The Health Buzz: Weighing the Benefits and Drawbacks of Your Daily Coffee Habit Beyond the morning jolt, your daily cup of coffee is packed with bioactive compounds, like caffeine and potent phytochemicals, that may contribute to improved mood, cognitive function, and a reduced risk of chronic disease, provided you keep consumption moderate and additions minimal. Culinary Medicine by Lori A Smolin, PhD and Mary B Grosvenor, MS, RD Almost three quarters of Americans start their day with coffee.[1] For some, this morning cup is from a pot brewed at home, but for many it is from the local coffee shop where we can order it hot or iced, flavored and sweetened, and with various ratios of coffee, milk, and foam. The result is an ever-expanding selection of coffee drinks including Americano, espresso, cappuccino, flat white, latte, mocha, frappe, and cortado. Most of us seek out this slightly bitter beverage for its taste, to boost alertness and to fight off fatigue, but coffee may also benefit our overall health. [1,2] History of Coffee Legend has it that coffee was discovered in the 9th century by an Ethiopian goat herder who noticed that when his goats ate the cherries of a particular tree, they were so energized they did not even sleep. He shared this observation with a local abbot who used the cherries, which contain the seeds or beans of the coffee plant, to make a drink that helped him stay awake during evening prayers.[3] The cultivation of coffee began in the 15th century when plants were brought from Ethiopia to the Arabian Peninsula. Coffee was traded throughout the Ottoman Empire in the 16th century and then brought to Europe in the 17th century. [3,4] The 17th century also saw the rise of coffee plantations in Indonesia, particularly on the island of Java, which gave coffee this nickname. Today, the United States, the largest consumer of coffee in the world, imports beans from around the globe, with over 60% coming from Indonesia, Brazil, Colombia, and Vietnam.[4,5] Even early in its history, this brew was often consumed in coffee houses, which became hubs for social gathering. In London, coffee houses were called "penny universities" because admittance cost a penny and the houses were packed with people discussing the social issues of the time. This tradition spread west and during the American revolutionary war coffee houses became meeting places for political discussion.[3] An Energy Jolt and More Your morning coffee gives you an energy boost and it may also improve your mood, cognitive function, and even athletic performance but did you know that coffee has also been associated with a reduction in the risks of chronic disease. [2,6] Some evidence even suggests that coffee increases life expectancy.[7] The nutrients in coffee are not responsible for its health benefits. A cup of black coffee provides about two Calories, no protein, carbohydrate or fat and only small amounts of vitamins and minerals. However, bioactive compounds in coffee, such as caffeine and phytochemicals may make significant contributions to our health in both the short and long term. Caffeine is responsible for coffee’s short-term stimulant effect. It is absorbed quickly from the stomach and intestine and then metabolized by the liver. Although the rate of metabolism varies depending on genetics, age, hormone levels, and lifestyle factors, caffeine levels in the blood generally peak about an hour after ingestion and half of it is still in your system 4 to 5 hours later. [8] Caffeine acts primarily by blocking receptors in the nervous system, therefore preventing signals of sleepiness, making us feel alert, awake, and even enhancing strength, power, and endurance during exercise.[8,9] The long-term health benefits of coffee have been attributed to the phytochemicals it contains as well as its caffeine content. [10] Coffee, with or without caffeine, contains polyphenol phytochemicals that provide antioxidant and anti-inflammatory benefits. The antioxidants in coffee, particularly chlorogenic acid, have been suggested to reduce the risk of developing type 2 diabetes, stroke, and neurodegenerative diseases such as Alzheimer’s and Parkinson’s.[11] The anticancer potential of coffee has been related to both its antioxidant content and its caffeine. Caffeine may also help ward off depression.[12] The role of coffee or caffeine in reducing mortality is unclear. There is epidemiological evidence consuming black coffee, or coffee with small amounts of added sugar or saturated fat, is associated with lower all-cause mortality.[6,13] This association occurs irrespective of caffeine content, but the association is less robust with decaffeinated than caffeinated coffee.[6] Whether coffee increases longevity by reducing the risk of many chronic diseases or because it interferes with the aging process is not known.[6,11,13] Whatever the mechanism, if your morning coffee includes added creamers and sweeteners the extra calories, saturated fat, and added sugar diminish the mortality and health benefits of the coffee.[7] How Much is Too Much Three to four cups of coffee per day may be beneficial for most healthy adults. [14] This amount provides about 400 mg of caffeine, depending on the variety of the bean and the roasting, grinding, and brewing method used. Studies on the effect of coffee intake on lifespan have resulted in a J-shaped curve; one cup-a-day results in some benefits with maximum benefits occurring with 3 to 4 cups/day. Fewer and fewer benefits occur as coffee consumption increases above this level. [6] This reduction in benefits is likely that too much caffeine can negatively affect health. Excess caffeine causes anxiety and jitters and can interfere with sleep. It can also increase blood pressure, produce heart palpitations, increase urination, and cause heartburn and upset stomach.[14] Coffee drinkers who become caffeine dependent may experience withdrawal symptoms like headaches or irritability when reducing their caffeine intake. Pregnant women should keep their caffeine intake at 200mg or less per day, because some studies suggest an association between caffeine intake and the risk of miscarriage and lower birthweight. [15] Maximize Your Morning Java Many people cannot imagine starting their day without a cup of coffee. To maximize the health benefits, keep your consumption to 3-4 cups/day (400 mg caffeine or less) and do not overdo the added sugars, syrups, and creams. Whether enjoying a lively coffee shop conversation or alone in your kitchen, coffee is the silent hero that wakes us up in the morning, gets us through that afternoon slump while also enhancing our health. Editor’s note- Can coffee improve your overall health? The references below certainly suggest yes. Nevertheless, I expect our science community will continue to study this question and hopefully they will continue to prove that the overall benefits of coffee are far greater than its disadvantages. Significant disadvantages include gastroesophageal reflux, worsening of essential tremor and worsening of palpitations that may trigger a tachyarrhythmia. Rich's Picks: As an Amazon Associate FibonacciMD earns from qualifying purchases. Maximize your healthy coffee routine with a high-quality, organic brew! We recommend trying these delicious Costa Rican Jim's Organic Coffee Ground Beans [https://amzn.to/47F9lVX] Upgrade Your Brew: Getting the most out of your coffee starts with a quality machine! With Grinder (for maximum freshness): The Cuisinart Automatic Grind and Brew handles the whole process, grinding beans just before brewing for superior flavor. [https://amzn.to/4oOda1S] Without Grinder: If you already love your separate grinder, the classic Cuisinart Brew Central offers reliable, programmable 12-cup brewing. [https://amzn.to/4i3pV6N] More about coffee: Green Tea Drinking Reduces Brain White Matter Lesions While Coffee Drinking Does Not Matcha, more than just tea Gout: Foods to Include and Foods to Avoid (coffee is one of them) References [1] Driveresearch. Rogers E. Coffee Statistics: Consumption, Preferences & Spending. February 1, 2024. https://www.driveresearch.com/market-research-company-blog/coffee-survey/ [2] Gunnars K. Coffee — Good or Bad? Healthline. Published 2018. https://www.healthline.com/nutrition/coffee-good-or-bad [3] History of coffee. NCA - About Coffee. Published December 5, 2024. https://www.aboutcoffee.org/origins/history-of-coffee [4] World Population Review. Coffee Consumption by Country 2020. World Population Review. Published 2021. https://worldpopulationreview.com/country-rankings/coffee-consumption-by-country [5] Cantor A. Historic coffee prices percolated after a bitter global supply crisis : Beyond the Numbers: U.S. Bureau of Labor Statistics. www.bls.gov. Published September 2023. https://www.bls.gov/opub/btn/volume-12/historic-coffee-prices-percolated-after-a-bitter-global-supply-crisis.htm [6] Lopes CR, Cunha RA. Impact of coffee intake on human aging: Epidemiology and cellular mechanisms. Ageing Research Reviews. 2024;102:102581. doi:https://doi.org/10.1016/j.arr.2024.102581 [7] Zhou B, Ruan M, Pan Y, Wang L, Zhang FF. Coffee Consumption and Mortality Among U.S. Adults: A Prospective Cohort Study. Journal of Nutrition. Published online May 1, 2025. doi:https://doi.org/10.1016/j.tjnut.2025.05.004 [8] Reddy VS, Shiva S, Manikantan S, Ramakrishna S. Pharmacology of Caffeine and Its Effects on the Human Body. European Journal of Medicinal Chemistry Reports. 2024;10(10):100138. doi:https://doi.org/10.1016/j.ejmcr.2024.100138 [9] Martins GL, Guilherme JPLF, Ferreira LHB, de Souza-Junior TP, Lancha AH. Caffeine and Exercise Performance: Possible Directions for Definitive Findings. Frontiers in Sports and Active Living. 2020;2(2). doi:https://doi.org/10.3389/fspor.2020.574854 [10] Makiso MU, Tola YB, Ogah O, Endale FL. Bioactive compounds in coffee and their role in lowering the risk of major public health consequences: A review. Food Science and Nutrition. 2023;12(2). doi:https://doi.org/10.1002/fsn3.3848 [11] Dewland TA, Rob, Marcus GM. Coffee and cardiovascular disease. PubMed. Published online July 8, 2025. doi:https://doi.org/10.1093/eurheartj/ehaf421 [12] Torabynasab K, Shahinfar H, Payandeh N, Jazayeri S. Association between dietary caffeine, coffee, and tea consumption and depressive symptoms in adults: A systematic review and dose-response meta-analysis of observational studies. Frontiers in Nutrition. 2023;10. doi:https://doi.org/10.3389/fnut.2023.1051444 ‌[13] Zhou B, Ruan M, Pan Y, Wang L, Zhang FF. Coffee Consumption and Mortality Among U.S. Adults: A Prospective Cohort Study. Journal of Nutrition. Published online May 1, 2025. doi:https://doi.org/10.1016/j.tjnut.2025.05.004 [14] U.S. Food and Drug Administration. Spilling the beans: How much caffeine is too much? U.S. Food and Drug Administration. Published August 28, 2024. https://www.fda.gov/consumers/consumer-updates/spilling-beans-how-much-caffeine-too-much [15] UCLA Small amount of caffeine OK in pregnancy. Uclahealth.org. Published February 14, 2022. https://www.uclahealth.org/news/article/small-amount-of-caffeine-ok-in-pregnancy ‌

