The United States Has a Gun Problem

In 2022, there were 48,204 gun deaths in the United States, 132/day. Of these, 27,032 were suicides, 19,651 homicides, 463 unintentional and 643 fatal shootings by law enforcement.

White males have by far the highest rate of suicide by gun while black males are much more likely to be victims of homicide. The U.S. has 33 times the rate of firearm homicide as Australia.

Among 15- to 24-year-olds, homicide is the second leading cause of death (following unintentional injuries) and suicide is third. For 25- to 34-year-olds, suicide is second after unintentional injuries and homicide third.

Worst is what we do to our children. Excluding infants, gun violence accounts for 15% of deaths among those under age 20. The firearm death rate for children 1-19 in the U.S. is 29 times that of comparable large wealthy countries.

Barring a dramatic turn-around at the Supreme Court, we are not going to get rid of guns, but that does not mean we are helpless to change this story.

Much of the laws and rules governing gun ownership and safety are still set at the state level, and this has given us “natural experiments,” as we can observe what happens in states with differing policies.

State laws vary across a variety of issues. The leading areas where states can be more or less strict include universal background checks, minimum age limits for gun purchase, waiting periods, child access rules, concealed carry and “stand your ground” laws.

Of these, three had dramatic effects on lowering gun homicides and suicides: requiring universal background checks, forbidding concealed carry and not having “stand your ground” as a legitimate excuse for firing a gun. States imposing these rules had 70-90% fewer firearm deaths than states which took the opposite position.

Children benefit from stricter gun laws. In 2010 the Supreme Court allowed states to set their own firearm rules. Researchers ranked all the U.S. states into most permissive (31 states), permissive (11) and strict (8) and compared what happened to pediatric gun death rates ten years later. In the states with the most permissive laws, death rates of children by firearms went up by roughly 50% while in the states with the strictest laws, pediatric deaths fell by about 20%.

"Red flag" laws—also known as Extreme Risk Protection Orders (ERPOs)—allow courts to temporarily remove firearms from individuals deemed to be a threat to themselves or others. These have been shown to clearly reduce the risk of death by suicide, though their effect on homicide is less proven.

If you value your life, and the lives of your children and grandchildren, demand that your state legislatures enact sensible gun restrictions.


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mRNA vaccines - are they dangerous?

RFK Jr, our anti-science Secretary of Health and Human Services, has declared that new vaccines should be developed without using mRNA technology and has cast doubt on the safety of mRNA.

What do we know about this technology?

mRNA occurs normally in our bodies. It carries instructions from our DNA out to the cells where these “blueprints” are used to make proteins. mRNA is inherently short-lived. It delivers instructions and then is programmed to die. It typically lasts a few days at most.

The traditional way to make vaccines is to grow viruses in culture, break them apart, and use the fragments of viral proteins to make vaccines. When these are injected, the body’s immune system recognizes them as foreign and develops an immune response that ramps up if the virus later attacks us.

When mRNA is used to create vaccines, mRNA carries instructions into our cells to build proteins that form part of a virus, such as the spike protein of the Covid virus. The body’s cells make these proteins, which the body recognizes as foreign and makes antibodies against them. These antibodies are now prepared to fight off the virus should we encounter it.

The big advantage of using mRNA to create vaccines over the traditional method is that vaccines can be made much more quickly, typically within weeks of a new virus being identified. The old method, growing viruses in culture and using disrupted virus particles to stimulate the immune system, typically took months.

Should we experience another pandemic, mRNA vaccines will save countless lives.

Are these vaccines dangerous?

They do NOT change our DNA. mRNA makes a one-way trip and does not enter the nucleus or change our DNA.

Yes, people can get muscle aches and fever, but this can happen with any vaccine – it is part of the body’s response to a foreign protein.

There were cases of heart muscle inflammation after the Covid vaccination, but there were many more in people who got infected with Covid.

It has been over four years since the mRNA vaccines were introduced, and there have been no new safety concerns.

Do not let fear-mongering persuade you. The vaccines are safe and could save your life.


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Radon - what you don't know can hurt you

Radon is a breakdown product of uranium, which is found naturally in soil and rocks everywhere. Radon is a gas, and it is odorless, colorless and tasteless.

Radon can seep into your house from the ground on which it is built and, particularly if your house is tightly-sealed, can build up.

Some amount of radon is unavoidable, but levels above 4 picocuries per liter are considered a cause of lung cancer. Radon is the number one cause of lung cancer in non-smokers, and the combination of smoking and radon is particularly lethal.

There is natural variation in radon levels depending on geography. You can Google “EPA radon zones” to find a map and spreadsheet that will tell you to the county level how likely you are to be at a high level of radon.

Some states, including Massachusetts, mandate radon tests before a house is sold, but most states do not.

Testing is easy. You can get a test kit at the hardware store or on-line. You leave the kit in a central part of your basement (or ground floor if you have no basement) and mail it in.

If the test comes back at 4 or higher, you should take action.

While there are some helpful things you can do yourself, such as sealing cracks in the basement floor or walls and improving the ventilation in your home, major improvement will require professional help.

Seek a certified radon mitigator – certified by NRPP (National Radon Proficiency Program) or NRSB (National Radon Safety Board). The typical solution involves a pipe system running from beneath the foundation that draws air through an external pipe to above the roof using a fan.

Remediation does not come cheap: it will probably cost between $1000 and $2500. Add to that the cost of electricity to run a fan continuously.

So, as well as having smoke and carbon monoxide detectors in your home, one more thing to add. Forewarned is forearmed.


