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Psoriasis is a chronic disease in which skin cells rapidly divide, causing the skin to develop rough, red, scaly patches. Plaque psoriasis is the most common form: affected skin has sharply defined, inflamed patches (plaques) with silvery or white scales, often near an elbow or on the shins and trunk.

The cause of psoriasis isn’t known, but there are a number of treatment options. Possibly you’ve seen a glossy, happy ad for one of these treatments, a drug called Skyrizi. It’s been in heavy rotation and in 2020, hit number four on a top 10 list for ad spending by a drug company.

Splashing in blue water

A woman in a bathing suit sprints down a dock and jumps into the water with several friends. There’s lots of smiling and splashing. A voiceover says “I have moderate to severe plaque psoriasis. Now, there’s Skyrizi. Three out of four people achieved 90% clearer skin at four months after just two doses.”

Then, the voiceover moves to warning mode: “Skyrizi may increase your risk of infections and lower your ability to fight them. Before treatment your doctor should check you for infections and tuberculosis. Tell your doctor if you have an infection or symptoms such as fever, sweats, chills, muscle aches, or cough, or if you plan to or recently received a vaccine.”

As these warnings are delivered, we’re treated to uplifting pop music — “nothing is everything,” a woman sings — while attractive young people flail about in the water.

“Ask your doctor about Skyrizi,” a voice instructs. Did I mention a plane is skywriting the drug’s logo? I guess it’s putting the “sky” in Skyrizi.

What is Skyrizi?

Skyrizi (risankizumab) is an injectable medication that counteracts interleukin-23, a chemical messenger closely involved in the development of psoriasis. The standard dosing is two injections to start, followed a month later by two injections once a month, and then two injections once every three months.

Did you catch that “injectable” part? This is not a pill. If you missed that point while watching the commercial, it’s not your fault. The word “injection” appears once, written in faint letters at the very end of the commercial.

By the way, the FDA has only approved this drug for moderate to severe — not mild — plaque psoriasis. The studies earning approval enrolled people with psoriasis on at least 10% of their skin and two separate measures of severity.

What the ad gets right

• The ad states that 75% of people with moderate to severe psoriasis experienced 90% clearance of their rash within four months after only two doses of Skyrizi. This reflects the findings of research studies (such as this one) that led to the drug’s approval.
• The recommendations regarding screening for infections (including tuberculosis) and telling your doctor if you’ve gotten a recent vaccine are appropriate and should be standard practice. By lowering the ability to fight infection, this drug can make current infections worse. It may reduce the benefit of certain vaccines, or increase the risk of infection when a person gets a certain type of vaccine called a live-attenuated vaccine.

And the theme song? People with visible psoriasis often cover up their skin due to embarrassment or stigma. The rash isn’t a contagious infection or a reflection of poor health, but other people may react as if it is. So, an effective treatment could potentially allow some to forego covering up and show more skin: it means “everything” to someone suffering with psoriasis to cover “nothing.” Thus, a theme song is born.

What else do you need to know?

A few things about this ad may be confusing or incomplete, including:

• Currently, each dose of Skyrizi is actually two injections. So, a more accurate way to summarize its effectiveness would be to say that improvement occurred within four months after four injections (rather than “just two doses”).
• Like most newer injectable medications, this one is quite expensive: a year's supply could cost nearly $70,000. The drug maker offers a patient assistance program for people with low income or limited health insurance, but not everyone qualifies. Health insurance plans generally require justification from your doctor for medications like Skyrizi, and your insurer may decide not to cover it. Even if covered, this prior approval process can delay starting the medication, which may still be expensive due to copays and/or deductibles.
• There is no mention of the many other options to treat psoriasis, some of which are far less costly. These include medications that do not have to be injected (such as oral methotrexate or apremilast), and UV light therapy (phototherapy). And there are other injectable medications. So, ask your doctor about the best options for you.

The bottom line

Some people appreciate the information provided by medication ads. Others favor a ban on such advertising, as is the case in most other countries. And recently, two advocacy groups asked the FDA not to allow drug ads to play music when the risks of drug side effects are presented, arguing that it distracts consumers from focusing on this important information.

Since these ads probably are not going away anytime soon, keep in mind that they may spin information in a positive light and leave out other important information altogether. So, be skeptical and ask questions. Get your medication information from your doctor or another unbiased, authoritative source, not a company selling a product.

Regardless of how you feel about medical advertising, it’s hard to hate the Skyrizi theme song. Feel free to sing along.

What can you add to a wide variety of foods, from cereals to salads, that’s crunchy, filling, and flavorful — and good for your heart? The answer is nuts. While all varieties of nuts are chock full of important nutrients, walnuts may be especially good for protecting cardiovascular health, according to a recent study in the journal Circulation that supports earlier research in this realm.

What is the study?

The Walnuts and Healthy Aging study is a randomized controlled trial supported by a grant from the California Walnut Commission that tracked healthy older adults living in two communities. For the study, researchers recruited 708 adults ages 63 to 79 living in Loma Linda, California, or Barcelona, Spain, and split them into two groups. One group added about a quarter-cup to a half-cup of walnuts to their daily diet for two years, while the other group ate no walnuts.

After two years, average levels of harmful low-density lipoprotein (LDL) cholesterol were modestly lower in the walnut group. Of note: nearly a third of the participants were taking cholesterol-lowering statins, so the average cholesterol levels of both groups were already in a normal range. The researchers speculate that the cholesterol-lowering benefits from walnuts might be more pronounced in people with elevated cholesterol levels. There is no way to know from the current data if this is true.