Roast Chicken with Squash and Apples for a Nutritious Autumnal Delight Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Low-Calorie | Low-Carb | Low-Fat | High-Fiber Embrace the cozy flavors of autumn with this Fall Feast Chicken Recipe, a culinary medicine creation that combines tender marinated chicken with roasted butternut and delicata squashes, crisp apples, and sweet onions for a balanced, health-boosting meal. This dish highlights seasonal ingredients rich in vitamins, fiber, and antioxidants, making it perfect for those seeking gourmet tastes without compromising on nutrition. Pair it with wild rice or crusty bread for a complete, satisfying dinner that serves three. Ingredients 1 Butternut squash 1 delicata squash 2 large boneless skinless chicken breasts 3 tb olive oil 2tb maple syrup 1 tsp dried thyme 2 tsp brown mustard 1/2 teaspoon salt, plus more for seasoning 1/2 teaspoon freshly ground black pepper 1 apple ½ red onion Instructions Follow the instructions for the chicken, the butternut squash, the remaining filling, and the baked assembled dish. Marinated Chicken Cut each chicken breast into 3 or 4 pieces Mix together the olive oil, maple syrup, salt and pepper Add chicken and marinate from 1 to 4 hours Pre-Roast the Butternut Squash Preheat oven to 400 F. Line a baking sheet with parchment paper Peel the butternut squash with an apple peeler, scoop out the seeds. Cut the squash into 1” cubes  In a large bowl, toss cubed butternut squash with the olive oil, thyme, brown mustard, salt, and pepper Place the squash pieces in a single layer on a parchment paper-lined baking sheet, Bake for about 10 minutes.  Cut & Toss Delicata Squash, Onion and Apple Cut Delicata squash into rings and remove seeds Cut apple into wedges Slice onion Toss Delicata squash, onion and apple in 1 tb olive oil Sprinkle with salt and pepper Baking Cover baking pan in aluminum foil Remove chicken from marinate and add to baking sheet with butternut squash Add apples, Delicata squash, and onions and arrange all in a thin layer Roast for 20 to 30 minutes until the chicken reaches an internal temperature of 165°F and the veggies are tender.  Makes 3 - 4 servings Nutrition information per serving (based on 3 servings total and excluding the wild rice) Calories 256, Fat 8g, Saturated fat 3.2g, Cholesterol 60mg, Carbohydrate 28g, Fiber 3.3g, , Protein 21g, Sodium 600mg, Potassium 743mg, Sodium 563mg, Potassium 738mg Nutrition Chef Authors: Mary B Grosvenor, MS, RD Medically Reviewed by FibonacciMD editors. Editor's Note: The recipe is shown with a serving of wild rice; it also pairs well with warm some crusty bread. Prep time - one hour plus. This recipe is appropriate for a low calorie, low saturated fat dietary regimen. It is also a good source of fiber and protein. If you limit the wild rice the recipe would also be appropriate for a low-carb regimen. Since you love squash , we have more recipes featuring the versatile zucchini —a type of summer squash—including our savory Rustic Ratatouille recipe . You can also check out " Keen on Zucchini " to learn more about the vegetable's health benefits. And our Flavors of Fall Casserole recipe . Mary Recommends: As an Amazon Associate FibonacciMD earns from qualifying purchases. Where to buy fresh Organic Delicata Squash for Your Fall Feast? Brighten your Fall Feast Chicken recipe with vibrant, organic delicata squash! Its sweet, creamy flesh and edible skin make it a star ingredient. Get Organic Delicata Squash delivered fresh via Amazon Fresh for a healthy, seasonal dish. ( https://amzn.to/3WWQErA ) For Organic Wild Rice (Recommended Pairing) "Elevate your Fall Feast Chicken with nutty, organic wild rice – the ideal side for absorbing those roasted flavors! Try Lundberg Regenerative Organic Certified Wild Rice (8 oz) for a gluten-free, sustainable boost. Shop now on Amazon ( https://amzn.to/47arnAi )

Beyond the Parm: Exploring the History, Health Benefits, and Culinary Art of Eggplant Culinary Medicine by Mary B Grosvenor, MS, RD and Lori A Smolin, PhD Shiny, deep purple eggplant is a farmer’s market favorite in mid to late summer. While this Globe eggplant is the most common in the US, eggplant comes in a variety of shapes, sizes, and colors. This plump spongy fruit, also known as aubergine, is treated as a vegetable in savory dishes from cultures ranging from Japan and India to France and Italy. But eggplant did not make its way into American kitchens until the end of the 19 th  century. Before that it was considered an ornamental plant, prized for its purple flowers and small, white, oval-shaped fruit that resembled chicken eggs, resulting in the name egg plant.   [1,2] Eggplant is a Nightshade Along with tomatoes, potatoes, and peppers, eggplant belongs to the Solanaceae family, commonly known as nightshades.  The most infamous nightshade, the deadly belladonna, was used as a poison by assassins in Medieval times. [3] In the modern world, we know that belladonna, and all nightshades, contain potentially harmful alkaloid compounds. Generally, the nightshades that are part of our diet do not contain enough of these alkaloids to cause a reaction. For example, most individuals can consume 70 mg of the alkaloid solanine without ill effects and an entire eggplant contains about 11 mg of solanine. [4]   Some individuals may be allergic to nightshades; this is rare but can occur resulting in hives, abdominal symptoms, and muscle aches. An intolerance to these complex plants is more common. Those with an intolerance aren’t able to completely digest nightshades and may experience gas, bloating, diarrhea, and in some cases, fatigue and joint pain.   [5,6] There is also a concern that the alkaloids in nightshades can trigger inflammation, particularly in individuals with preexisting inflammatory or autoimmune diseases such as arthritis and inflammatory bowel disease. [5]  There have not been any large studies that demonstrate this connection, but some individuals may benefit from reducing their consumption of nightshades.[7]  Nutrients and Health-Promoting Substances  Eggplant is a low-calorie source of nutrients and phytochemicals. A cup of cooked eggplant has only about 35 calories but provides 3 grams of fiber and is a good source of folic acid, potassium, and magnesium. The high-fiber content of eggplant helps slow the rate at which it, and the foods consumed with it, are digested and absorbed from the GI tract. This promotes satiety, helping to reduce cravings and calorie intake in those trying to lose weight. Slower absorption also helps keep blood sugar levels steady, moderating spikes and crashes.[8] Eggplant is also rich in antioxidant phytochemicals, including anthocyanins and polyphenols, which offer a variety of health benefits. Nasunin, an anthocyanin that gives eggplant its purple color, has been shown to have anti-cancer properties. [9] Chlorogenic acid is a polyphenol in eggplant that has been shown to be cardioprotective and may also slow sugar absorption, helping to attenuate rises in blood sugar after a meal. [10]  How to Consume It Eggplant can be baked, fried, grilled, or roasted into an exquisite dish with a creamy texture and complex flavor. Enjoy it in an Asian inspired stir-fry, an Italian eggplant parmesan, a French ratatouille, a Greek moussaka, or a middle eastern brinjal curry.  Egg Plant Curry or Brinjal Masala also known as Baigan ki sabzi Whether you choose long slender Japanese eggplant, the traditional Globe variety, or a round Black Beauty, be sure to choose one with smooth shiny skin that bounces back when you press lightly and use it within a day or two of purchase. [11]  Though delicious and nutritious, there are some tricks to preparing exquisite eggplant. Its small soft seeds are generally cooked with the flesh, adding a subtle texture to your dish.  While eggplant can be eaten with or without the skin, peeling it before cooking provides a more uniform texture. Eggplant has a slightly bitter taste; you can reduce this by salting sliced eggplant lightly and letting it stand and drain before and after cooking. Fried egg plant with Chinese chili sauce  Roasting or grilling can keep eggplant low in calories because eggplant absorbs fat readily when fried. If you do choose to fry, use the salting technique to draw out water from the eggplant; this reduces the amount of frying oil it absorbs and prevents it from getting soggy.  No matter how you prepare it, eggplant takes on the other flavors in your dish.  Its meaty texture makes it a versatile plant-based alternative in a range of recipes.  Crave Eggplant? Get it Delivered! As an Amazon Associate FibonacciMD earns from qualifying purchases. Skip the market trip! Eggplants farm-fresh produce ( https://amzn.to/3JeRcWy ), or ready-to-eat jarred/canned favorites like caponata and marinated aubergine ( https://amzn.to/48zPbP7 ). Fresh or jarred—delivery to your door! References [1] Tisch Food Center An Eggplant Exploration Teachers College, Columbia University. Teachers College - Columbia University. Published August 2024. https://www.tc.columbia.edu/tisch/tisch-dish/news/an-eggplant-exploration/ ‌ [2] Torpey J. How Eggplant Got its Name - Fine Gardening. Fine Gardening. Published August 8, 2016. https://www.finegardening.com/article/how-eggplant-got-its-name?srsltid=AfmBOoqoBelwMmqMKbUXg6bg8d9KKFmllapBpIjggmEy5hLDfoa3JbHi . ‌ [3] Largo M. The Big, Bad Book of Botany. Harper Collins; 2014. [4a] WebMD. What to Know About Nightshade Vegetables. Published April 8, 2021. https://www.webmd.com/diet/what-to-know-about-nightshade-vegetables [5] Nightshade allergy: Symptoms, diagnosis, and intolerances. www.medicalnewstoday.com . Published May 23, 2018. https://www.medicalnewstoday.com/articles/321883#diagnosis-and-treatment [6] Healthline. Nightshade Allergy: Symptoms, Causes, and Treatments. Healthline. Published April 12, 2017. https://www.healthline.com/health/allergies/nightshade-allergies [7] What’s the Deal With Nightshade Vegetables? Cleveland Clinic. https://health.clevelandclinic.org/whats-the-deal-with-nightshade-vegetables [8] Ajmera R. 7 Surprising Health Benefits of Eggplants. Healthline. Published June 30, 2017. https://www.healthline.com/nutrition/eggplant-benefits#could-help-with-weight-loss [9] Wang LS, Stoner GD. Anthocyanins and their role in cancer prevention. Cancer Lett. 2008 Oct 8;269(2):281-90. doi: 10.1016/j.canlet.2008.05.020. Epub 2008 Jun 20. PMID: 18571839; PMCID: PMC2582525. [10] Nguyen V, Taine EG, Meng D, Cui T, Tan W. Chlorogenic Acid: A Systematic Review on the Biological Functions, Mechanistic Actions, and Therapeutic Potentials. Nutrients. 2024;16(7):924-924. doi: https://doi.org/10.3390/nu16070924 ‌ ‌ [11] Ghafari L. 13 Best Eggplant Varieties to Grow [with Recipes & Photos]. Urban Farm and Kitchen. Published January 2, 2024. https://urbanfarmandkitchen.com/13-best-eggplant-varieties-to-grow-with-recipes-photos/