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It is just an over-the-counter supplement - it must be safe

Many of us take dietary supplements such as vitamins, minerals, herbs, or other products to boost our health. Since many supplements contain natural ingredients, it’s easy to assume they are always safe. But “natural” does not always mean safe, especially when combined with medications. Nor does it always mean effective.

Let’s get the “effective” part out of the way first. A law passed by Congress in 1994 restricts the FDA from reviewing dietary supplements before marketing as they do with prescription medications. Most of the claims made by the manufacturers about the benefits of their product have no basis in fact.

If these products were simply useless, you would only be wasting your money, but they are far from guaranteed safe.

Some products have been banned by the FDA after being on the market for extended periods when their side-effects were found to be very dangerous but may still be available by mail-order. These would include ephedra (Ma Huang) and DMAA, used for weight loss and energy, that cause high blood pressure and strokes.

Some are discouraged but still sold. Kava, easily available online, is used for anxiety but can cause severe liver damage. Yohimbe is used for erectile dysfunction and bodybuilding; it can cause high blood pressure, kidney failure and heart problems.

Colloidal silver is claimed to have immune support and anti-bacterial properties but can leave your skin permanently discolored.

Fat-soluble vitamins (A, E, D and K) are not easily removed from the body. While they are safe in low doses, high doses of Vitamin A can damage the liver, as several Texas families following RFK Jr’s advice discovered. High does of Vitamin D can dangerously raise your blood calcium.

Finally, some supplements can interact with prescription medicines you may be taking. St John’s Wort causes a more rapid breakdown of many medications so that they lose their effectiveness. These include birth control pills and anti-depressants.

Calcium supplements interfere with the absorption of many medications, causing them to be less effective. Green tea extracts (but not the amount in a cup of tea) affect the breakdown of many medications.

Finally, there is the serious concern that many supplements are adulterated with inactive and/or toxic ingredients. The under-staffed FDA is unlikely to ride herd on these products unless there is a mass poisoning event that commands their attention.

What should you do?

In general, don’t waste your money. Beyond a daily multivitamin, most OTC supplements are useless.

If you wish to take a supplement, buy it at a legitimate pharmacy or health food store that will be there if there are problems. Look for independent lab testing by the USP (U.S. Pharmacopeia) or NSF (National Science Foundation).

If you are taking prescription medications, ask your doctor to check for possible interactions before you start taking any supplements.


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Leaving the WHO/defunding USAID - penny unwise and pound foolish

President Trump announced on the day of his inauguration that he was withdrawing the U.S. from the World Health Organization, a process that takes a year under a joint resolution of Congress passed in 1948. The stated reason was the WHO’s failure to quickly sound the alarm about COVID-19.

In fact, the WHO’s general director told the world to get ready on Jan 23, 2020, and a week later declared a world-wide public health emergency. It was the Trump administration that down-played the pandemic and delayed the U.S. response, leading to hundreds of thousands of avoidable deaths.

On March 28, the Trump administration announced it was shutting down the US Agency for International Development (USAID), including all its disease-fighting initiatives around the world.

Do either of these decisions help the U.S.?

U.S. foreign aid in all its facets accounts for some 1% of the federal budget, and health-related spending is only a fraction of that.

What do we get for our financial support?

A global vaccination campaign led by the WHO led to the elimination of smallpox from the world. Global efforts have produced a 99.9% reduction in yearly polio cases, with polio now endemic only in Pakistan and Afghanistan. American support has led to a dramatic reduction in AIDS in South Africa. Malaria and tuberculosis deaths will both rise because U.S. aid has been stopped, and American tourists will also suffer.

With the world totally connected by trade and tourism, outbreaks in a distant country will inevitably reach the U.S. and strain our health system. When a few imported cases of Ebola occurred in 2014, 45 health centers here spent over $53 million to gear up. Since the question is not “if” but “when” the next pandemic arises, do we want to fight it alone?

WHO initiatives have directly benefitted Americans. Efforts by the WHO led to the discovery and standardization of oral fluid replacement for children suffering severe diarrhea, and this treatment is now widely used in the U.S.

Cutting American support for the WHO and reducing our support of health efforts around the world will save us a little money in the short-run but at the cost of millions of deaths in less-developed countries and in the long-run will end up costing us more as diseases first spread abroad and then reach American shores.

Write your Representatives and Senators and beg them to reverse this short-sighted decision.


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Avoid the summer itch!

Here comes summer, bringing outdoor barbecues, swimming and sailing, but also sunburn, mosquito-borne illnesses and poison ivy.

Let’s focus today on the itchy rash that plagues so many.

Poison ivy, poison oak and poison sumac share the same sap oil, urushiol, in their roots, stems and leaves. The oil is colorless and odorless, so it may not be obvious that you have it on your skin. You can spread it from one part of your skin to another without knowing it.

About 2/3 of adults develop dermatitis after getting urushiol on their skin, typically 1-2 days after contact, though it may be delayed if a first contact.

The rash is red and bumpy and intensely itchy, and is often in streaks, reflecting brushing against the plant. If severe, blisters may develop. The rash typically clears in 2-3 weeks.

Treatment is for symptoms, not cure, and includes wet compresses, calamine lotion and topical steroid creams. If it is very extensive or involves sensitive areas like the face or genitals, oral steroids can be prescribed.

Much better is prevention. If you think you have been exposed, wash your entire body with mild soap; water alone will not remove the oil, which penetrates the skin. Use a soapy brush under the nails. Wash any clothing that may have contacted the oil in warm soapy water.

Pets can carry the oil on their fur and pass it to you when you touch them, so bathe them if they have run through the plants.

Best, of course, is to avoid contact!