“This recent trial confirms what earlier studies have found, namely, that that adding walnuts to your diet appears to improve your cholesterol levels,” says Dr. Deirdre Tobias, an obesity and nutritional epidemiologist at Harvard-affiliated Brigham and Women’s Hospital. The new trial also lasted much longer than past walnut studies. However, it’s not clear what foods were being replaced by the walnuts in the participants’ diets, which might affect the magnitude of benefits the researchers saw. For example, replacing unhealthful, ultra-processed snacks with walnuts would presumably have a greater benefit than a lateral move from healthy options to walnuts, Dr. Tobias explains.

Lower levels of harmful blood fats, no additional weight

The researchers also analyzed the concentration and size of the LDL particles. Smaller, more dense LDL particles are more likely to trigger atherosclerosis, the buildup of fatty plaque inside arteries that’s the hallmark of most cardiovascular disease that results in heart attacks or strokes.

The walnut eaters had lower levels of these smaller particles. They also had decreased levels of intermediate-density lipoproteins (IDL), which are also linked to a rise in cardiovascular-related risks. And even though a quarter-cup of chopped walnuts is about 190 calories (and a half-cup is about 380 calories), the walnut eaters did not pack on any extra pounds.

Earlier research has found that people who eat nuts regularly are less likely to have heart disease, and many studies have focused specifically on walnuts. In 2018, Dr. Tobias and colleagues published a meta-analysis and systematic review of studies that examined how eating walnuts affects a person’s blood lipids and other heart-related risks. The review included 26 controlled trials involving a total of more than 1,000 people. It found that walnut-enriched diets led to lower total cholesterol, LDL cholesterol, and triglycerides, the most common form of fat in the bloodstream.

What’s special about walnuts?

Although all nuts are good sources of healthy unsaturated fats, walnuts are especially rich in alpha-linolenic acid (ALA). This is a precursor to the omega-3 fatty acids EPA and DHA found in fatty fish that are known for their heart-protecting powers. Our bodies convert ALA to EPA and DHA, although the efficiency of this varies from person to person.

What’s more, walnuts are usually eaten raw. So they have greater antioxidant abilities than nuts that are usually eaten roasted. (Antioxidants help prevent or reduce the artery-damaging oxidation that contributes to heart disease).

Adding walnuts to your diet

It’s worth noting that the FDA allows a qualified health claim on some nuts (including walnuts). Foods made with them are permitted to include the following statement: “Eating a diet that includes one ounce of nuts daily can reduce your risk of heart disease.” An ounce of walnuts is about a handful, or one-quarter cup.

You can sprinkle walnuts onto oatmeal or other hot or cold cereals; stir them into pancakes, muffins, or other quick breads; or toss them with vegetables or into salads. If high cholesterol is a health concern for you, there are other foods that may help lower your LDL cholesterol and boost your heart health.

Insomnia is a sleep disorder that affects approximately 10% of adults in the United States. It is characterized by difficulty with falling asleep, staying asleep, and/or waking up too early, at least three times per week for a period of three months or more. Contrary to some beliefs that insomnia will get better by itself over time, evidence suggests that it will persist if not actively treated. In one study, 37.5% of patients with insomnia reported that their insomnia was still a problem five years later.

What are common treatment options used for insomnia?

Perhaps the most common nonpharmacological intervention used for insomnia is something called sleep hygiene. It describes a series of good sleep habits to engage in (such as keeping your bedroom quiet at night) and ones to avoid (turning off electronic devices before going to bed).

Unfortunately, as many patients know, sleep hygiene is not a very effective treatment for insomnia when implemented by itself. When sleep hygiene is used as one part of a multimodal approach, such as cognitive behavioral therapy for insomnia, it can be an effective complement to other important strategies. While cognitive behavioral therapy for insomnia is recommended as the gold-standard treatment by the American Academy of Sleep Medicine and the American College of Physicians, finding a clinician with expertise in behavioral sleep medicine can be a challenge — even via telemedicine.

Integrative treatment approaches are popular

Many people are interested in pursuing other treatment options for insomnia that do not involve prescription medications. Increasing evidence suggests that a number of approaches may be beneficial, including mindfulness-based practices and mind-body movement practices like yoga. Some people may use dietary supplements such as valerian, melatonin, chamomile, and cannabis, though evidence is more limited regarding their efficacy. You should always tell your doctor if you are taking any dietary supplements, as these may interact with other prescription medications.

An integrative option for people with insomnia and a psychiatric disorder

Insomnia is a common issue for people with a psychiatric disorder, possibly because of overlapping neurobiology. For example, someone with insomnia is 10 times more likely than someone without insomnia to also have depression. Among patients receiving psychiatric care, compression and weight have been used therapeutically. It has been hypothesized that the calming (and possibly sleep-promoting) effects of such an approach may be similar to what is experienced with acupressure or massage.

A team of researchers at the Karolinska Institute in Stockholm, Sweden conducted a study to determine whether a weighted metal chain blanket could improve insomnia symptoms compared to a light plastic chain blanket. They recruited outpatients with elevated insomnia symptoms who were being treated for one of several mood disorders: major depressive disorder, bipolar disorder, generalized anxiety disorder, or attention deficit hyperactivity disorder (ADHD).

Participants were randomly assigned to receive either a weighted metal chain blanket or a light blanket with plastic chains that were sewn on, which were the same shape and size as the metal chains on the weighted blanket. Those who were provided with a weighted metal chain blanket first tried on an 8-kilogram (17.6 pound) blanket. If this was too heavy, a 6-kilogram (13.2 pound) blanket was then provided. Over a four-week period, their sleep was assessed using surveys and a wrist-based device called an actigraph.

What did the researchers learn?