This rustic ratatouille recipe transforms fresh vegetables into a soft, chunky, and satisfying French stew, perfect as a main dish or a side. Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Low-Calorie | Low-Carb | Low-Fat | Vegan | Fiber This classic French stewed vegetable dish is a great way to take advantage of fresh summer vegetables. Slowly cooking the eggplant and other vegetables yields a soft, chunky texture amidst a smooth, almost creamy consistency. Serve it warm or at room temperature, as a main course or a side.  Ingredients 1 large eggplant cut into 1-inch cubes 1-2 Tbsp salt, plus 1 tsp ¼ cup olive oil 2 medium onions, chopped 3 red and/or yellow bell peppers cut into ½ inch squares 1 28-ounce can diced tomatoes, undrained 1 medium zucchini , sliced 2 cloves garlic, minced 1 Tbsp minced fresh tarragon or 1 tsp dried tarragon ¼ tsp black pepper 1/8 tsp cayenne pepper Feta cheese, crumbled, about ½ cup Instructions Place eggplant cubes in a colander and toss with 1-2 Tbsp salt. Allow to drain for 30 minutes to 2 hours. Rinse under running water and pat dry. Heat oil in a large nonstick fry pan or pot. Add onions and sauté over moderate heat for 5 minutes. Add red and yellow peppers and cook for about 5 minutes, stirring frequently, until soft. Add eggplant and sauté for about 10 minutes, until it loses its raw, whitish color. Add tomatoes, zucchini, garlic, tarragon, 1 tsp salt, black pepper, and cayenne. Cover and simmer for 10 to 15 minutes, stirring frequently. Uncover and cook for a few more minutes to reduce liquid. Sprinkle with crumbled feta cheese.  Makes 8 one-cup servings Nutrition information per serving of ratatouille  Calories 185, Fat 11g, Saturated fat 2.3g, Cholesterol 6mg, Carbohydrate 20g, Fiber 4.7g, Protein 4g, Sodium 561mg, Potassium 700mg Nutrition information per serving of ratatouille with 1 cup pasta  Calories 395, Fat 12g, Saturated fat 2.5, Cholesterol 6mg, Carbohydrate 62g, Fiber 6.7g, Protein 11g, Sodium 563mg, Potassium 738mg Nutrition Chef Authors: Lori A Smolin, PhD Mary B Grosvenor, MS, RD Medically Reviewed by FibonacciMD editors. Editor's Notes Appropriate for a low calorie, low saturated fat, low cholesterol, vegan dietary regimen and an excellent source of fiber! Recipe is shown here with pasta but can also be served over rice or with a slice of French bread To make it a higher protein meal, serve with eggs or alongside grilled fish or beans. Read " Keen on Zucchini " to learn more about the health benefits of zucchini. Mary Recommends: As an Amazon Associate FibonacciMD earns from qualifying purchases. Want to perfect that Rustic Ratatouille ? This Lodge Enameled Cast Iron Oval Casserole  with superior heat retention is your secret for a soft, satisfying stew. ( https://amzn.to/4qdkl5c )

Meat Allergy from Tick Bites Alpha-gal syndrome is a potentially life-threatening allergy that can occur after tick bites.  Alpha-gal is a sugar (galactose-α-1,3-galactose) that is present in the saliva of many animals, including ticks and some mammals, but not in humans.  When a tick bites, it can transfer alpha-gal into a person’s body through its saliva. The alpha-gal may be perceived as a foreign substance and a potential threat in some individuals. Their immune system produces alpha-gal antibodies, which can lead to an allergic reaction when they are re-exposed to it.   Alpha-gal syndrome typically occurs after the bite of a lone star tick, and less commonly from the bite of a blacklegged tick  or a western blacklegged tick .  However, not everyone who is bitten develops the sensitivity.  Adult Female Lone Star Tick  What Foods and Animal Products Contain Alpha-gal?  When a person with alpha-gal sensitivity eats red meat or organ meat, an allergic reaction may be triggered.  Dairy products also may contain some alpha-gal, but many people with alpha-gal sensitivity are able to tolerate drinking milk.  Other food products such as gelatin made from beef or pork, mammal fats, such as lard, tallow, or suet, and meat broth, bouillon, stock, or gravy may potentially contain alpha-gal.  Some medications and vaccines may contain small amounts of alpha-gal-containing additives, stabilizers, or coatings; however, not all patients with alpha-gal syndrome react to these ingredients.  Artificial heart valves from pigs or cows may also contain some alpha-gal, although genetically engineered pigs that lack alpha-gal have been developed. Prevalence, Symptoms and Diagnosis  The CDC reports that between 2010 and 2022, 110,000 suspected cases were identified in the U.S., and as many as 450,000 people may have alpha-gal syndrome. Alpha-gal syndrome may cause a wide range of symptoms, including hives or itchy rash, nausea or vomiting, heartburn, indigestion or severe stomach pain, diarrhea, cough, shortness of breath, wheezing, or difficulty breathing, hypotension (drop in blood pressure), swelling of the lips, throat, tongue, or eyelids, dizziness or faintness, or anaphylaxis.  Symptoms typically appear two to six hours after eating food or being exposed to other products containing alpha-gal, such as gelatin-coated medications derived from animals. Diagnosis of alpha-gal syndrome is based on clinical history, particularly allergic reactions after ingestion of mammalian meat or related products.  Confirmation is obtained through measurement of serum alpha-gal–specific IgE antibodies.  In some cases, skin testing for allergy may be used as a supplemental diagnostic tool. Treatment Reactions to Alpha-gal can range from mild to severe.  Standard allergy or anaphylaxis  treatment is recommended depending on the extent of the reaction. Prevention of tick bites can decrease the incidence of this syndrome.  Avoiding substances that contain alpha-gal is the primary treatment for allergic individuals.   To reduce the severity or number of attacks, some researchers have investigated oral desensitization for alpha-gal allergy.  This is a process where patients, under strict medical supervision, consume gradually increasing amounts of meat.  However, there are only a limited number of studies on alpha-gal desensitization, and this type of therapy may potentially cause life-threatening anaphylactic reactions. If you are interested in learning about tickborne illnesses in more depth, read the FibonacciMedicine article, Diagnosis and Treatment of Four Tickborne Diseases. Be Prepared: As an Amazon Associate FibonacciMD earns from qualifying purchases. The risk of Alpha-gal Syndrome—a potentially severe meat allergy—starts with a tick. Take the essential step in prevention. Stop Ticks Before They Climb! Ticks don't jump; they crawl up from the ground. Lymeez Stretch Mesh Tick Repelling Leg Gaiters are your frontline defense. Buy on Amazon https://amzn.to/4n4YOJb References Emerging Tick Bite-Associated Meat Allergy Potentially Affects Thousands. CDC. July 27, 2023. Retrieved from: https://www.cdc.gov/media/releases/2023/p0727-emerging-tick-bites.html Ünal D et al. Oral immunotherapy in alpha-gal red meat allergy: Could specific IgE be a potential biomarker in monitoring management?. Allergy. 2023;78(12):3241-3251. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/37545316/ Fast Facts: Products That May Contain Alpha-gal. CDC. June 26, 2025. Retrieved from: https://www.cdc.gov/alpha-gal-syndrome/data-research/products-containing-alpha-gal/index.html About Alpha-gal Syndrome. CDC. June 26, 2025.Retrieved from: https://www.cdc.gov/alpha-gal-syndrome/about/index.html Platts-Mills TAE et al. J Allergy Clin Immunol Pract. 2020 January ; 8(1): 15–23. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6980324/pdf/nihms-1060828.pdf Vaz-Rodrigues R, Mazuecos L & de la Fuente J. (2022) Current and Future Strategies for the Diagnosis and Treatment of the Alpha-Gal Syndrome (AGS). Journal of Asthma and Allergy, 957-970.18 Jul 2022. Retrieved from: https://www.tandfonline.com/doi/pdf/10.2147/JAA.S265660

Black Widow Bites: A Venomous Threat Black widow spider envenomation occurs when a black widow spider injects its potent venom into its victim. Learn about the symptoms and treatment of black widow spider bites. By Stuart M. Caplen, MD This article will review the diagnosis and treatment of envenomations of black widow spiders. Whether an individual clinician will commonly treat these envenomations depends on where in the country they are practicing. In the United States, anti-venom for black widow spider has helped reduce morbidity and mortality. Recognizing the Black Widow Spider Black widow spider with typical hourglass marking In North America the Latrodectus species or black widow spider is a cause of significant envenomation. The spider can be identified by its black body and red hourglass-shaped marking on the abdomen. The black widow moniker results from observation of the female frequently devouring the male after a mating session. Black widow spiders typically range from 0.5 to 1.5 inches in length[20] and have fangs and venom. The female has larger venom glands, longer fangs, and can be many times larger in size than the male and as such is more of a threat to humans. Males may have red or yellow spots or bands on the back rather than an hourglass-shaped marking.[20] The two species that most commonly cause envenomation within the United States are the Latrodectus mactans , or the southern black widow spider, found in the Southeast US and the Latrodectus hesperus or the western black widow spider, found in most of the Western U.S.[21] A third species Lactrodectus variolus or northern black widow spider is found in northern Florida up to the Middle Atlantic states and occasionally in southern Canada. In variolus species the red hourglass pattern on the female is typically separated into two distinct triangles.[20] Black Widow Spider Venom The venom of the black widow spider consists of a number of biologically active substances. Alpha-latrotoxin is the major component which binds irreversibly to receptors on presynaptic neurons. It causes an influx of calcium ions releasing massive amounts of neurotransmitters, which cause most of the symptoms in an envenomation.[21] Black Widow Spider Envenomation Black widow spider bites can occur while hiking, gardening, in garages, and frequently in outdoor bathrooms. Fang marks may be seen and within minutes of being bitten there is pain, and the wound may become erythematous and edematous. There may be local diaphoresis around an area of central clearing. Severe muscle pain and cramping usually occur within an hour. Increased autonomic function leading to tachycardia, tachypnea and hypertension may occur.[21] The Bite: Symptoms and Signs of Black Widow Spider Envenomation When patients develop systemic symptoms the term latrodectism is used. There may be diffuse muscle rigidity and cramping, tenderness, burning around the bite, truncal and abdominal tenderness, diaphoresis, headache, nausea, and vomiting. Occasionally black widow bites have been misdiagnosed as an acute intra-abdominal emergency such as appendicitis due to the muscle pain and rigidity.[22] The pain associated with latrodectism spreads from the bite site, so if someone is bitten on the foot the pain will initially move proximally up the leg and then to the rest of the body. Lab values are generally non-specific but may show an elevated white blood cell count, hematuria, and elevated liver enzymes. Occasionally rhabdomyolysis or myocarditis may occur.[21] In one case series of over 23,000 exposures to black widow venom, 65% of patients presented with minor clinical effects, 33.5% moderate effects, and 1.4% had major potentially life-threatening symptoms.[23] Seeking Relief: Treatment for Black Widow Spider Envenomation Initial management of black widow envenomation includes local wound management, ice packs, and tetanus prophylaxis. Calcium gluconate and methocarbamol, which were recommended in the past for the resulting muscle spasms have been shown to be ineffective and are no longer recommended. Pain management may be required with oral analgesics and occasionally opioids. Benzodiazepines may be required for muscle spasms.[21] There is an antivenom that can be used for cases of latrodectism that is very effective but allergic reaction, serum sickness, and anaphylaxis may occur as it is made out of horse proteins.