash or other symptoms of monkeypox, especially if you have traveled to places where cases are now being reported.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, 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