Participants who used the weighted metal chain blanket reported that their insomnia symptom severity declined significantly, while those who had used the light blanket did not experience such notable improvements. Furthermore, depressive symptoms and anxiety symptoms decreased much more for those who used the weighted blanket than those who used the light blanket. This secondary finding is consistent with other work showing that interventions designed to treat insomnia can have a meaningful impact on mood.

These promising findings are tempered by data showing that there were no significant improvements to key insomnia metrics, such as the amount of time spent awake after falling asleep, when sleep was tracked objectively using the actigraph. Other research conducted in children has also failed to demonstrate that weighted blankets significantly change sleep outcomes when measured using an actigraph.

Should you buy a weighted blanket?

While these findings are intriguing, more research is needed. It is important to note that there is a very real placebo effect for insomnia symptoms. This means that if you are someone who believes a weighted blanket could have a positive effect on your sleep tonight… well, it's quite possible that it will. For healthy adults, weighted blankets are considered safe as long as the individual can lift the blanket off when necessary. Because sleep is such a subjective experience, the cost of a weighted blanket may be money well spent — as long as you don’t forget that there are other options available to treat insomnia, with much more research data to support their effectiveness.

Migraine is a common and disabling headache disorder. Painful migraine headaches frequently affect people in their most productive years of life, between the ages of 18 and 44. Many common medication treatments for migraine may cause side effects that are difficult to tolerate, and can lead people to not take their medications as recommended, or to stop taking them altogether. A recent study suggests that up to 20% of patients with migraine have used opioids to treat their pain in the past year. Therefore, there is a great need for better and more tolerable treatments for people who have migraines.

Research has shown that combining behavioral treatments with preventive medication treatments works better for preventing headaches than medications alone. Mindfulness practice has also been associated with improvements in individuals with chronic pain, including migraine. Mindfulness is the mind-body treatment that involves purposely focusing one’s attention on the present momentary awareness and accepting it without judgment.

Stress is a well-known trigger for migraine. Moreover, stressful events have been associated with people experiencing more frequent or chronic migraines versus having them occasionally. Mindfulness can result in stress reduction, reduced emotional response to stress, and improved general happiness. In patients with migraine, pain severity and unpleasant symptoms can be reduced with this treatment.

Mindfulness can potentially strengthen emotional and cognitive control of pain by helping to train someone with migraine to reassess their pain in a nonjudgmental way and modify their evaluation of the pain. In addition, mindfulness practices can help to control depression, anxiety, and pain catastrophizing (an exaggerated negative feeling toward pain experiences), which can play a role in chronic migraine.

The study

In a recent study published in JAMA, a group of researchers investigated whether mindfulness-based stress reduction may provide benefit for people experiencing migraine. The study randomly assigned half of participants with migraine to the mindfulness treatment and the other half to only headache education.

The mindfulness-based stress reduction treatment incorporated eight weeks of two-hour, in-person classes, which included sitting and walking meditation, body scanning (sequential attention to parts of the body), and mindful movement (bodily awareness during gentle stretching using hatha yoga), bringing attention back to the natural rhythm of the breath. In addition, the study participants were encouraged to build their capacity to address physical and mental perceptions of their pain, and they were provided audio files for at-home practice.

The headache education treatment included a standardized protocol of eight weeks of two-hour, in-person classes that contained education about the biological, psychological, and environmental processes associated with migraines, headache triggers, and stress. The patients were also given time for questions, answers, and discussion during each class.

The results

The researchers demonstrated that mindfulness-based stress reduction treatment significantly improved people’s disability, quality of life, self-efficacy, pain catastrophizing, and depression compared to patients who only had headache education. Reductions in monthly migraine days were observed in those with mindfulness-based stress reduction treatment, but were not significantly different from those receiving headache education. The authors of the study explain that the reason they could not demonstrate improvement in the headache frequency could be the use of an active control group such as headache education, which itself may result in improvement of headache frequency.

Most importantly, the study demonstrated that mindfulness-based treatments can reduce the burden of migraine. With mindfulness, the participants of the study may have learned a new way of processing pain that may have a significant effect on their long-term health. The results of this study have major implications for both patients and clinicians, and the research can support a holistic, integrative treatment plan for patients with migraine, with less emphasis on nonmedical treatments.

What you can do

Many healthcare providers, including headache specialists, pain specialists, neurologists, and primary care physicians, have started to incorporate mindfulness-based treatment in their practices, or they have sought mindfulness-based programs or specialists for their patients.

There are also many ways for patients with migraine to practice mindfulness at home. Patients with migraine can integrate some of the following mindfulness-based practices in their daily life, including during a migraine headache:

• Accept yourself, your present moment.
• Lie on your back or in a comfortable position with no distractions, and direct your awareness to your body and breathing. Scan your body and observe your feet, legs, hands, arms, and other parts of your body.
• Try to sit down in a comfortable and quiet place, close your eyes, take a deep breath. Try to do breathing exercises, paying attention to the sensations of your breath while inhaling and exhaling.
• Sitting or walking meditation done outside in nature may be very relaxing. Focus on the experience of walking, being aware of the sensations of standing and the subtle movements that keep your balance.

Resources

There many are apps and quality resources for mindfulness and migraine learning and practice. Here are few online resources to explore:

Body scan mindfulness exercise for pain (Harvard Health Publishing)

Mindfulness Meditation for Migraine (American Migraine Foundation)

Mindfulness series for Migraine & Headache Disorders (Miles for Migraine)

Mindfulness and Migraine (National Headache Foundation)

During the first year of life, naps are crucial for babies (who simply cannot stay awake for more than a couple of hours at a time), and crucial for parents and caregivers, who need breaks from the hard work of caring for an infant.