[24] The drug information sheet recommends a skin or conjunctival test be performed prior to administration to check for allergies. The dose is one vial intravenously which can be repeated if needed.[25] A more purified antivenom has been developed and tested to try to reduce the possibility of allergic reactions, but is not available commercially, and currently in clinical testing.[26,27] The prognosis for black widow bites is good. Most pain and systemic symptoms are self-limited and recovery is typically within 24 to 48 hours.[21] A Venomous Threat: Final Thoughts on Black Widow Spider Envenomation Fortunately, most of the envenomations from black widow spiders are not severe. However, severe systemic toxicity can occur. Deaths are rare, especially with the availability of anti-venom for black widow spider envenomations. Related Topics: Here's another article on " Brown Recluse Spider Envenomations " Prevention Ideas: As an Amazon Associate FibonacciMD earns from qualifying purchases. After reading about black widow bites, you may want to ensure a secure sleeping environment. For a simple and effective protective barrier, consider a high-quality mosquito net bed canopy  for your bed at home or while traveling. References [20] Vail KM, et al. The Black Widow Spider. Agricultural Extension Service, The University of Tennessee. 2002. Retrieved from: https://extension.tennessee.edu/publications/Documents/PB1193.pdf [21] Williams M, Anderson J, Nappe TM. Black Widow Spider Toxicity. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK499987/ [22] Diaz, JH, Leblanc KM. Common Spider Bites. American Family Physician. 2007 Mar 15;75(6):869-873. Retrieved from: https://www.aafp.org/afp/2007/0315/p869.html#afp20070315p869-b11 [23] Monte AA, Bucher-Bartelson B, Heard KJ. A US perspective of symptomatic Latrodectus spp. envenomation and treatment: a National Poison Data System review. Ann Pharmacother. 2011 Dec;45(12):1491-8. Retrieved from: https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.949.6955&rep=rep1&type=pdf [24] Clark RF, Wethern-Kestner S, Vance MV, Gerkin R. Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases. Ann Emerg Med. 1992 Jul;21(7):782-7. Retrieved from: http://www.clinicalmonster.com/blog/wp-content/uploads/2013/10/black-widow.pdf [25] ANTIVENIN, (LATRODECTUS MACTANS)(Black Widow Spider Antivenin). Merck and Co. 2020. Retrieved from: https://www.merck.com/product/usa/pi_circulars/a/antivenin/antivenin_pi.pdf [26] Dart RC et al. The Efficacy of Antivenin Latrodectus (Black Widow) Equine Immune F(ab')2 Versus Placebo in the Treatment of Latrodectism: A Randomized, Double-Blind, Placebo-Controlled, Clinical Trial. Ann Emerg Med. 2019 Sep;74(3):439-449. Retrieved from: https://www.fresno.ucsf.edu/wp-content/uploads/2019/04/EfficacyAntivenin.pdf [27] Rare Disease Therapeutics, Inc. Retrieved from: https://www.raretx.com/products/ on Sept. 14, 2021. Published October 2021, 2024

The First Aid Guide for Jellyfish Stings: A Physician's Review Don't let a jellyfish sting ruin your beach day. Encountering a jellyfish on your beach day can turn a fun time into a medical emergency. It's vital to know how to identify the culprit and treat the sting. Dr. Stuart M. Caplen provides a physician's perspective on managing jellyfish stings and protecting yourself with preventive measures. by Stuart M. Caplen, M.D. Jellyfish are free-swimming marine animals found in waters all over the world. They have stinging tentacles used to capture prey, and some species can deliver a painful sting to humans. It is estimated there are approximately 150 million jellyfish stings a year, typically near coastal beaches.[1] Taxonomy [1] Jellyfish come from the class Scyphozoa or true jellyfish which includes Cyaneidae and Pelegiidae. Other jellyfish-like members of the Cnidarians phylum have venomous tentacles but taxonomically are not considered true jellyfish. These include Staurozoa or stalked jellyfish, Cubozoa or box jellyfish, Hydrozoa of which the Physalia physalis or Portuguese man-of-war (PMOW) is a member. The PMOW and the Physalia utriculus (Bluebottle) are classified as siphonophores or animals made up of a colony of organisms working together. Both of the Physalia species have gas filled bladders that float above the water.[2] For linguistic simplicity jellyfish and jellyfish-like organisms will be referred to as jellyfish in this article. From: Cegolon et al. How Jellyfish Sting and Adverse Effects of Envenomation Some jellyfish have a jellylike substance surrounding internal structures, others have a gas bladder or an umbrella-shaped bell. The tentacles are of varying size, ranging from a few millimeters to over 40 meters in length depending on the species. One type of cell in the tentacle is called the nematocyst which is a capsule containing a tightly coiled filament immersed in venom. Tentacles can contain thousands of nematocysts. Jellyfish venom discharge is triggered by mechanical stimuli, such as rubbing against a person or fish. These stimuli lead to the uncoiling of the filament, which can penetrate tissue, and cause the nematocyst to discharge venom into or onto whatever has caused the activation. Nematocysts can function even when separated from the jellyfish or if the jellyfish is dead. [1] The most common adverse effect of jellyfish stings is a skin reaction. The toxin carried in the tentacles can produce linear, urticarial, painful, or erythematous lesions initially. Stings can also be inconspicuous marks with red flaring, goosebumps, wheals, or just sweating at the site.[3] Later on, the injured areas can become vesicular, hemorrhagic, or even necrotic.[4] The tentacles can become adherent to the skin and potentially cause more venom to be released, even if the jellyfish body is no longer attached. The wounds eventually scab over and may leave permanent scars. Delayed eczematous skin reactions have also been observed in victims days to months after exposure.[4] Conjunctivitis, iritis and corneal ulcerations may occur with ocular stings.[4] Seabather's eruption is a pruritic dermatitis due to jellyfish larvae that get inside a swimsuit and can cause repeated symptoms if the swimsuit is worn again without proper washing.[4] Box Jellyfish Linear Lesions Systemic symptoms can include abdominal pain, nausea/vomiting, muscular pain and muscle spasms. Severe envenomation may produce neurological symptoms such as headache, drowsiness, fainting, or confusion. Dyspnea, respiratory distress and chest pain may also be seen. Symptoms vary by species, and some jellyfish have cardiotoxins able to produce ventricular dysrhythmias and/or cardiac arrest. Neurotoxins may cause respiratory failure and respiratory arrest. Intravascular hemolysis can lead to acute renal failure.[1] While many jellyfish can potentially cause systemic symptoms, severe illness is more likely to be seen in Cubozoans, or box jellyfish stings, which are the most toxic jellyfish. One species, Chironex fleckeri is found in the waters around Australia. It is transparent and not easily seen in the water. Many of the stings are mild with minimal symptoms, but severe cases can result in dyspnea, hypotension, unconsciousness, arrhythmias and cardiopulmonary arrest. If lethal, death usually is a result of cardiac asystole from a cardiotoxin.[1] Irukandji syndrome is most commonly caused by Carukia barnesi, a small box jellyfish found around Australia. It typically begins about 30 minutes after a relatively minor sting, and causes diaphoresis, agitation, vomiting, severe muscle cramps and pain, especially of the lower back, hypertension, and in severe cases acute heart failure.[1] Prevention Prevention of stings can be achieved by avoiding swimming in jellyfish infested waters, or use of a lycra whole body stinger suit.[1] A repellent cream of octyl methoxycinnamate and zinc oxide, sold commercially in some countries has been demonstrated to reduce the severity of jellyfish stings as well as providing sunburn protection.[1] Another commercial jellyfish sting inhibitor and sunblock, that contains octinoxate, titanium dioxide and multiple other ingredients has also been demonstrated to reduce sting severity.[1,6,7] Treatment Treatment of jellyfish stings differs depending on the species, degree of envenomation, and which geographic area the sting occurred in. There are much conflicting data and opinions on the best treatment of jellyfish stings. There have been a number of remedies suggested for stings including covering the attached tentacles in fresh water, meat tenderizer, ethanol, ammonia or sand.[5,6] All have been found to potentially cause the nematocysts to fire and increase the envenomation. Urine has also been advocated as a treatment, but has not been found to be effective, and may stimulate nematocyst discharge.[4] Seawater appears to be relatively safe to apply to the nematocysts.[1,3,4,5,11] If gloves are not available, adherent tentacles may be removed with bare fingers, which will only cause relatively harmless prickling, due to the thick palmar skin.[1,3] Tweezers may also be used for tentacle removal.[1] Using seashells or a credit card to scrape off the tentacles has also been suggested, but one study of box jellyfish found more discharged nematocysts after scraping rather than pulling the tentacles off.[8] Vinegar Vinegar (5–8% acetic acid) has historically been recommended as treatment to be applied to the nematocysts before trying to remove them from the skin,[1,9] but its universal use is now questioned.[1,5] Vinegar deactivates undischarged nematocysts in some species, so they don't fire when removed,[10] but vinegar also has been found to increase venom release from already discharged Chironex fleckeri nematocysts.[11] Some authorities suggest initially applying the vinegar in a small area after a sting to see if pain or symptoms worsen before using more diffusely.[9] The general recommendation of the Australian Resuscitation Council is to use vinegar for tropical jellyfish stings, but not for ones in non-tropical areas. This is due to the presence of species such as a multi-tentacled Physalia utriculus (Bluebottle) living in Australian waters where vinegar was found to cause activation of nematocysts.[3] The American Red Cross guidelines suggest that since vinegar has been confirmed to cause discharge of the nematocysts of some species of jellyfish, it is no longer recommended for most jellyfish stings in U.S. coastal waters.[12] Baking Soda For Chrysaora quinquecirrha, also known as the sea nettle, a baking soda slurry made with seawater is the recommended therapy to inactivate the nematocysts by some experts.[1,5] Conversely, the American Red Cross 2016 guidelines removed baking soda slurries as a recommended therapy for U.S. jellyfish stings.[12] Heat Use A Cochrane review found heat immersion provided better pain relief than ice packs for Physalia, Carybdea alata (Hawaiian box) and the Carukia species.[13] A trial comparing hot water immersion to ice packs found that 20 minutes of 450C hot water immersion did significantly improve pain over ice packs for bluebottles and PMOW.[14] However, a study of Chironex fleckeri stings found heat had no improved effect on pain control over ice packs.[15] One animal study found that exposure to heat reduced the lethality of Chironex fleckeri venom.