Poison ivy usually has three broad, tear-shaped leaves. It can grow as a climbing or low-spreading vine that sprawls through grass and often grows along rivers, lake fronts and ocean beaches. It is found everywhere in the continental U.S.

Poison oak has leaves that look like oak leaves and it grows as a vine or a shrub. The plant can have 3 to 5 leaflets per group. It is most common in the western U.S.

Poison sumac has seven to 13 leaflets per stem that are characterized by smooth surfaces and pointed tips. It is most often found in wooded, moist areas of the southern U.S.

Summer will be a lot more fun without the itch!


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Should parents "do their own research" on vaccines?

A few months ago, I was unsure which cabinet member was least qualified for their role, but it is now clear that Robert Kennedy Jr. can claim this dubious distinction. Not only is he temperamentally and by experience unfit to head a massive government agency, but he is actively fighting against the agency’s purpose.

Measles is a highly contagious disease that is 98% preventable by vaccination. Because measles spreads so easily, about 97% of the population must be vaccinated to prevent outbreaks.

The very success of vaccination in reducing childhood diseases has led many parents to worry less about these diseases. Measles, mumps, rubella, chicken pox, and whooping cough were once “the usual childhood diseases” but should now be rare. Polio should be exceedingly rare.

Instead, 2025 has seen 935 cases of measles to date, 121 (13%) of whom were sick enough to be hospitalized, and 3 children have died. 96% of those sickened have been unvaccinated. There have also been outbreaks in Canada, with Ontario and Alberta the hardest hit.

The U.S. has also seen whooping cough make a comeback. In 2024 there were 35,000 cases reported and 10 deaths.

Mr. Kennedy’s solution is to “do research on treatments” for measles, though the remedies he suggests such as cod liver oil have been extensively studied for decades and found worthless.

Kennedy has made himself wealthy from his vaccine-denial activities, earning a large salary from his foundation, Children’s Health Defense, and getting kick-backs from lawyers by sending them parents to join class-action suits against vaccine manufacturers. Children’s Health Defense is an activist group mainly known for anti-vaccine advocacy and is one of the main sources of misinformation on vaccines.

Instead of urging parents to vaccinate their children, as recommended by every medical group that has studied this subject, Kennedy suggested “parents should do their own research.” For most parents, this does not mean careful review of published scientific studies but rather going on Facebook or other social media platforms, where misinformation abounds.

Vaccines, while not 100% perfect, are very effective and very safe. Vaccines do not cause autism. This claim has been studied by numerous groups over recent decades and demonstrated to be false. While nothing we inject or ingest is 100% safe, the risks from vaccines are much less than the risks of the diseases they prevent.

Parents who care about their children should listen to their pediatrician and get their kids vaccinated so these ancient scourges can remain history and not current plagues.


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For Men Only; how does my prostate grow?

Of our many organs, the prostate gland seems to offer the most annoyance to men as we age. The prostate produces most of the fluid that carries semen and so is critical to reproduction. It is located near the bladder outlet and in young men is about the size of a walnut. As men age, the prostate grows. Unlike heart disease, there is nothing one can do with diet or healthy habits that impacts the prostate.

The two major problems that impact men’s health are prostate cancer and blockage of urine flow from a growing gland.

Growth of the prostate, called benign prostatic hypertrophy (BPH), is a normal part of aging, and occurs in essentially all men. Because of the location of the gland, it can impede flow of urine out of the bladder. It is a good rule that a 60-year-old man, however healthy, should not expect the urine flow of a 20-year-old.

What one does about BPH is entirely based on symptoms. The hallmark of BPH is incomplete emptying of the bladder. You may finish urinating and then feel you need to go again. Most older men will get up at night to void. It may cause urgency – the feeling that if you do not get to the bathroom you are going to lose control.

If these symptoms are mild, no treatment is needed. If they are more severe, medication can help. One class is alpha-blockers, that make it easier to void, that were originally developed to treat high blood pressure. They are generally easy to take, though may be a problem if you tend to have low blood pressure.

The more definitive treatment is to take a testosterone-blocker. Finasteride in low dose is used to treat male-pattern baldness (Propecia) and in high dose to shrink the prostate. It has been shown to reduce the need for surgery and the likelihood of complete urinary blockage. The downside is reduced sexual drive and erectile dysfunction (ED).

ED drugs like tadalafil help urinary flow and may be a good option to improve flow while also treating erectile dysfunction. Your insurance may not pay for this, as most still ration these drugs.

If medicines fail, surgery will usually work.

Prostate cancer occurs in the same organ, but otherwise is unrelated. Cancer occurs in small glands and huge ones equally. As men age, prostate cancer occurs more often and at the same time becomes less aggressive. If a 50-year-old has prostate cancer, unless it is surgically cured, he will probably die of this cancer. If an 80-year-old has prostate cancer, he will almost certainly die of something else, with his cancer but not due to his cancer.

I must also note that African-American men have almost twice the risk of white men.

While prostate cancer can be detected on a rectal exam, by this time it is usually advanced. Early detection is done with a blood test, the PSA (prostate-specific antigen). To say that PSA testing is controversial is an understatement; arguments for and against have raged in the medical literature for years.

I can best sum up the thousands of pages written by saying that screening men with regular PSA testing modestly reduces death from prostate cancer but has minimal effects on overall death rates. There is also consensus that PSA testing should stop at advanced age, though exactly when is debated. I would suggest 75.

If the PSA is elevated, in 2025 the best next step is an MRI of the prostate to detect and quantify any cancer. In low-risk patients, “watchful waiting” is a very viable option. In high-risk men, complete removal of the prostate offers the best chance for cure, with radiation therapy an acceptable alternative. Both treatments have significant side-effects, including bowel and/or urinary incontinence and loss of erection, hence the idea that not all cancers should be treated.