But as children become toddlers and preschoolers, naps aren’t always straightforward. Children often fight them (following the “you snooze you lose” philosophy), and they can conflict with daily tasks (such as school pick-up when there are older siblings) or lead to late bedtimes.

Here are some tips for making naps work for you and your child — and for knowing when they aren’t needed anymore.

Making naps work for your baby

Most infants will take at least two naps during the day, and early in toddlerhood most children will still take both a morning nap and an afternoon nap. Naps are important not just for physical rest and better moods, but also for learning: sleep allows us to consolidate new information. As children get older, they usually drop one of the naps, most commonly the morning nap.

Every child is different when it comes to napping. Some need long naps, some do fine with catnaps, some will give up naps earlier than others. Even within the same family, children can be different. A big part of making naps work is listening to and learning about your child’s temperament and needs. Otherwise, you can end up fighting losing battles.

The needs of a parent or caregiver are also important: everyone needs a break. Sometimes those breaks are particularly useful at specific times of the day (like meal prep time). While you can’t always make a child be sleepy at the most convenient time for you, it’s worth a try — which leads me to the first tip:

Schedule the naps. Instead of waiting for a child to literally drop and fall asleep, have a regular naptime. We all do better when our sleep routines are regular, even adults. If you can, put the child down awake (or partially awake). Learning to fall asleep without a bottle or a breast, or without being held, is a helpful skill for children to learn and can lead to better sleep habits as they grow.

A couple of scheduling notes:

• If you need a child to fall asleep earlier or later than they seem to do naturally, try to adjust the previous sleep time. For example, if you need an earlier morning nap, wake the child up earlier in the morning. It may not work, but it’s worth a try.
• Naps later in the afternoon often mean that a child won’t be sleepy until later in the evening. That may not be a problem, but for parents who get tired early or need to get up early, it can be. Try to move the nap earlier, or wake the child earlier. If the problematic afternoon nap is in daycare, talk to the daycare provider about moving or shortening it.

Create a space that’s conducive to sleep. Some children can sleep anywhere and through anything, but most do best with a space that is quiet and dark. A white noise machine (or even just a fan) can also be helpful.

Don’t use screens before naptime or bedtime. The blue light emitted by computers, tablets, and phones can wake up the brain and make it harder for children to fall asleep.

When is it time to give up naps?

Most children give up naps between the ages of 3 and 5. If a child can stay up and be pleasant and engaged throughout the afternoon, they are likely ready to stop. Some crankiness in the late afternoon and early evening is okay; you can always just get them to bed earlier.

One way to figure it out, and ease the transition, is to keep having “quiet time” in the afternoon. Have the child go to bed, but don’t insist on sleep; let them look at books or play quietly. If they stay awake, that’s a sign that they are ready to stop. If they fall asleep but then end up staying up very late, that’s another sign that the afternoon nap needs to go.

Whether or not your child naps, having some quiet time without screens every afternoon is a good habit to get into. It gives your child and everyone else a chance to relax and unwind, and sets a placeholder not just for homework but also for general downtime as children grow — and just like naps for babies, downtime for big kids is crucial.

Follow me on Twitter @drClaire

Neurodiversity describes the idea that people experience and interact with the world around them in many different ways; there is no one “right” way of thinking, learning, and behaving, and differences are not viewed as deficits.

The word neurodiversity refers to the diversity of all people, but it is often used in the context of autism spectrum disorder (ASD), as well as other neurological or developmental conditions such as ADHD or learning disabilities. The neurodiversity movement emerged during the 1990s, aiming to increase acceptance and inclusion of all people while embracing neurological differences. Through online platforms, more and more autistic people were able to connect and form a self-advocacy movement. At the same time, Judy Singer, an Australian sociologist, coined the term neurodiversity to promote equality and inclusion of “neurological minorities.” While it is primarily a social justice movement, neurodiversity research and education is increasingly important in how clinicians view and address certain disabilities and neurological conditions.

Words matter in neurodiversity

Neurodiversity advocates encourage inclusive, nonjudgmental language. While many disability advocacy organizations prefer person-first language (“a person with autism,” “a person with Down syndrome”), some research has found that the majority of the autistic community prefers identity-first language (“an autistic person”). Therefore, rather than making assumptions, it is best to ask directly about a person’s preferred language, and how they want to be addressed. Knowledge about neurodiversity and respectful language is also important for clinicians, so they can address the mental and physical health of people with neurodevelopmental differences.

Neurodiversity and autism spectrum disorder

Autism spectrum disorder (ASD) is associated with differences in communication, learning, and behavior, though it can look different from person to person. People with ASD may have a wide range of strengths, abilities, needs, and challenges. For example, some autistic people are able to communicate verbally, have a normal or above average IQ, and live independently. Others might not be able to communicate their needs or feelings, may struggle with impairing and harmful behaviors that impact their safety and well-being, and may be dependent on support in all areas of their life. Additionally, for some people with autism, differences may not cause any suffering to the person themself. Instead, the suffering may result from the barriers imposed by societal norms, causing social exclusion and inequity.

Medical evaluation and treatment is important for individuals with ASD. For example, establishing a formal diagnosis may enable access to social and medical services if needed. A diagnostic explanation may help the individual or their family understand their differences better and enable community connections. Additionally, neurodevelopmental conditions may also be associated with other health issues that require extra monitoring or treatment. It is important that people who need and desire behavioral supports or interventions to promote communication, social, academic, and daily living skills have access to those services in order to maximize their quality of life and developmental potential. However, approaches to interventions cannot be one-size-fits-all, as all individuals will have different goals, desires, and needs.