[16] American Red Cross Scientific Advisory Committee First Aid Recommendations [12] Recommendations by the American Red Cross Scientific Advisory Committee for tentacle removal and initial pain control vary for different geographic regions of North America. In Hawaiian waters, gently lift up or scrape to remove any remaining tentacles with a blunt object, to avoid further stings. The blunt removal object that is recommended is a seashell combined with washing the tentacles with seawater. Rinse the affected area with seawater and follow by application of hot water (approximately 106-113°F) or hot pack. If a hot pack is not available a cold pack can be used to attempt to relieve the pain. In U.S. coastal Pacific Ocean waters, the recommendation is to treat as for Hawaiian stings. Gently lift up or scrape to remove any remaining tentacles with a blunt object, to avoid further stings. Rinse the affected area with seawater and follow by application of hot water or hot pack (approximately 106-113°F). If a hot pack is not available a cold pack can be used to attempt to relieve the pain. In coastal Atlantic Ocean waters, gently lift up or scrape to remove any remaining tentacles with a blunt object, to avoid further stings. The blunt removal object that's recommended is a seashell combined with washing the tentacles with seawater. If topical lidocaine is available, this can be applied to inhibit further nematocyst discharge and provide pain relief. This should be followed by application of hot water or hot pack (approximately 106-113°F). If a hot pack is not available a cold pack can be used to attempt to relieve the pain. Lidocaine for pain control and possible nematocyst inactivation is only specifically discussed in the Atlantic Ocean section of the Red Cross recommendations, but it is recommended as an option for pain control for all geographic areas in the summary section. Heat can be applied to the affected area, preferentially by hot water immersion or in a shower in a range of 106-113ºF, or practically as hot as the patient can tolerate without scalding them. If a tub for hot water immersion or a shower is not available, a chemical heat pack can be applied. Heat application should take place for a duration of up to 20 minutes or until pain is relieved. Cold packs are felt to be less beneficial than heat packs in relieving pain but may be of some benefit when heat or lidocaine are not available. Salt seawater, according to these guidelines, has not been found to cause nematocysts discharge and thus is recommended for rinsing a sting site prior to applying heat or hot water. Australian Resuscitation Council(ARC) First Aid Recommendations [3] Current recommendations for tentacle removal and initial pain control are: Due to the different jellyfish species around Australia, there are separate recommendations depending on whether the sting occurred in a tropical or non-tropical region. In Australian tropical areas apply vinegar for 30 seconds, except if it is a Bluebottle (Physalia utriculus), where vinegar increases nematocyst discharge. Then pick off the tentacles, applying ice packs after. ( There is a theoretical concern that heat, by increasing blood flow, may potentially increase venom absorption of some tropical jellyfish. )[1] Seawater may be used to cleanse the area, but fresh water should not be used. In non-tropical areas, and for bluebottle stings, the ARC recommends picking off the tentacles and washing with seawater, followed by immersing the area in hot water. For immediate treatment of pain after jellyfish stings, ice packs can be used, but hot water(45° C) or hot showers were found to decrease pain in some species better than ice packs. Other Post-Sting Treatments BLS or ACLS interventions as required for severe life-threatening envenomations. [12] Anti-venom for Chironex fleckeri and other box jellyfish is available in Australia.[3] It can be administered in severe cases of cardiopulmonary instability, cardiac arrest, cardiac arrhythmias, or severe pain not relieved by opiates.[3] In animal models it was found that magnesium sulfate may also be helpful for cardiac instability in combination with the antivenom.[17] Over-the-counter analgesics or if the pain is severe, narcotic medications may be needed for pain relief.[4] Antihistamines can be used for urticaria or allergic-type symptoms.[4] Consider tetanus immunization if the victim's immunization status is not up-to-date. [4] An elastic compression bandage, or wrap was previously recommended for the affected extremity to try to limit venom circulation similarly to snake bites, but several studies found it actually increased envenomation and its use has been curtailed.[18] Some references recommend prophylactic topical antibiotic ointments after a sting. Oral and intravenous antibiotics are only needed for confirmed infections.[4] There are some commercial products available with limited scientific evidence for their use. A commercially sold solution of 20% aluminum sulfate and surfactant, was found to be significantly more effective than seawater as a painkiller in testing.[1] In an inventor authored study, a commercial spray of copper gluconate, urea, magnesium sulfate and 3% acetic acid, was found to be effective in neutralizing Alatina alata (a Hawaiian box jellyfish) venom, and assisting with removal of nematocysts.[19] Portuguese Man-of-War Common Jellyfish in U.S. Waters [12] In the Pacific Ocean near Hawaii, the most common stings are due to the box jellyfish (Carybdea alata), and Portuguese man-of-war (Physalia physalis). The pacific sea nettle, Chrysaora fuscescens is found widely on the Pacific coast. A box jellyfish, Carybdea marsupialis can be occasionally found off Southern California in the late summer or fall. The most abundant species of jellyfish in the Gulf of Mexico are the sea nettle and moon jellyfish (Aurelia aurita), which typically swarm during summer months. The Portuguese Man-of-war is also commonly reported in the Gulf. Sea Nettle Chrysaora quinquecirrha, the Atlantic Sea Nettle, can be found along the entire U.S. east coast, particularly in the Chesapeake Bay. The box jellyfish, Carybdea marsupialis is occasionally found in the Atlantic ocean and has been reported as far north as New York. The Portuguese man-of-war has been reported along the southern Florida Atlantic Coast and can be carried by the Gulf Stream as far north as New York. Moon jellyfish (Aurelia aurita) are commonly found in the tropical waters surrounding Puerto Rico and the Virgin Islands. Key Recommendations Treatments for jellyfish stings have variable responses and conflicting results depending on the study and species tested. A treatment that works for one species’ sting may worsen an envenomation from another. This creates considerable confusion about which therapeutic modalities are best for jellyfish stings, even when the species is known. The American Red Cross and the Australian Research Council (ARC) first aid recommendations vary in some respects. The Red Cross recommends either lifting or scraping off the adherent tentacles, and the ARC recommends only pulling them off. The ARC has recommendations for vinegar use in tropical stings, while the Red Cross recommends not using it for stings in the U.S. Heat is the recommended first choice of therapy for all U.S. stings, while ice packs are recommended for tropical Australian stings. Part of the disparity is due to the different species and toxicity of local jellyfish, but part is also due to the contradictory literature on the treatment of jellyfish stings. However, one can use these official recommendations as a general guide to jellyfish sting treatment. Using other therapies will depend on if there is definitive identification of the stinging species, what treatments are available, the expertise of the rescuer, and the predominant jellyfish species in the geographic area of the sting. Editor’s note : When I was twelve years old I remember very clearly the stings of the PMOW. Although I do not remember exactly my treatment. I do remember the lifeguard debating between vinegar and cream. I may have received both! Rich Strongwater, M.D. Related Topics: Here is another article on " Mauve Stinger Jellyfish (Pelagia noctiluca) Envenomation " Fun Finds: As an Amazon Associate FibonacciMD earns from qualifying purchases. After learning about these fascinating creatures, you might enjoy assembling a beautiful 1,000 piece jellyfish jigsaw puzzle  by Cavallini Papers & Co.  It's a great way to relax and appreciate the intricate beauty of jellyfish from the safety of your home. References: American Red Cross Scientific Advisory Council Advisory Jellyfish Stings, June 2016. Retrieved from: redcross.org PDF AUSTRALIAN RESUSCITATION COUNCIL, GUIDELINE 9.4.5, ENVENOMATION - JELLYFISH STINGS, , July 2010. Retrieved from: secureservercdn.net PDF Boer Kimball A, Efficacy of a Jellyfish Sting Inhibitor in Preventing Jellyfish Stings in Normal Volunteers, Wilderness & Environmental Medicine, Volume 15, Issue 2, June 2004, Pages 102-108. Retrieved from: sciencedirect.com Boulware D, eMD, A Randomized, Controlled Field Trial for the Prevention of Jellyfish Stings With a Topical Sting Inhibitor, Journal of Travel Medicine, Volume 13, Issue 3, 1 May 2006, Pages 166–171, Retrieved from: doi.org Carrette T, et al., Temperature effects on box jellyfish venom: a possible treatment for envenomed patients?, Med J Aust 2002; 177 (11): 654-655. retrieved from: www.mja.com.au/journal/ Cegolon L, Heymann WC, Lange JH, Mastrangelo G. Jellyfish stings and their management: a review. Mar Drugs. 2013;11(2):523-550. Published 2013 Feb 22. Retrieved from: www.mdpi.com Fenner P, Awareness, Prevention and Treatment of world-wide marine stings and bites, International Life Saving Federation Medical/Rescue Conference Proceedings, September 1997. Retrieved from: www.ilsf.org PDF Isbister G, et al., Hot water immersion v icepacks for treating the pain of Chironex fleckeri stings: a randomised controlled trial, Med J Aust 2017; 206 (6): 258-261. Retrieved from: mja.com.au/journal/ Lakkis N, Jellyfish Stings: A Practical Approach, Volume 26, ISSUE 3, P422-429, September 01, 2015. Retrieved from: wemjournal.org Li L, et al., Interventions for the symptoms and signs resulting from jellyfish stings, Cochrane Database of Systematic Reviews, John Wiley and Sons, Dec 9, 2013. Loten, C.; Stokes, B.; Worsley, D.; Seymour, J.; Jiang, S.; Isbister, G. A randomised controlled trial of hot water (45 °C) immersion versus ice packs for pain relief in bluebottle stings. Med. J. Aust. 2006, 184, 329–333 Portuguese Man-of-War, National Geographic. Retrieved from: nationalgeographic.com Ramasamy, S.; Isbister, G.K.; Seymour, J.E.; Hodgson, W.C. The in vivo cardiovascular effects of box jellyfish Chironex fleckeri venom in rats: Efficacy of pre-treatment with antivenom, verapamil and magnesium sulfate. Toxicon 2004, 43, 685–690. sciencedirect.com Seymour J, Are we using the correct first aid for jellyfish?, Med J Aust 2017; 206 (6): 249-250. Retrieved from: mja.com.au/journal/ Yanagihara A, et al., Experimental Assays to Assess the Efficacy of Vinegar and Other Topical First-Aid Approaches on Cubozoan (Alatina alata) Tentacle Firing and Venom Toxicity, Toxins, January 11, 2016. retreived from mdpi.com PDF Yanagihara A, Wilcox C, Cubozoan Sting-Site Seawater Rinse, Scraping, and Ice Can Increase Venom Load: Upending Current First Aid Recommendations, Toxins, 2017 Mar; 9(3): 105. retrieved from: ncbi.nlm.nih.gov Ward N, et al., Evidence-Based Treatment of Jellyfish Stings in North America and Hawaii, Annals of Emergency Medicine, June 08, 2012. retrieved from: annemergmed.com Welfare P, et al., An in-vitro examination of the effect of vinegar on discharged nematocysts of Chironex fleckeri, Diving Hyperb Med, Vol 44 No. 1, 2014. Retrieved from: eubs.org #EmergencyMedicine Originally Published July 2021