Prostate disorders are clearly conditions in which dialogue between the patient and doctor are key and second opinions critical. Do not accept the first option offered.


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It's a matter of balance

Falls can have very serious consequences as we age. Every year more than 25 percent of adults 65 or older have a fall, and 3 million are treated in emergency departments for fall injuries, according to the CDC.

Several things increase your risk of falling. Blood pressure that falls when you get up is a common culprit, and this in turn can be due to medication you take. If you feel light-headed when getting up, have your BP checked sitting and standing and if there is a fall of more than 10 points, discuss this with your doctor.

Poor vision, particularly when combined with poor light, can lead to a fall. Be sure that you have adequate light in your bedroom if you get up to go to the bathroom.

Be wary of electric cords that are everywhere and can easily trip you. Tape them down or to the wall.

Inadequate leg strength and poor sensation in the feet can lead to falls, as can vertigo from inner ear problems.

What can you do to reduce your risk of falling in addition to the above suggestions?

Doing specific exercises regularly will help. Start with three simple ones:

1. Stand with your feet shoulder-width apart for 10 seconds, increasing this to 30 seconds

2. Next, stand with feet together for 10 increasing to 30 seconds

3. Stand on one leg then the other

If these are too easy, do them with your eyes closed. (Be sure there is a sturdy surface you can touch such as a kitchen counter available.)

Walk heel-to-toe near a wall that can offer support.

Sit on a sturdy chair; get up without using your hands if possible. Sit down. Repeat, aiming for 10 times.

Do these exercises twice a day.

When you are going up or down stairs, hold on to the railing!

Finally, three points of contact are much more secure than two. If you are concerned about falling, a walking stick can be a great safety device.


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Is there calcium in my coronary arteries?

For many decades, doctors have used the traditional coronary disease “risk factors” to predict an individual’s risk of developing heart attacks or other major coronary events. These include smoking, diabetes, high blood pressure and elevated cholesterol.

These factors can be plugged into various formulas to predict the likelihood of a coronary event occurring in the next 10 years, and are used to decide if a person should be started on lipid-lowering therapy.

If the calculated risk is very low or very high, no other information is needed. Many people, however, fall into an intermediate risk range. In some instances, even those with high risk of coronary disease may not want to start a statin drug because of feared side effects (which are uncommon).

Such situations suggest the use of a coronary artery calcium (CAC) score.

As plaque (cholesterol deposits) builds up in coronary arteries, calcium is also deposited. A low-dose CT scan can measure the amount of calcium. Ideally, you would have a score of 0, and the higher the score, the higher the risk of developing symptomatic coronary disease.

Who might benefit from this testing?

If your doctor has recommended you start a statin but you are hesitant, a zero score would allow you to postpone the drug while a score over 100 would strongly suggest you take it.

If your calculated risk is intermediate, a zero score would suggest you do not need to begin cholesterol-lowering therapy while a non-zero score would push you to do so.

If your cholesterol is not bad but you have other risk factors for coronary disease, a CAC score will give useful information. If several family members had early heart attacks, a non-zero CAC score suggests that even if your cholesterol is not high, a statin might be a good idea.

If you have not tolerated a prescribed statin and stopped it, a CAC score may help you to decide whether to try a different statin or one of the newer injectable cholesterol-lowering drugs.

Who should not get a CAC score done?

If you are under 40, a zero score is expected and will not impact decision-making; use the traditional risk factors to guide your thinking. If you are over 80, and not on a statin, the results are unlikely to change recommendations to begin.

If your risk for coronary disease based on the traditional risk factors is high, a CAC is a waste of money: take a statin. If you are on a statin and doing well, be happy and do not get a CAC test.

Finally, if your score is zero, repeating the test can wait at least 3 and probably 5 years.


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Oh, My Aching Back. Part 2: Chronic back pain

About 20% of adults 20-59 and even more people 60 and over suffer from chronic back pain, pain that lasts 3 months or more and bothers you most days. Chronic low back pain can interfere with your enjoyment of life and is the leading cause of disability world-wide.

Unfortunately for sufferers and their doctors, most of this pain has no clear cause and no great remedy available.

There are two specific causes of chronic back pain that have a defined cause and a potential surgical treatment: spinal stenosis and ruptured disk.

Lumbar spinal stenosis is rare in young people but gets more common with age. The symptoms are classically pain in the legs when standing or walking with almost immediate relief upon sitting down. If it is truly disabling, surgery is an option to consider.

A ruptured disk can put pressure on the nerve root coming out of the spine; the pain will run down the back of one leg, usually as far as the ankle. On examination, lifting the leg when you are lying on your back is very painful. Most acute disk ruptures will improve with time. Unless you have obvious leg weakness, you should NOT rush to surgery. In a minority of people, however, the pain persists.

What about the majority of sufferers, whose back pain has no clear cause?

There are numerous treatments available, their number and variety testify to the fact that most do not work well for most people.

Anti-inflammatories such as ibuprofen and naproxen have the best success rate. There is no good evidence supporting nerve ablation, epidural injections or intramuscular injections, and all of these have potentially serious side effects.

Unless there is strong clinical evidence for spinal stenosis or a nerve root compression, do not get imaging of your back. If you are over 50, there is a 60% likelihood imaging will show one or more abnormalities, and if you are over 70 this rises to almost 100%. This is true even if you have never had a backache in your life! Never allow anyone to operate on you based on imaging; imaging should confirm a clinical diagnosis, not substitute for one.