Fostering neurodiversity in the workplace

Stigma, a lack of awareness, and lack of appropriate infrastructure (such as office setup or staffing structures) can cause exclusion of people with neurodevelopmental differences. Understanding and embracing neurodiversity in communities, schools, healthcare settings, and workplaces can improve inclusivity for all people. It is important for all of us to foster an environment that is conducive to neurodiversity, and to recognize and emphasize each person’s individual strengths and talents while also providing support for their differences and needs.

How can employers make their workplaces more neurodiversity-friendly?

• Offer small adjustments to an employee’s workspace to accommodate any sensory needs, such as
  • Sound sensitivity: Offer a quiet break space, communicate expected loud noises (like fire drills), offer noise-cancelling headphones.
  • Tactile: Allow modifications to the usual work uniform.
  • Movements: Allow the use of fidget toys, allow extra movement breaks, offer flexible seating.
• Use a clear communication style:
  • Avoid sarcasm, euphemisms, and implied messages.
  • Provide concise verbal and written instructions for tasks, and break tasks down into small steps.
• Inform people about workplace/social etiquette, and don’t assume someone is deliberately breaking the rules or being rude.
• Try to give advance notice if plans are changing, and provide a reason for the change.
• Don’t make assumptions — ask a person’s individual preferences, needs, and goals.
• Be kind, be patient.

Resources to learn more about neurodiversity

Neurodiversity in the Workplace

In science, advances are a daily occurrence, but true breakthroughs are rare. What does it take to achieve world-changing scientific breakthroughs? Some are the result of a lucky accident, combined with curiosity: scientists traveling down one road suddenly find reason to veer onto another road, one they never planned to travel — a road that may well lead nowhere.

Other major breakthroughs stem from scientists pursuing a very specific dream. One day, usually early in their career, they get an idea that they can’t stop thinking about. It’s crazy, they say to themselves, but is it really impossible? They talk to respected colleagues who often remind them of all the reasons their idea might not work, and how damaging this could be for their career. It’s a sobering message, yet the idea won’t die. So, they scramble to find financial support and seek out colleagues willing to risk traveling that road with them — a road that may well lead nowhere. But sometimes the road leads to major breakthroughs like penicillin and mRNA vaccines.

Breakthroughs due to lucky accidents and curiosity

One day in 1928, Dr. Alexander Fleming at St. Mary’s Hospital in London was growing bacteria in a laboratory dish. Fleming was not pursuing a scientific dream. He was a microbiologist, just doing his job.

Then he noticed something odd: overnight, another kind of microbe, a fungus, had traveled through the air, landed on the laboratory dish, and started to grow and spread on the dish where the bacteria were growing. Fleming soon noticed that the growing fungus seemed to be killing the bacteria. He surmised that it was making some substance that killed the bacteria. Because the name of the fungus was Penicillium rubens, he called the substance the fungus was making “penicillin.”

When Fleming published a paper about his discovery, few were interested. It took another 10 years before other scientists tried to generate large amounts of penicillin to see if it might be able to cure bacterial infections and save lives. We all know how that worked out.

Fleming’s scientific breakthrough, like some others, occurred not because Fleming had a brilliant idea and exclaimed “Eureka!” Instead, it occurred because he noticed something and said, “That’s odd,” and then tried to figure it out.

Breakthroughs due to persistence and resilience in pursuit of a dream

The story of mRNA vaccines, like the Pfizer/BioNTech and Moderna vaccines for COVID-19, is very different from the story of penicillin. For 30 years, a small group of scientists believed that mRNA vaccines would have great advantages over traditional vaccines — if only several obstacles could be overcome. Many of these scientists gave up as they encountered those obstacles, but a few persisted and, ultimately, succeeded. (I described what mRNA vaccines are, how they work, and how obstacles were overcome in a previous blog post.)

One scientist, Dr. Katalin Karikó, joined the faculty of the University of Pennsylvania in the early 1990s with the dream of creating an mRNA vaccine. She applied for grants to support her work, but was repeatedly rejected: the reviewers stated that it was so unlikely that she or anyone could overcome the obstacles that supporting her research would be a wasted investment. Her university only agreed to continue supporting her work if she accepted a demotion and a pay cut. She accepted both, and doggedly pursued her dream.

One major obstacle to mRNA vaccines particularly fascinated her: the violent reaction of the immune system when it encounters mRNA from a virus. Ten years of dogged work helped Karikó and her colleague Drew Weissman figure out how to make a small change in mRNA that prevented that violent immune response — a major step in making all mRNA vaccines possible. Without this, the world wouldn’t have mRNA COVID vaccines today.

Two other scientists who created the Pfizer/BioNTech COVID vaccine, Uğur Şahin and Őzlem Turëci, are Turkish immigrants to Germany who met, fell in love with the idea of creating an mRNA vaccine, and then fell in love with each other. According to The Wall Street Journal, one day in 2002 they took a break for lunch, got married, and then returned in the afternoon to their laboratory to finish an experiment — just one more among many conducted over 30 years. Each experiment was one more possible step toward their ultimate dream until finally, in 2020, they achieved that dream: their mRNA vaccine for COVID-19 proved to be very safe and effective.

Holding hard to their dreams

Whichever path scientists who achieve lifesaving breakthroughs travel, they often endure disinterest, like Fleming, or repeated skepticism, ridicule, and rejection, like Karikó, Weissman, Şahin, and Turëci. Only through sheer persistence did these scientists bring their dreams to life. They have been rewarded with fame and wealth and something even more valuable: the knowledge that because of their work hundreds of millions of people around the world never got sick, and millions never died before their time.