Mauve stinger jellyfish are making waves. Mauve stinger jellyfish are making headlines once again. Following significant blooms in 2024 across parts of Europe and in 2022 in the Mid-Atlantic U.S., these jellyfish have returned in increased numbers in new areas. Their presence, pushed northward by warming sea temperatures and unusual weather patterns, serves as a timely reminder to learn about their sting symptoms, treatment options, and preventive measures. by Stuart M Caplen, MD In late summer and fall of 2024, some areas of Europe were inundated with mauve stinger jellyfish sightings (also known as the purple-striped jellyfish or Pelagia noctiluca ).  In September, 120 swimmers in a swim challenge event off the coast of the Isles of Scilly, in southwest Britain, ran into two swarms of mauve stinger jellyfish, with most of the swimmers being stung.[1]  In October, tens of thousands of mauve stingers washed up on beaches in South Finistère, France.  It was thought that tropical storms had brought them further north than normal.[2]  In August and early September 2022, there were numerous mauve stinger jellyfish sightings and stings in Long Island and the New Jersey Shore in the U.S.[3,4]  These jellyfish are typically seen offshore and rarely found on the Northeastern U.S. coastline.  Weather and tide conditions were thought to be responsible.[4]  The mauve stinger jellyfish is most commonly found in the Mediterranean Sea but has been seen in other coastal parts of Europe, as well as off the California coast.[5] Jellyfish Anatomy [6] Mauve Stinger Jellyfish Stings Mauve stinger jellyfish are typically 1 to 5 inches in diameter and are colored pink, mauve, or light brown with a phosphorescent bell.  The nematocysts (the stinging cells of a jellyfish) are on the tentacles, the oral arms, and, what is somewhat unusual for a jellyfish, on the surface of the bell.  Envenomation can occur from contact with either alive or dead mauve stinger jellyfish.  Typically, the stings are usually limited to the skin surface and cause only erythematous (reddish), edematous (swollen), and vesicular (blistering) lesions, with localized pain that can last for one to two weeks. Systemic complications or cutaneous infections are rare.  The skin lesions can be circular or irregularly shaped, and scarring and hyperpigmentation may occur after healing.  The venom is also able to cause severe generalized allergic reactions.  Studies have revealed that most stings produce localized skin reactions, but a small percentage will have more serious systemic symptoms.  There are no reports of fatalities, but there is a case report of Guillain-Barré syndrome following envenomation.[7]  A relapse of the skin rash some years later may occur if re-stung by another mauve stinger jellyfish and has also been reported in some individuals who had no further contact with the jellyfish.  There may be some cross-reactivity between mauve stinger jellyfish venom and Portuguese man-o’-war venom, which can stimulate an allergic reaction.[5] Mauve Stinger Jellyfish Stings[8,9] Treatment The treatment of all jellyfish stings is controversial, and the scientific literature in some cases is inconclusive or conflicting.  For some species, vinegar (acetic acid) is recommended, while in others baking soda slurry (sodium bicarbonate) is the recommended method to inactivate the nematocysts.  For some jellyfish stings, hot water is recommended as initial therapy, while in other species ice packs are suggested.[10] Vinegar (acetic acid) is no longer recommended by the U.S. Red Cross for most jellyfish stings in U.S. waters, as there have been some studies that showed increased release of venom with its use.[11]  Several studies found vinegar increased nematocyst discharge in mauve stinger envenomations, but seawater did not.[12,13]  However, an in vitro study (a study done in the laboratory) conversely found that vinegar did reduce nematocyst discharge.[14]  Sodium bicarbonate or baking soda is recommended for some jellyfish envenomations, such as for the sea nettle.  However, it has been found to increase nematocyst discharge in mauve purple jellyfish.[13]  Although there are conflicting recommendations, use of alkaline or acidic solutions may possibly cause a worsening of the envenomation in mauve stinger jellyfish stings, and based on available literature, probably should be avoided.[5] It has been reported that 1% lidocaine, 70% ethanol, and 20% ammonia in vitro reduced nematocyst discharge[14], but as is not atypical, another study found that ammonia activated the nematocysts.[13]  Used alone, topical lidocaine has been found in several mauve stinger studies to inactivate the nematocysts.[13,14]  It has also been found that calcium ions may be an important part of nematocyst activation, and gadolinium, which blocks cellular calcium channels, was found to block nematocyst discharge in one study, but had no effect in another one.[5,13,15] Though there are conflicting data and recommendations, the general recommendation for local care of mauve stinger jellyfish stings is first washing the area with seawater.  As removing the attached nematocyst may cause increased envenomation, any adherent jellyfish parts should gently be removed with gloves or tweezers after seawater washing.[10,11]  They can also be scraped off with a seashell,[11] but scraping has been shown to potentially increase nematocyst discharge in some jellyfish species.[10]  If gloves are not available, adherent tentacles may be removed with bare fingers, which may only cause relatively harmless prickling due to the thick palmar skin, but this is not a first choice.[16,17]  Topical lidocaine is recommended as an option in jellyfish stings by the Red Cross to reduce pain[11] and has been found in several mauve stinger studies to inactivate the nematocysts[13,14], so that can be one treatment option prior to removing the attached jellyfish parts.  The maximal recommended lidocaine dose should not be exceeded to avoid toxicity. There has been some controversy about whether to use heat or ice packs as initial therapy after a jellyfish sting after the nematocysts have been removed.  In Australia, ice packs are recommended for tropical jellyfish stings and heat for non-tropical ones.[17]  As heat can inactivate jellyfish venom, which can decrease pain, the U.S. Red Cross guidelines advise applying hot water or a hot pack between approximately 106 - 113° F (41 - 45° C) or as hot as tolerated (not scalding), for 20 minutes or until pain is relieved.[11] Mauve Stinger Jellyfish Over-the-counter medication is generally adequate for treating pain.  Medical treatment, including possible hospitalization, may be needed for more severe reactions.  For all jellyfish stings, a tetanus booster is recommended if not up to date.  Prophylactic antibiotics are typically not necessary.  Antihistamines can be used for urticaria or allergic-type symptoms.[18] There have been some studies using proprietary formulations to treat purple mauve stinger jellyfish stings, but one positive study, authored by manufacturer employees, was unblinded and had no control group.[8]  The other was an in vitro study which found 10% lidocaine and some compounds used in cosmetics also work as inhibitors of nematocyst discharge.  It was thought that due to its viscous consistency, one of the compounds, butylene glycol, wraps around the tentacle to act as a physical barrier.[13] Prevention Prevention of stings can be achieved by avoiding swimming in jellyfish-infested waters, or by use of a Lycra whole body stinger suit.[16]  A repellent cream of octyl methoxycinnamate and zinc oxide, sold commercially in some countries, has been demonstrated to reduce the severity of jellyfish stings as well as providing sunburn protection.[16]  Another commercial jellyfish sting inhibitor and sunblock that contains octinoxate, titanium dioxide, and multiple other ingredients has also been demonstrated to reduce sting severity from some species.[16,19,20] Conclusions Mauve stinger jellyfish stings are generally painful but not life-threatening.  This year they were seen in increased numbers in some areas of Europe and previously have been found in New Jersey and New York State coastal waters.  The literature, as is typical with jellyfish research, is sometimes contradictory.  Avoidance of jellyfish when they are seen in the water is the best advice, but once stung, washing with seawater and gentle removal of attached parts of the jellyfish is recommended.  Topical lidocaine may reduce pain and inactivate nematocysts.  Immersion of the affected area, showering in warm water, or using hot packs to try to deactivate the venom appears to be a reasonable recommendation.  Acid and alkali solutions have in some studies shown to worsen the venom discharge from nematocysts and are probably best avoided.  Other products that have been tested may have some benefit, but the studies were either in vitro or were not of sufficient scientific quality. Download the Mauve Stinger Jellyfish article as a PDF: Related Topics: Here is another article on Jellyfish Stings . Fun Finds: As an Amazon Associate FibonacciMD earns from qualifying purchases. After learning about these fascinating creatures, you might enjoy assembling a beautiful 1,000 piece jellyfish jigsaw puzzle by Cavallini Papers & Co. It's a great way to relax and appreciate the intricate beauty of the Pelagia noctiluca  from the safety of your home. References [1] Carpenter F and Parkman C. Swimmers suffer 'chemical burn' jellyfish stings. BBC. 30 September 2024. Retrieved from: https://www.bbc.com/news/articles/cp9527gjkz4o [2] Lynall A. Thousands of jellyfish wash up on Brittany beaches. The Connexion. November 1, 2024. Retrieved from: https://www.connexionfrance.com/news/thousands-of-jellyfish-wash-up-on-brittany-beaches/687304 [3] Chinese V. Mauve stinger jellyfish sting more than 200 swimmers at Robert Moses and Jones Beach. Newsday. Updated September 5, 2022. Retrieved from: https://www.newsday.com/long-island/suffolk/mauve-stinger-jellyfish-painful-sting-robert-moses-jones-beach-a9msdgw1 [4] Kudisch B. Rare mauve stinger jellyfish found at the Jersey Shore. Its sting is ‘intense,’ scientists warn. NJ.com . Aug. 31, 2022, Updated: Sep. 01, 2022. Retrieved from: https://www.nj.com/news/2022/08/rare-mauve-stinger-jellyfish-found-at-the-jersey-shore-its-sting-is-intense-scientists-warn.html [5] Mariottini GL, Giacco E, Pane L. The mauve stinger Pelagia noctiluca (Forsskål, 1775). Distribution, ecology, toxicity and epidemiology of stings. A review. Mar Drugs. 2008;6(3):496-513. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579739/ [6] Wikipedia jellyfish- adapted from Zina Deretsky, National Science Foundation; derived from: Anatomy of "true" jellyfish (class Scyphozoa). Retrieved from: https://upload.wikimedia.org/wikipedia/commons/8/8e/Anatomy_of_%22true%22_jellyfish_%28class_Scyphozoa%29.jpg [7] Pang KA, Schwartz MS. Guillain-Barré syndrome following jellyfish stings (Pelagia noctiluca). J Neurol Neurosurg Psychiatry. 