Finding arthritis in the spine will not change treatment.

What can you do?

Exercise helps, particularly exercises that strengthen the core. Heat and massage often help. Spinal manipulation by a physical therapist or a chiropractor may help.

Avoid narcotics. They may help initially but often must be taken in increasing doses and carry the risks of addiction and side-effects.

Proper use of pillows or other forms of back support are key when sitting or driving.

If surgery is recommended, ALWAYS get a second opinion.

Try to stay as active as possible. Exercise within your limits.


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Oh, my aching back. Part 1 - acute back pain

Most of us have (or will have) experienced an acute lower back pain. Sometimes the cause is obvious – you unloaded six bags of loam from the trunk of your car – while other times “I just bent over to pick up a pencil.” Our back muscles extend over a long distance and stretching them just the wrong way may be all it takes.

Whatever the cause, it can make for a very uncomfortable time. What should you do?

First, what you should not do is go to the emergency room. Unless you have one of the “red flags” I list below, you do not need X-rays or CT scans. What you need is pain relief and a short period of rest.

Pain relief for acute onset back pain takes many forms, no one of which works for everybody. Getting flat with your knees bent and some pillows under your knees may be all you need. Both heat and cold can be very helpful. For acute pain, I tend to start with ice rather than heat, but if you have found a heating pad works, stick with it.

Note that you should only spend an hour or two lying down. After that, gentle movement such as walking is fine.

Get some over-the-counter pain relievers: acetaminophen, ibuprofen or naproxen are equally likely to help but each of us has a favorite. If one anti-inflammatory does not work, try a different one.

When might you need an imaging test? If the pain extends down the back of one leg towards the ankle you might have a ruptured disk, a condition that can be suspected based on clinical exam and confirmed with a CT scan. If you have known osteoporosis or cancer, or have been on long-term cortisone-type medication or the pain comes after a serious fall, you may be dealing with a fracture of one or more vertebra. This can be proven with a plain X-ray.

Cancer, an unexplained fever, IV drug use or a depressed immune system raise worry about an infection near the spine and suggest you seek early medical attention.

Assuming none of these uncommon situations fits, your pain should subside within a day or two with rest, pain relievers and ice or heat. Don’t try to ignore it and push through or the pain will last longer.

Next week: what about back pain that does not go away?


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What price for "miracles," and who pays for them?

There are now five drugs on the market to treat genetic disorders that are each priced at over $2 million.

They have been approved by the FDA to treat illnesses that had no curative therapy. Some, such as spinal muscular atrophy, were fatal while others such as hemophilia and sickle cell anemia led to repeated crises and frequent hospitalizations.

Are these astronomical prices justified? The pharmaceutical companies justify the prices by citing two factors: the high cost of drug development and the long-term financial benefits.

The problem with using research costs as a justification for the prices is that much of the basic research is funded by NIH grants or academia rather than by industry.

In the case of Zolgensma, Novartis’ $2.1 million drug for spinal muscular atrophy, the bulk of the early funding came from a private charity founded by parents whose child had the disease. ProPublica documented how their efforts, both financial and emotional, were ignored when the commercial potential of the drug began to become apparent. They hoped for a cure for their daughter and others similarly afflicted, not a windfall for the executives of the start-up they helped fund. See: https://www.propublica.org/article/zolgensma-sma-novartis-drug-prices-gene-therapy-avexis

Research published in JAMA provided details of the sponsorship and funding of 341 trials of gene therapy. Fewer than half were industry-funded. Academic hospitals, universities and the NIH were more often the funders, and yet the financial rewards almost all go to the pharmaceutical industry.

One could make a case that the sky-high one-time cost of gene therapy pays for itself by preventing the numerous emergency room visits and hospitalizations that it will eliminate. The estimated lifetime cost of hemophilia is $20 million! This makes the one-time $3.5 million cost of Hemgenix seem a bargain.

The big if is that the only data we have is that the benefits last 3 years – hopeful, but only a short span in a life-long disease. If the benefits fade after 4-5 years will CSL Behring refund the cost?

Will health insurance companies be willing to pay for a drug that may benefit the patient for 50 years or more when they know that their average subscriber is probably going to change insurers in a few years?

We need a different way to pay for these “miracle” drugs. One option is to have them paid for on an annual basis, spreading the cost over the patient’s estimated lifespan, with payment to stop if the drug stops working. A plan must be devised soon, or scientific advances plus pharmaceutical greed will exceed society’s ability to pay.





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Osteoporosis: could I have it?

Osteoporosis, thin weak bones, is common in post-menopausal women and older men. While not fatal, it is a major risk for fractures and can severely impact your quality of life.

Estrogen in women and testosterone in men are needed to maintain healthy bones and the biggest risk factor for developing osteoporosis is aging. The precipitous drop in estrogen levels in women who go through “the change” accelerates bone loss, and some 80% of those with osteoporosis are female.

Other factors increasing your risk are smoking, alcohol consumption, poor intake of calcium and vitamin D, lack of weight-bearing exercise, taking cortisone-type drugs and being thin. (One of the few health benefits of obesity is that you are less likely to get osteoporosis.)

How do you know if you have it? Osteoporosis is a “silent disease,” with no symptoms until it is advanced, and may first be discovered when you suffer a fracture.

The best way to find it before a fracture is to have a modified X-ray called a DEXA scan, which measures the density of your bones at the hip, spine and/or wrist. This gives you two numbers, a T-score, which compares your bones to those of a young healthy adult, and a Z-score, which compares you to an average person of your age.

If your T-score is: (note that these numbers are a consensus, not “truth.”)

• –1 or higher, your bone is healthy.