Of course, a relentless obsession with an improbable dream fails to pay off for many scientists. Their ideas, while quite brilliant, in the end are proved wrong: nature doesn’t turn out to operate the way they predicted. In the end, their beautiful theory is murdered by a brutal gang of facts.

Still other scientific dreamers ultimately prove to have been on the right track all along and would have achieved their dream — if only they had done the experiment a little differently, if only they had persisted a little longer, or if only the support for their work had not run out. As a result, neither they nor the rest of us benefitted from what would have been — until other scientists rediscovered their work years later.

Ultimately, scientific breakthroughs are possible only if a society is willing to invest in dreamers, recognizing that not all investments will lead to major breakthroughs. However, the investments that do lead to breakthroughs bring an economic return that is far greater than the investment — as well as preventing suffering and death and changing the world.

Want to participate in COVID-19 research? Download the COVID Symptom Study app to help researchers track symptoms and hot spots across the US. Click here for information.

When I was on the junior varsity basketball team in high school, I wasn't surprised when I developed a case of itchy, flaky athlete's foot. After all, I was an "athlete," so I assumed it was a sign of dedication and hard work.

I was shocked when my mother told me the truth: it was due to poor foot hygiene, not my dribbling skills.

Fast-forward almost four decades, and I’m much more diligent about skin care. Still, some skin issues plague me at times, like they do many men. Here is a look at two common problems and solutions.

Dry skin

Symptoms of dry skin include scaly patches (with or without redness), itching, and overall dryness. You can get dry skin year-round — from the heavy heat of summer to the bitter cold of winter. Sun exposure damages skin, leaving it thinner and less likely to hold in moisture over time. Also, aging skin produces less of the natural oils that keep skin lubricated.

Treatment. The first line of defense is a moisturizer that softens and smooths skin with water and lipids (fats). Some moisturizers attract water to the skin and seal it in. Others prevent moisture loss by coating skin with a thick, impermeable layer.

• Petroleum jelly. This waxy, greasy substance stops water loss without clogging pores. It can be used by itself but is also an ingredient in many moisturizers and ointments. Because petroleum jelly doesn’t contain water, it’s best used while the skin is still damp after bathing to seal in moisture.
• Mineral oil. Mineral oil has the same effect but without a greasy feeling. It also should be used while skin is damp.
• Moisturizing lotions and creams. These products contain both water and oils. They’re less greasy and more cosmetically appealing than petroleum jelly or oils. Look for moisturizers with at least one of the following ingredients: glycerin, urea, pyroglutamic acid, sorbitol, lactic acid, lactate salts, or alpha hydroxy acids.

Prevention. Try a few changes to help prevent dry skin:

• Add moisture to the air with a humidifier or a pan of water set atop the radiator.
• In the shower or bath, use lukewarm water (hot water can dry the skin by stripping it of natural oils).
• Choose nondrying soaps with no abrasives or irritants. Super-fatted soaps or cleansing bars are less drying than regular, liquid, or antibacterial soaps.
• To retain the water your skin absorbs while showering or bathing, apply jelly, oil, or moisturizer immediately afterward.

Athlete’s foot

Athlete’s foot is caused by dermatophytes, a group of fungi on the surface of the skin. Tell-tale signs include intense itching; cracked, blistered, or peeling areas of skin, especially between the toes; and redness and scaling on the soles. Dermatophytes thrive in warm, moist environments like pools, showers, and locker rooms where people walk with bare feet. The warm, moist environment of sweaty socks and shoes encourages them to grow.

Treatment. First, try an over-the-counter antifungal ointment, cream, or powder, such as clotrimazole (Lotrimin AF, Mycelex, generic), terbinafine (Lamisil AT, Silka,), or miconazole (Lotrimin AF spray, Micatin). It can take weeks for an infection to improve, and recurrences are common. If symptoms don't improve after several weeks, consult a doctor, who may prescribe antifungal pills.

Prevention. Keeping feet clean and dry is the best way to ward off athlete’s foot. Also, do the following:

• Wash your feet well every day, and wear a clean pair of socks after your bath or shower.
• Take time to dry your feet thoroughly (including each toe and especially the web space between the toes) after you bathe, shower, or swim.
• Wear flip-flops or sandals around public pools and in gym locker rooms and showers.
• Wear moisture-wicking socks that absorb sweat.
• Don’t wear the same shoes two days in a row. Give shoes a 24-hour break between wearings to air out and dry.

Various versions of low-carbohydrate diets have been popular for many years. The details of what is allowed and what is not vary quite a bit, and the amount of carbohydrates also differs. The common impression is a plate devoid of bread, pasta, and starchy vegetables, piled high with bacon, meat, eggs, and cheese, and maybe a small amount of vegetables and nuts. Due to the high saturated fat content in these diets, doctors and nutritionists worry about their potential adverse effect on cardiovascular disease.

Recently, a new study published in the American Journal of Clinical Nutrition has found that a low-carbohydrate, high-saturated fat diet might not be as bad as we feared. That sounds like good news, but is it that simple? Let’s take a look at what this randomized diet trial did and what the results really mean.

What did the study actually involve?

The 164 participants in this study were all considered overweight or obese, and had just finished a weight loss trial to lose 12% of their body weight. They were randomly assigned to one of three diets containing different proportions of carbohydrates and fat. Protein content was kept the same (at 20% calories) for everyone. They were not planning to lose any more weight.