1993 Oct;56(10):1133. [8] Hall A, Mathieu L, Blomet J. Pelagia noctiluca jellyfish: Can lesions and symptoms be prevented or ameliorated? Journal of Marine Biology and Aquaculture. 12/29/2018. Retrieved from: https://www.ommegaonline.org/article-details/iPelagia-noctilucai-jellyfish--Can-lesions-and-symptoms-be-prevented-or-ameliorated/1971 [9] Shapo L, Saker L. A case of immediate and delayed reactions after contact with a venomous mauve-stinger jellyfish in a diabetic patient. International Journal of Case Reports and Images 2013;4(7):388–391. Retrieved from: http://www.ijcasereportsandimages.com/archive/2013/007-2013-ijcri/012-07-2013-shapo/ijcri-012072013112-shapo-full-text.php [10] Caplen, S. Jellyfish Stings. FibonacciMD. Jul 14, 2021. Retrieved from: https://www.fibonaccimd.com/post/jellyfish-stings [11] American Red Cross Scientific Advisory Council Advisory Jellyfish Stings. June 2016. Retrieved from: https://www.redcross.org/content/dam/redcross/Health-Safety-Services/scientific-advisory-council/Scientific%20Advisory%20Council%20ADVISORY%20-%20Jellyfish%20Stings.pdf?srsltid=AfmBOooHVQYS7MXcVZszCSVnUalMwT68QCjzrceVP9JXf_epm2X8EImk [12] Ballesteros A et al. Differing Effects of Vinegar on Pelagia noctiluca  (Cnidaria: Scyphozoa) and Carybdea marsupialis  (Cnidaria: Cubozoa) Stings-Implications for First Aid Protocols. Toxins (Basel). 2021 Jul 21;13(8):509.Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8402392/ [13] Ballesteros A, et al. Inhibition of Nematocyst Discharge from Pelagia noctiluca (Cnidaria: Scyphozoa)—Prevention Measures against Jellyfish Stings. Marine Drugs. 2022; 20(9):571. Retrieved from: https://www.mdpi.com/1660-3397/20/9/571/htm [14] Morabito R, Marino A, Dossena S, La Spada G. Nematocyst discharge in Pelagia noctiluca (Cnidaria, Scyphozoa) oral arms can be affected by lidocaine, ethanol, ammonia and acetic acid. Toxicon. 2014 Jun;83:52-8. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/24637105/ [15] Salleo A, La Spada G, Barbera R. Gadolinium is a powerful blocker of the activation of nematocytes of Pelagia noctiluca. Journal of Experimental Biology. 01 February 1994. Retrieved from: https://journals.biologists.com/jeb/article/187/1/201/6649/Gadolinium-is-a-powerful-blocker-of-the-activation [16] Cegolon L, Heymann WC, Lange JH, Mastrangelo G. Jellyfish stings and their management: a review. Mar Drugs. 2013 Feb 22;11(2):523-50. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3640396/#B98-marinedrugs-11-00523 [17] ANZCOR, Guideline 9.4.5 - Envenomation - Jellyfish Stings. 2010. Retrieved from: https://www.anzcor.org/home/first-aid-for-bites-stings-and-poisoning/guideline-9-4-5-envenomation-jellyfish-stings/ [18] Lakkis N. Jellyfish Stings: A Practical Approach. Wilderness Environmental Medicine Volume 26, ISSUE 3, P422-429. September 01, 2015. Retrieved from: https://www.wemjournal.org/article/S1080-6032(15)00008-3/fulltext [19] Boulware D. A Randomized, Controlled Field Trial for the Prevention of Jellyfish Stings with a Topical Sting Inhibitor. Journal of Travel Medicine, Volume 13, Issue 3, 1 Pages 166–171. May 2006. Retrieved from: https://academic.oup.com/jtm/article/13/3/166/1816684 [20] Boer Kimball A. Efficacy of a Jellyfish Sting Inhibitor in Preventing Jellyfish Stings in Normal Volunteers. Wilderness & Environmental Medicine, Volume 15, Issue 2, Pages 102-108. June 2004. Retrieved from: https://www.sciencedirect.com/science/article/abs/pii/S1080603204704548 Initially published Sept 2022. Updated 2024

Zika - A Mosquito Borne Viral Disease by Stuart M Caplen, MD The Aedes Aegypti Mosquito[1] The Zika virus is a mosquito borne viral disease. No other animal infects and causes disease as effectively as mosquitos, which are the deadliest animals in the world to humans. Infections caused by mosquitos kill over 700,000 people a year.[2] This is part 1 of a four part series on mosquito borne viral diseases. In this article we will look at Zika. The future articles will cover Dengue , chikungunya, and West Nile . Currently West Nile is endemic in the continental US, but clinicians may see the other three diseases in travelers who are either from, or who have visited endemic areas. It is also possible that like Zika a few years ago, these diseases may become endemic in the U.S. at some time in the future. The following is Part 1- Zika. Zika Virus In 2015 and 2016 Zika was a front-page news story due to surging infections in the Americas, with the threat of severe fetal brain defects occurring if pregnant women were infected. Since then, Zika has almost disappeared.[3] In 2016, there were 5,168 reported cases in the U.S. and 36,512 cases in U.S. territories, with widespread transmission in Puerto Rico and the U.S. Virgin Islands, and limited local transmission in Florida and Texas.[4] Brazil had 200,000 reported Zika cases in 2016, and infants born with microcephaly increased 10-fold from prior levels in late 2015 to early 2016.[5] By 2019, there were only 27 reported U.S. cases in travelers and 74 cases in U.S. territories.[6] There are currently no countries with a large outbreak of Zika. Some experts do not think pesticide spraying has caused the decline, and it is possible that a form of herd immunity in endemic areas has occurred, limiting the ability of mosquitos to spread Zika to humans.[3] Zika virus is an RNA Flavivirus transmitted by Aedes aegypti and Aedes albopictus mosquitos. Human to human transmission also occurs, and potentially it can be transmitted by blood transfusion and sexual contact. Zika virus was first discovered in 1947 and is named after the Zika Forest in Uganda. The first human case was reported in 1952.[7] Zika Clinical Disease[8] Most people infected with Zika virus are asymptomatic. Clinical findings typically are acute onset of fever with rash, arthralgia (joint aches), and/or conjunctivitis (pinkeye). Myalgias (muscle aches) and headaches are common. The illness is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon, and fatalities are rare. There have been some cases of Guillain-Barré syndrome (an autoimmune disease that can cause numbness, weakness and potentially paralysis starting in the legs and moving up the body) reported after a Zika infection. Zika virus infection during pregnancy can cause fetal microcephaly (smaller than expected head size), decreased brain tissue, and damage to the back of the eyes.[9] Zika virus infection[10] Treatment No specific treatment is available for Zika virus disease, other than supportive care. As dengue presents similarly, and in the same geographic areas as Zika, aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen should be avoided until dengue can be ruled out, to reduce the risk of hemorrhage. People infected with Zika, should be protected from mosquito exposure during the first few days of illness to reduce the risk of further human to mosquito to human transmission. Sexual relations should be curtailed to prevent passing on the infection.[8] A vaccine has been developed, but gaining approval by testing it in an environment of decreasing cases has proved difficult.[3] Sexual Transmission [11] Zika can be sexually transmitted by sharing sex toys, and by vaginal, anal, and possibly oral sex, even if asymptomatic. Zika virus has been detected in semen, vaginal fluids, saliva, urine, and breast milk. There is no evidence however, that Zika can be transmitted through saliva during kissing. Zika virus has been reported to persist in semen for up to 69 days. It is recommended that pregnant women with sexual partners who live in, or have traveled to, an endemic Zika area, use condoms during sex, or abstain from sexual relations for the duration of the pregnancy. Condom use is recommended after travelling to an endemic area for two months for nonpregnant females, and three months for males, due to the longer survival time in semen. Testing [12] Zika testing of symptomatic male and female non-pregnant patients is not currently recommended by the CDC based on current epidemiology, but this guidance may change in the case of a renewed outbreak of cases. However, these patients should be tested for dengue virus, which is more common, and has similar presenting features. Testing asymptomatic males and non-pregnant females for either dengue or Zika viruses is not currently recommended. Zika testing involves a very complex algorithm for pregnant women. Recommended testing is different if the woman is symptomatic, asymptomatic, has had an abnormal fetal ultrasound consistent with a congenital Zika infection, or has had sexual relations with someone suspected of having the disease. If you are interested in learning more about the complete CDC Zika testing guidelines algorithm for pregnant women, follow this link: https://www.cdc.gov/zika/hc-providers/testing-guidance.html Mosquito-borne Viruses [49] Cache Valley Chikungunya Dengue Eastern equine encephalitis Jamestown Canyon Japanese encephalitis La Crosse encephalitis Rift Valley fever Ross River virus disease St. Louis encephalitis West Nile Yellow fever Zika Mosquito Borne-Parasites Dirofilariasis (dog heartworm) Lymphatic filariasis Malaria #InfectiousDisease #mosquito Zika, Dengue, West Nile, and Chikungunya online CME Your Must-Have Defense for Outdoor Health As an Amazon Associate, FibonacciMD may earn from qualifying purchases. Don't just repel bugs—get a wearable defense against disease! This Permethrin-Treated Athletic Hoodie  is registered to repel Ticks, Mosquitoes, and other insects that can carry serious illnesses like Lyme disease, West Nile, and Zika virus. With built-in UPF 50+ sun protection, this long-sleeve shirt is the ultimate piece of gear for fishing, hiking, and all your active adventures. References [2] Nuwer R. Mosquitoes Kill More Humans Than Human Murderers Do. SMITHSONIANMAG.COM. April 30, 2014. Retrieved from: https://www.smithsonianmag.com/smart-news/mosquitoes-kill-more-humans-human-murderers-do-180951272/ [3] Cohen J. Zika has all but disappeared in the Americas. Why? Science. Aug. 16, 2017. Retrieved from: https://www.sciencemag.org/news/2017/08/zika-has-all-disappeared-americas-why [4] Zika, 2016 Case Counts in the US. CDC. Last reviewed: April 24, 2019. Retrieved from: https://www.cdc.gov/zika/reporting/2016-case-counts.html [5] Lowe R et al. The Zika Virus Epidemic in Brazil: From Discovery to Future Implications. Int J Environ Res Public Health. 2018;15(1):96. Published Jan 9, 2018. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5800195/#B18-ijerph-15-00096 [6] Zika Virus, 2019 Case Counts in the US. CDC. Last reviewed: December 2, 2020. Retrieved from https://www.cdc.gov/zika/reporting/2019-case-counts.html [7] Zika Virus, History of Zika. CDC. Last reviewed: October 7, 2019. Retrieved from: https://www.cdc.gov/zika/about/overview.html [8] Zika Virus, Clinical Evaluation & Disease. CDC. Last reviewed: January 28, 2019. Retrieved from: https://www.cdc.gov/zika/hc-providers/preparing-for-zika/clinicalevaluationdisease.html [9] Zika Virus, Microcephaly & Other Birth Defects. CDC. Last reviewed: May 14, 2019. Retrieved from: https://www.cdc.gov/zika/healtheffects/birth_defects.html [10] Pictures by Jose Antonio Suarez in Rodriguez-Morales A et al. Introductory Chapter: Clinical and Epidemiological Implications of Zika Virus Infection -The Experience of RECOLZIKA in Colombia. Intechopen. 2018. Retrieved from: https://www.researchgate.net/publication/325754352_Introductory_Chapter_Clinical_and_Epidemiological_Implications_of_Zika_Virus_Infection_-The_Experience_of_RECOLZIKA_in_Colombia/download [11] Zika Virus, Clinical Guidance for Healthcare Providers for Prevention of Sexual Transmission of Zika Virus. CDC. Last reviewed: January 28, 2019. https://www.cdc.gov/zika/hc-providers/clinical-guidance/sexualtransmission.html [12] NEW Zika and Dengue Testing Guidance. CDC. Updated November 2019. Retrieved from: https://www.cdc.gov/zika/hc-providers/testing-guidance.html Initial publication 12/16/2021