• –1 to –2.5, you have osteopenia, a less severe form of low bone mineral density than osteoporosis.

• –2.5 or lower, you might have osteoporosis.

The risk of broken bones increases by 1.5 to 2 times with each 1-point drop in the T-score.

A DEXA should be done when a woman is 65, a man 75, unless they have many risk factors for osteoporosis. While there is no hard rule, it should be repeated in about 2 years. If the results are stable, you can probably wait 5 years before a third.

If you want a precise estimate of your risk of fractures, google “FRAX Score.” The first link that shows up (https://frax.shef.ac.uk/FRAX/tool.aspx?country=9) will take you to the validated tool developed at the University of Sheffield in England. In addition to your T score, it asks for information such as age, height and weight and will then tell you your risk of a major fracture in the coming decade.

How can you prevent osteoporosis? Don’t smoke; don’t drink much alcohol; do resistance exercise (weights); get adequate calcium in your diet (dairy, leafy greens, almonds) and get adequate Vitamin D. Note that dietary calcium is better than pills. We get D from sun exposure and fortified milk.

Since few adults are big milk drinkers, and most of us do not spend all day outdoors soaking up sun, a vitamin D supplement is a good idea, and the amount in a multivitamin is probably adequate for most.

If you are at high fracture risk, many different medicines are available that have been shown to reduce the likelihood of fractures – but are not a guarantee. The best-studied are the “bisphosphonates,” taken as a weekly or monthly pill, but there are many other classes of drugs highly marketed. All these remedies have the potential for serious side-effects, so the decision to start requires a careful dialog with your doctor.

There is also good evidence that taking a bisphosphonate for a couple of years and then stopping is a better idea than taking it forever.

Remember: prevention is better than treatment, so start early. The bones you preserve will be the ones to keep you upright and moving.



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Measles: do I need a booster?

It may be hard for younger people to accept this, but when I was in medical school, we talked casually of patients having had “the usual childhood diseases,” referring to measles, mumps, chicken pox and rubella (German measles).

Measles is a highly contagious disease that spreads easily to others with near 100% transmission. While generally a flu-like illness with a rash from which children recover, about 5% of measles patients develop pneumonia, 1 in 1000 develop brain swelling with deafness and/or intellectual disability resulting and 3 per 1000 die.

A vaccine to prevent measles was introduced in 1963 with dramatic results. Prior to 1963, nearly every child got measles by age 15. There were 3-4 million cases a year, with 48,000 hospitalizations and 500 deaths annually. This fell dramatically after the vaccine was available. Reported cases fell 97% between 1965 and 1968 and measles was declared “eliminated” in the U.S. in 2000.

Unfortunately, this very success has led to complacency, and the disinformation by “anti-vaxxers” has contributed to a falling off of vaccination rates.

Not surprisingly, measles has recurred. In 2024, the U.S. saw 16 outbreaks (3 or more cases) involving a total of 285 cases. As of the end of February, 2025 has seen 9 outbreaks, with a total of 164 cases. The best known is the Texas outbreak, but there have been others around the country. 95% of the cases involve people who were unvaccinated.

Do you need to worry?

If you were born before 1957, you almost certainly had measles, whether you remember this or not, and if you were born before 1963, you probably did. Natural infection gives virtually 100% life-long immunity, so there is no need to get a booster.

If you were vaccinated between 1963 and 1968, you may have received a less-effective vaccine and may want to have your antibody levels checked with a blood test.

If you received two doses of the standard MMR (measles/mumps/rubella), you are 97%+ protected unless you have an immune deficiency.

So, for most of us, protected by childhood infection or vaccination, no worries. For our children and grandchildren: GET VACCINATED. The MMR does NOT cause autism, and there have been no deaths from the vaccine in healthy people. Children with immune deficiency, a very rare condition, cannot get the vaccine, and depend on the other 99% of us preventing outbreaks by getting vaccinated.



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Influenza - NOT just a "bad cold"

Unless you are Chinese, you have probably never heard of Barbie Hsu, but in the Chinese-speaking world this Taiwanese actress is famous. That world was shocked to learn of her death from influenza while on a family vacation in Japan.

Ms. Hsu was young (48), healthy, rich and treated in a country with an excellent health care system. Why did she die?

People tend to dismiss “the flu” as just another cold, and only a minority of people around the world get their annual flu shot. As of Feb 1, about 45% of Americans have received their vaccination. For younger adults, it is well under 40%.

Influenza is much worse than the run-of-the-mill winter respiratory virus. While it is not usually fatal except in infants and frail elders, Ms. Hsu’s death reminds us that even healthy people do die from influenza.

Even if you rarely die, influenza is a very nasty illness. You have a terrible cough, ache all over, and are usually sick for a week or more. In the U.S., for the 2023-24 flu season, there were 18 million flu-related medical visits, 470,000 flu-related hospitalizations, and 28,000 flu-related deaths.

This year, there have been a larger than average number of influenza cases, office visits and hospitalizations. It looks as if this will be the worst flu season since 2009-2010.

What should you do?

Get your flu shot! While far from perfect, the immunization does reduce your chance of catching influenza by about 40% and reduces your risk of being sick enough to require hospitalization by 60%. It is not too late to get the shot.

Given the surge in cases, you should also consider wearing a mask when you are in crowded indoor environments.

If you are sick, please stay home! Sharing life’s bounties is good. Sharing your respiratory virus is not.

Good hand hygiene is also important.

Remember – the life you save could be that of your best friend or favorite aunt.



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Cannabis and health

Marijuana, now most often called cannabis, use is growing. In recent years, almost 20% of the U.S. population have used cannabis, with 4% using it daily or almost daily. What is the impact on the health of regular users?