The three diets were:

• Low carbohydrates (20%), high fat (60%), saturated fat comprising 21% of calories: this resembles a typical low-carbohydrate diet and has much higher saturated fat than recommended.
• Moderate carbohydrate (40%), moderate fat (40%), saturated fat comprising 14% of calories: this is not far from the typical American diet of 50% carbohydrates and 33% fat, and it is quite similar to a typical Mediterranean diet, which is slightly lower in carbohydrates and higher in fat than an American diet.
• High carbohydrate (60%), low fat (20%), saturated fat comprising 7% of calories: this meets the recommendation of the Dietary Guidelines for Americans and is a typical high-carbohydrate diet, including a lot of grains, starchy vegetables, and fruits or juices.

The study participants received food prepared for them for 20 weeks. They had their blood measured for a number of risk factors of cardiovascular disease, and a lipoprotein insulin resistance (LPIR) score was calculated using a number of blood markers to reflect the risk for cardiovascular disease. (LPIR is a score that measures both insulin resistance and abnormal blood cholesterol all in one number, and it is used for research purposes.)

The researchers found that at the end of eating these diets for five months, the low-carbohydrate group, which also had consumed the highest amount of the presumably worrisome saturated fat, did not have the worst cardiovascular disease blood markers. The amount of good and bad cholesterol in the blood was not different from the other groups. In fact, the LPIR cardiovascular risk score and two other disease markers (Lp(a) and adiponectin) also were improved the most in this group. This seems to suggest that we can go ahead and not worry about the saturated fat that typically goes with a low-carbohydrate diet.

What were the participants actually eating?

Alas, those who were eating the low-carbohydrate diet were not piling up their plate with steak and bacon, and those eating the high-carbohydrate diets were not drinking unlimited soda. All three diets were high in plant foods and low in highly processed foods (it is easier to stick to a diet when all the food is prepared for you). Even the low-carbohydrate group was eating lentils, a good amount of vegetables, and quite a bit of nuts.

And although the diet was quite high in saturated fat, it was also high in the healthy poly- and monounsaturated fats as well. The meat was a combination of higher amounts of healthy (salmon) and a small amount of unhealthy (sausage) choices. In addition, fiber intake (at about 22 grams/day) was slightly higher than the average American intake (18 grams/day). Overall, except for saturated fat being higher than recommended, the diet as a whole was quite healthy.

What is the take-home message?

It seems that among a relatively young and healthy group of people (the average age of those who completed the study was 45 years old), higher amounts of saturated fat in the context of a healthy diet do not seem to adversely affect certain cardiovascular risk markers in the short term. How it would affect actual disease — such as heart attack, stroke, and diabetes — in the long run is unknown. However, there is ample evidence showing that a diet that consists of healthy foods and has moderate amounts of carbohydrate and fat can lower the risk of these diseases.

Preventing diseases is a long-term process; a healthy diet must not only be effective, but it should also be flexible enough for people to stick to in the long run. Therefore, a healthy diet with moderate amounts of healthy carbohydrates and ample healthy fats may be the easiest with which to achieve good health. Lower-carbohydrate diets might be promising, but further long-term testing is needed.

Get expert advice on gathering safely from Harvard Health Publishing. Spoiler alert: vaccination is key to helping keep everyone healthy. Below, our faculty contributors share their own plans and advice for safely enjoying the holidays this year while answering three important questions.

Roger Shapiro, MD

Associate professor of immunology and infectious diseases, Harvard T.H. Chan School of Public Health, Boston

What are your plans this year for gathering — or not gathering — with family or friends during Thanksgiving and other winter holidays, and why?

Unlike 2020, my family will be gathering for Thanksgiving in 2021. Everyone in the family is vaccinated, and most are now boosted as well. We are all comfortable with the protection that being vaccinated brings, and there is agreement that if a COVID-19 exposure were to occur, it is unlikely to cause severe illness.

What advice can you offer people planning to gather in person to reduce the chance of getting or spreading the virus that causes COVID-19?

Everyone who can get vaccinated should be vaccinated, and those who qualify for a booster should get one. Children 5 to 11 may not have their second shot by Thanksgiving but can certainly be fully vaccinated by Christmas. If there are unvaccinated members of your family, your situation is no different than in 2020: gathering is unsafe for the unvaccinated because the first exposure to this virus can be lethal without protection from a vaccine. Additionally, people who are unvaccinated are more likely to be infected before traveling, so they are more likely to bring the virus to the table, possibly causing illness (even if mild) among those who are vaccinated. For families that are all vaccinated and wishing to further reduce the possibility of transmission, taking a rapid antigen test prior to gathering can add a layer of protection.

For people planning to travel to gatherings, what would you advise?

If you are all vaccinated, enjoy the return to a normal holiday season. Vaccines are your main source of protection. If you want to add additional protection, you can consider using rapid antigen tests just before gathering to confirm that everyone is negative. If there are immunocompromised members of your family who may not be fully protected by a vaccine, you should discuss the risks case-by-case with your doctor.

Suzanne Salamon, MD

Chief of clinical programs in gerontology, Beth Israel Deaconess Medical Center, Boston

What are your plans this year for gathering — or not gathering — with family or friends during Thanksgiving and other winter holidays, and why?

Let me start by saying my 99-year-old mother lives with us, and even though she’s had her third shot of the COVID vaccine, I’m very concerned about immune status. I also have a two-year-old granddaughter who cannot yet get the vaccine. So, everyone’s immune status is not equal. Certainly older people, even those who’ve had their third shot, may not have the same immune status as a 35-year-old.

We have really curtailed the size of our Thanksgiving dinner to under 10 people, since the CDC recommends smaller groups. Nobody wants to see people sitting at home alone during the holidays, but we have to make it as safe as possible for those who are there.

What advice can you offer people planning to gather in person to reduce the chance of getting or spreading the virus that causes COVID-19?

COVID cases are on the rise now in many places, even though a month ago the numbers were trending down. Unfortunately, we need to be more vigilant once again.

Many people are afraid to insult family and friends by asking them about vaccine status before they come. Tell people that you really want to see them, but some family or friends may be immune-suppressed or at higher risk if they get COVID-19, and you’re trying to make the gathering safe for everyone. That’s why I’d ask people to let you know their COVID vaccine status. Even after the two-vaccine series, research is showing diminished antibodies after six months, which may put people at higher risk for getting and/or spreading the virus. I would ask people who are not vaccinated not to come.

When people gather, ventilation is really important in reducing the concentration of any virus that might be present. Have the gathering outside or on a screened porch, if at all possible. We hosted Thanksgiving last year in our garage. We left the garage doors open and set up small tables and little space heaters for warmth. People could be social yet stay separated, and ventilation was great. You can decorate small tables with colorful plastic tablecloths and candles, even put down a rug. If you’re inside, windows and doors can be kept open, which will help move the air around. Have some small space heaters and sweaters available.

Ask everyone to bring a mask, or keep a box of masks available. Wear masks while you’re all chit-chatting until you sit down to dinner. In the bathroom, have a roll of paper towels or paper guest towels rather than a cloth towel, and leave the fan on for ventilation.

For people planning to travel to gatherings, what would you advise?

Planes are thought to be very safe. In the air terminal, sit apart from people. Keep your mask on during the flight.

Traveling by car is pretty safe. If you get out to go to the bathroom or get coffee, wear a mask and wash your hands. Traveling by bus or train is tricky, because even though there is a mask requirement, people will take off their masks. Be sure to wear your own mask. I personally double-mask. Two surgical masks block out a lot and can be a bit more comfortable than the N95 masks we wear in the hospital. A plastic face shield over the mask may be a good idea for added protection.

John J. Ross, MD

Hospitalist with specialty in infectious diseases, Brigham and Women’s Hospital, Boston

What are your plans this year for gathering — or not gathering — with family or friends during Thanksgiving and other winter holidays, and why?

We are having an unmasked, multigenerational, fully-vaccinated, traditional Thanksgiving dinner at my in-laws, just like the Before Times.

What advice can you offer people planning to gather in person to reduce the chance of getting or spreading the virus that causes COVID-19?

Everyone in attendance should have a primary COVID vaccination. Getting vaccinated against COVID reduces the risk of hospitalization or death due to COVID by more than 90%. It also reduces your risk of death from any cause. People who are eligible for booster shots should get them. That includes anyone over 65, and people over 18 with underlying medical conditions, high occupational risk, or those who live in high-risk settings such as group homes, shelters, and long-term care facilities.

Certain vaccinated people are more likely to get breakthrough COVID. This includes people of advanced age, and those with serious medical conditions or weak immune systems. These people should be extremely cautious around those who are not vaccinated or partly vaccinated. I would recommend that they mask around unvaccinated people, physically distance, and use extra ventilation (opening windows, or ideally moving the whole shebang outdoors). Rapid antigen tests may also be helpful in the setting.

For people planning to travel to gatherings, what would you advise?

For those who have long distances to travel, I would recommend flying if possible. Airplanes have excellent ventilation, and masks are mandatory. While masks are also required on trains, they are not as well ventilated as planes, and train travel has been associated with significant COVID risks.

Amy Sherman, MD

Division of infectious diseases, associate physician, Brigham and Women’s Hospital, Boston

What are your plans this year for gathering — or not gathering — with family or friends during Thanksgiving and other winter holidays, and why?

This Thanksgiving, my fiancé and I are driving to New Jersey and New York (with our dog!) to visit our families. We will have dinner with 14 others from my close family — larger than last year’s Thanksgiving, but smaller than pre-COVID years. Everyone has been vaccinated, and most have received a third dose. We will then visit with my fiancé’s 94-year-old-grandma, choosing to see her independently instead of bringing her to a large gathering.

Although no measures can absolutely make an indoor gathering 100% safe, we will apply layers of protective measures to reduce risk, with vaccinations as the base layer. Additionally, everyone will get tested for the virus that causes COVID-19 before gathering, limit exposure risks in the week before Thanksgiving, avoid public transportation, and drive instead of flying. When we’re together, we’ll spend time outdoors as much as possible. Maybe this year will bring new traditions — an outdoor bonfire instead of nighttime movie marathons, or Friday morning jogs instead of Jazzercise with my aunt!

What advice can you offer people planning to gather in person to reduce the chance of getting or spreading the virus that causes COVID-19?

We are in a much better place this year compared to last year. Connecting with family and friends is important for our mental health and well-being. However, we still need to be cautious, especially when gatherings include people who are older, immunocompromised, or at risk of severe COVID-19. We also have seen recent outbreaks in school-age kids who are not yet vaccinated. I would encourage your family and friends to get vaccinated if they haven’t already. For those family members at higher risk, consider smaller and more intimate gatherings, or do hybrid in-person/Zoom meetings. And layer up with the other risk reducing strategies I suggested!

For people planning to travel to gatherings, what would you advise?

Avoid public transportation if possible. If this is not possible, wear a mask on the bus, train, or airplane, even if you’ve been vaccinated. Vaccinations decrease the severity of disease, but you still could become infected and transmit the virus to others.

Read more advice on gathering for winter holidays this year, such as who can and should get a COVID-19 vaccine booster, whether to take a rapid test or PCR test before spending time with family or friends, how to navigate tricky relationships, and healthy eating through the holiday season.