Advocates describe better sleep, less pain and less anxiety. Unfortunately, these benefits come at a price.

Multiple studies have examined the association of regular cannabis use with symptoms and illness.

I can get the good news out of the way quickly. Regular users are less likely to report nasal congestion than non-users, unlike tobacco users who report more nasal and sinus issues.

Unfortunately, on the key major illness side, the news is not good. Regular cannabis users have more heart attacks and strokes than non-users, with even higher risk among those who use it daily or near-daily.

Regular cannabis smokers also have dramatically more (3-4 times) head and neck cancers than non-users. The highest risk was for laryngeal cancer, but higher rates of mouth and tongue cancer are also seen.

Middle-aged and older adults are increasingly using cannabis-based therapies (CBT) for symptoms, and this population suffers from many CBT-related side effects, including dry mouth, dizziness, balance problems, drowsiness and confusion.

Motor vehicle accident rates rose an average of 15% in states after recreational cannabis use was legalized, and the best evidence we have suggests that regular cannabis use is associated with a roughly 50% greater chance of having an accident and a 30% increase in fatal accidents.

Finally, there is the concern about cannabis’ effects on the developing brain. Cannabis use by mothers during pregnancy has been linked to problems with attention, memory, problem-solving skills, and behavior in their children.

Using cannabis before age 18 may affect how the brain builds connections for functions like attention, memory, and learning.

So, no, cannabis is not harmless. If you use it, do so with the knowledge that you may pay a price beyond the cost of the drug.



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What do we know about bird flu?

There are many influenza viruses. A and B are the main causes of seasonal flu outbreaks and while B only infects humans, influenza A can infect many bird and animal species.

A given influenza virus is identified by two proteins found on its surface, H and N. The common viruses causing winter influenzas are H1N1 and H3N2. The “bird flu” is H5N1.

When bird flu first appeared, it was thought to be a risk primarily to birds and was felt unlikely to infect people. Infecting birds is bad enough: the current outbreak among chickens has been a major cause of diminishing supply and increasing price of eggs. The infected flock must be slaughtered, so chicken also becomes scarcer and more expensive.

The story has gotten worse. H5N1 can clearly spread readily to dairy cattle; there have been major herd outbreaks around the U.S. It can also spread to cats, both wild and domestic and other animals.

From cattle, there has been spread to humans, so far rare and sporadic. Since 1997, there have been about 1000 proven human cases world-wide, reported from 23 countries. More than half of these have died, and this number is clearly an undercount, since testing for H5N1 is not routinely done.

In the U.S. since the start of 2024 there have been 66 proven cases of bird flu, most in dairy workers, and one death. One 13-year-old girl required life support but recovered.

So far, no human-to-human spread has been seen, but as we have learned, viruses mutate, and it would not be a shock for a mutation to appear that would allow this to happen.

Oseltamivir (“Tamiflu”) has been approved to treat H5N1 based on very little data. This drug has been available since 1999 to treat seasonal flu but is not that effective for most patients. Studies have shown that it shortens symptoms of influenza by a day. It does have benefit in very sick influenza patients, reducing the death rate by almost half.

A vaccine is available, but there are only a few million doses stockpiled and if the H5N1 mutates to spread human-to-human, the vaccine may need to be modified.

What should you do?

Avoid raw milk, which transmits H5N1 (as well as many other nasty infections!) and raw meat, and do not feed raw meat to your pets. Pasteurized milk is safe, as is properly-cooked meat.

Do not touch sick birds; call your animal control officer, who will know how to safely handle them.



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I heard about this new drug....

Among developed countries, only the U.S. and New Zealand allow direct-to-consumer advertising by pharmaceutical companies and boy, do they take advantage of this opportunity! You cannot watch television without seeing ads for pharmaceutical products.

The FDA relaxed its guidelines on radio and television advertising in 1997, and the boom took off. In 2012, spending on traditional media (mostly TV) advertising by the pharmaceutical industry was $3.2 billion and by 2024 it hit $7.5 billion.

As eyeballs turned from broadcast TV to social media, pharmaceutical advertising followed. In addition to the $7.5 billion spent on traditional broadcast media, pharma ads on social media hit $19.5 billion in 2024.

Why do they spend so much money on these ads? Because they work. People hear about new “wonder drugs” and ask their doctors about them.

Product claim ads, the majority, give the drug’s brand name (in large print) along with its generic name, the condition it treats and its benefits and risks. The benefits are up front and emphasized while the risks typically go by rapidly at the end. Cost is never mentioned.

Not surprisingly, there is no obligation for the ad to specify how the drug works or if there are competing drugs for the same condition that are safer or cheaper.

A fascinating study published in the Journal of the American Medical Association two years ago found that advertising expenses were much higher for drugs of limited benefit than for those with greater clinical benefit.

What should you do? If you think you have the condition the drug is supposed to help, it is perfectly OK for you to ask your doctor about it. They are in the best position to know if the drug might benefit you, if it is safe for you given any other medical conditions you have and medicines you are taking, whether there are better and/or cheaper drugs to use instead and if you can avoid the need for any drug by making lifestyle changes.

I must note that doctors are also heavily marketed by big pharma and not immune to the siren call of glossy ads and free lunches brought by pharma’s marketing representatives.

Remember, the purpose of any advertisement is to sell products. This is as true for pharmaceutical ads as it is for ads for cars or vacation time-shares. The primary goal of pharmaceutical advertising is not to help you but to sell more drugs, so take the claims with a large grain of salt.



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It is OK to "Talk Dirty" to your doctor

As toddlers, nothing is off-limits. We are fascinated by the whole world, including our bodies and the things that come out from them.

As we get older, we are socialized to regard many topics as not to be discussed, and this often colors the way we present ourselves to doctors and nurses, sometimes to our detriment.

It is said that 70% of the information a doctor needs to make a diagnosis comes from the history. This assumes the history given is accurate.

One good example is our bowels. While I agree that discussing one’s bowel habits at a dinner party would not be appropriate, the same does not hold true in the doctor’s office. If there has been a change in your frequency or the appearance of your movements, this may indicate disease and so should not be kept secret.

Ditto urination. Increased frequency of urination, loss of bladder control or change in urine color may all need to be addressed, but this will only happen if you tell your doctor about these things.

Your sexual habits may put you at higher risk for certain illnesses and may suggest certain tests be done, but these will only be ordered if the doctor is aware of the need.

Do you drink more than you let on? Do you use injectable drugs? These habits clearly increase your risk of liver disease and other conditions, and it is important that your doctor know about these behaviors.

Just as a Catholic going to confession feels safe in admitting their behaviors to the priest, a patient seeing their doctor should feel safe in discussing topics they would never bring up in any other situation.

Unless your doctor has limited their practice to convents, you will not be telling them anything they have not heard before, so there is no reason to be embarrassed. Knowing these behaviors and habits will get you more effective care than will keeping them secret.

While there is doctor-patient confidentiality, in an era of electronic medical records you may justifiably worry about privacy. If this is a concern, you can ask the doctor specifically not to put what you are telling them in their note. Since, in the U.S., you are entitled to see your medical visit notes, you can verify they have followed your request.

A well-informed doctor will give you better care. Nothing you say will shock them, so be open!



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Alcohol: how bad is it?

The news media have been filled with reactions to the U.S. Surgeon General’s recent pronouncement that alcohol was a major cancer risk, and that alcoholic beverages should carry a cancer warning label like that on cigarette packages. (Ireland currently requires such warning labels.)

The World Health Organizations estimates that about 4% of cancers worldwide are alcohol-related.

The long-touted heart protective effects of alcohol have been questioned.

What should you believe?

First, some definitions. A “standard” drink is defined as 5 ounces of wine, 12 of beer and 1.5 ounces of liquor.

Women metabolize alcohol differently than men, and so have higher blood levels than men from the same amount consumed.

Almost all studies of the effects of alcohol on health are flawed.

First, they depend on self-reported consumption. Since many, if not most, people know that heavy drinking is not good, there is a strong tendency to under-report what you drink.

Second, they are observational: groups are followed and their health outcomes studied. We know that this type of study is prone to bias. People who drink alcohol may have many other habits that non-drinkers do not share, such as smoking.

Alcohol consumption has been linked to higher incidences of head and neck cancer, liver cancer, colorectal cancer, esophageal cancer and breast cancer.

Even the most toxic of substances only cause harm at threshold doses, and for most toxins, the more, the worse. Consistent with this, the National Academy of Medicine estimated that 2 drinks/week would shorten your life by less than a week, 7 drinks/week would shorten your life by 2.5 months while 5 drinks/day would shorten it by over two years.

A recent study from Spain shed fascinating light on wine and the heart. Rather than ask subjects how much they drank, they took urine samples and measured metabolites of wine to objectively estimate how much they drank. They found that light-to-moderate drinkers (from ½ to 1 glass/day) had 50% fewer cardiac events over 6 years of follow-up. This protective effect disappeared in those who drank more than 1 glass/day.

My take-aways:

If you do not drink, there is no reason to start. There are no net health benefits to drinking.

If you drink heavily (more than 2 drinks/day for men, 1/day for women), please cut down. You are harming yourself.

If you enjoy a glass of wine a few times a week, relax. The slight increased cancer risk is probably balanced by less heart disease.

The Greeks had it right: all things in moderation.



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Norovirus - what you need to know

There are many gastrointestinal infections that spread person-to-person, including E. coli, salmonella and listeria, but by far the most common is the norovirus.

Norovirus typically infects some 20 million people in the U.S. every year, and this winter has seen an increase in reported outbreaks.

The virus is highly transmissible, resistant to alcohol (the active ingredient in most hand sanitizers) and heat, and persists for many days on surfaces such as counters.

Places where people are in close quarters and sharing food preparation are particularly prone to outbreaks: cruise ships, nursing homes, schools and day care centers.

The symptoms: nausea, vomiting, cramps and diarrhea, usually begin very abruptly – you feel fine one minute and then all the symptoms hit you. If there is a fever, it is usually low-grade. The symptoms generally only last 2-3 days and most people recover uneventfully.

There is no specific treatment; antibiotics are of no use. The most important therapy is fluids to prevent dehydration. Adults can drink plain water, tea, sports drinks or light fruit juices. Children will benefit from pediatric-tailored electrolyte solutions.

While most healthy people will do fine at home taking frequent small amounts of fluid, an ER visit or even hospitalization may be needed if you cannot keep down liquids.

A persistent fever of 101 or more is unusual and warrants at least a call to your doctor. Blood in the stool is also not expected and should prompt medical attention.

The best way to avoid catching norovirus is good hand-washing before you eat or prepare food, and cleaning surfaces with bleach if they may have been exposed to virus particles.

Note that virus may be shed in the stool for up to two weeks, long after you have recovered, so be careful if you have had such symptoms to wash well after using the toilet and you had best not handle food.

Norovirus has also spread via shellfish and other food. Cook shellfish to an internal temperature of over 145 F and wash all fresh fruits and vegetables.

If you do catch it, remember that “this too shall pass.”



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