Explore the Nutritional Benefits of Fresh, Frozen, & Canned Vegetables Fresh, frozen, and canned vegetables each have advantages and drawbacks. Understanding the differences can help you make informed choices to boost your vegetable intake. Culinary Medicine by Mary B Grosvenor, MS, RD and Lori A Smolin, PhD “Eat your vegetables.” Your mother probably told you that repeatedly when you were growing up. A diet rich in vegetables can lower blood pressure and reduce the risk of heart disease, stroke, obesity, and some types of cancer.[1] Yet, only about one in ten of American adults eat the recommended amounts of vegetables; the equivalent of about 3 cups per day.[1,2] Why? Some say it’s hard to find fresh vegetables, some say they cost too much and they spoil too quickly, and others feel they don’t have the time or know-how to prepare them well.[3]  But, expanding your choices beyond fresh to include frozen and canned vegetables offers a convenient, nutritious, and economical alternative to boost your vegetable intake. Is Fresh Best? We typically think of fresh produce as the healthiest choice and that is likely true if you are choosing a locally grown vegetable when it is in season. Vegetables begin to lose vitamins as soon as they are picked, so buying them close to home means losses that occur during shipping and storage are minimized. But we do not always have access to local produce. Fresh vegetables may be hard to find and expensive in areas of the country where winter limits the growing season and in urban areas where grocery stores and farmer’s markets are scarce.[4] Also, not everyone has the time and money to find and purchase locally grown produce. If you are fortunate enough to bring home fresh local produce, you need to consume it as soon as possible; produce that is bought fresh but sits in your refrigerator for weeks, is no longer fresh. What About Frozen?  Frozen vegetables have many advantages over fresh. They are more convenient to buy and don’t continue to lose quality or nutrients once you get them home; frozen vegetables can be stored for 8 to 12 months before quality begins to decline.[5] In some cases they may even be nutritionally superior because the vegetables are harvested ripe, when they are at peak nutrient content, and frozen within hours of harvest.[6] In contrast, the “fresh” vegetables we see in the supermarket are often harvested before they’re ripe, transported long distances, and spend time in storage before they appear on the grocery shelf.  Frozen vegetables are also more economical – they cost less to purchase, and we are less likely to have to discard them uneaten because we did not have time to prepare them before they spoiled. A downside is that freezing and thawing can change texture, so frozen vegetables do not always have the crisp feel and appearance of fresh ones. [6]  Benefits of Canned We tend to think of canned as less nutritious but there is evidence that people who eat more canned foods tend to have a higher intake of vegetables and certain nutrients compared to people who eat fewer canned goods.[7]  Although the canning process does destroy some water-soluble vitamins, the mineral, fat-soluble vitamin, and fiber content remain relatively unchanged. In some cases, the heat of canning increases the antioxidant content of canned vegetables. For example, more of the antioxidant lycopene is available for absorption from canned tomatoes than from fresh ones. However, as with frozen vegetables, canned products can lose their crispness during processing. Canned foods are generally cheaper, available year-round, and can be stored for several years so they do not go bad before you eat them.[8] Making Wise Choices Fresh can be best – when affordable and purchased in season at peak flavor and nutrient content. But fresh vegetables can be expensive and aren’t always so fresh: those we see in the supermarket have often been transported long distances and spend time in storage before and after they reach the grocery store and then again in your home before you eat them. These factors can make frozen and canned better choices; they are generally less expensive and maintain nutrients and quality longer in your home.[9]  In addition, there are many options available that include interesting combinations and added flavors to make preparation easier. One caveat is that these products may contain added sugar, salt, or saturated fat, nutrients that we should be limiting in our diets. For example, canned baked beans contain added sugars, canned peas and green beans are usually high in salt, and frozen broccoli may include saturated fat if it is packaged in a cheese sauce.[10]  But canned and frozen products also come with a Nutrition Facts label, which prominently lists these nutrients so you can see at a glance how much your choices contain.   The bottom line is, eat your vegetables. Try to fill half of your plate with veggies at lunch and dinner. Or intersperse them throughout the day. Add some frozen peppers to your eggs in the morning, slip frozen kale into your smoothie, snack on fresh carrots before dinner, and add some canned corn to your bowl of soup. Fresh, frozen, and canned vegetables all boost the variety and nutrient content of your daily diet. Try these healthy vegetable recipes Vegetarian Chili Recipe Grilled Asparagus Recipe Mango and Tomato Salad Recipe Zesty Zucchini with Pesto, Pasta, & Sun Dried Tomatoes Chicken Noodle Soup with Zoodles Kitchen Safety & Convenience : As an Amazon Associate FibonacciMD earns from qualifying purchases. If you're using canned vegetables as part of your healthy diet, you need a safe and reliable way to open them. The Good Cook Safe Cut Can Opener cuts along the side of the can, leaving no sharp edges on the lid or the can itself. It even holds the lid for hands-free disposal and lets you safely reuse the lid for short-term storage of leftovers! References [1] Zucchini - World Food Map. Worldfoodmap.org . Published 2024. Accessed January 7, 2025. https://www.worldfoodmap.org/food-groups/other-vegetables/food/zucchini [2] Zucchini History - Where Did Zucchini Come From? Vegetablefacts.net . Published 2024. https://www.vegetablefacts.net/vegetable-history/zucchini-history/ [3] Moulton M. Zucchini vs. Summer Squash: Are They The Same? What’s The Difference? Epic Gardening. Published January 15, 2022. Accessed January 7, 2025. https://www.epicgardening.com/zucchini-vs-summer-squash/ [4] Records GW. Longest zucchini/courgette. Guinness World Records. Published May 9, 2018. Accessed January 7, 2025. https://www.guinnessworldrecords.com/world-records/longest-zucchini-courgette [5] Martínez-Valdivieso D, Font R, Fernández-Bedmar Z, et al. Role of Zucchini and Its Distinctive Components in the Modulation of Degenerative Processes: Genotoxicity, Anti-Genotoxicity, Cytotoxicity and Apoptotic Effects.  Nutrients . 2017;9(7). doi: https://doi.org/10.3390/nu9070755 [6] Petre A. 12 Health and Nutrition Benefits of Zucchini. Healthline. Published February 19, 2019. https://www.healthline.com/nutrition/zucchini-benefits [7] Kaushik U, Aeri V, Mir SR. Cucurbitacins - An insight into medicinal leads from nature. Pharmacogn Rev. 2015 Jan-Jun;9(17):12-8. doi: 10.4103/0973-7847.156314. PMID: 26009687; PMCID: PMC4441156. [8] Raman R. Can You Eat Raw Zucchini? Healthline. Published April 15, 2019. Accessed January 7, 2025. https://www.healthline.com/nutrition/can-you-eat-zucchini-raw#safety [9] The 9 Best Ways to Cook Summer Squash. Better Homes & Gardens. https://www.bhg.com/recipes/how-to/cook-with-fruits-and-vegetables/summer-squash/

References for CME Article " New Treatments for Parkinson’s Disease " References [1] Hariz M, Blomstedt P. Deep brain stimulation for Parkinson's disease. J Intern Med. 2022; 292: 764–778. Retrieved from: https://onlinelibrary.wiley.com/doi/epdf/10.1111/joim.13541 [2] Stoker TB, Barker RA. Recent developments in the treatment of Parkinson's Disease. F1000Res. 2020;9:F1000 Faculty Rev-862. Published 2020 Jul 31. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7400683/ [3] How many people have Parkinson’s disease? The American Parkinson Disease Association. September 24, 2024. Retrieved from: https://www.apdaparkinson.org/article/parkinsons-disease-registries/ [4] Sivanandy P, et al. Systematic Review on Parkinson’s Disease Medications, Emphasizing on Three Recently Approved Drugs to Control Parkinson’s Symptoms. International Journal of Environmental Research and Public Health . 2022; 19(1):364. Retrieved from: https://www.mdpi.com/1660-4601/19/1/364 [5] Parkinson’s Disease Medications. Cleveland Clinic.  Last reviewed on 11/09/2023. Retrieved from:  https://my.clevelandclinic.org/health/treatments/parkinsons-disease-medications [6] Antonini A. Apomorphine and levodopa infusion therapies for advanced Parkinson's disease. J Mov Disord. 2009;2(1):4-9. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4027699/ [7] McFarthing K, Prakash N, Simuni T. Clinical Trial Highlights: 1. Gene Therapy For Parkinson's, 2. Phase 3 Study In Focus - Intec Pharma's Accordion Pill, 3. Clinical Trials Resources. J Parkinsons Dis. 2019;9(2):251-264. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6598021/ [8] Keown A. Intec Pharma Crashes as Phase III Parkinson’s Treatment Fails in Comparison Trial. Biospace. July 22, 2019. Retrieved from: https://www.biospace.com/intec-pharma-crashes-as-phase-iii-parkinson-s-treatment-fails-in-comparison-trial [9] Lobo A. Vaccine for early Parkinson’s showing safety in Phase 2 trial. BioNews. November 18, 2024. Retrieved from: https://parkinsonsnewstoday.com/news/vaccine-early-parkinsons-showing-safety-phase-2-trial/ [10] Bendor JT, Logan TP, Edwards RH. The function of α-synuclein. Neuron. 2013;79(6):1044-1066. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC3866954/ [11] Polymeropoulos MH, Lavedan C, Leroy E, et al. : Mutation in the -Synuclein Gene Identified in Families with Parkinson's Disease. Science. 1997;276(5321):2045–7. Retrieved from: https://www.researchgate.net/profile/Aglaia-Athanassiadou/publication/14022561_Mutation_in_the_-Synuclein_Gene_Identified_in_Families_with_Parkinson%27s_Disease/links/58ef92790f7e9b6f82dbb604/Mutation-in-the-Synuclein-Gene-Identified-in-Families-with-Parkinsons-Disease.pdf [12] Alfaidi M, Barker RA, Kuan WL. An update on immune-based alpha-synuclein trials in Parkinson's disease. J Neurol. 2024;272(1):21. Published 2024 Dec 12. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11638298/ [13] Gorbatyuk OS, Li S, Nash K, et al. In vivo RNAi-mediated alpha-synuclein silencing induces nigrostriatal degeneration. Mol Ther. 2010;18(8):1450-1457. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2927065/ [14] Freed CR et al. Transplantation of embryonic dopamine neurons for severe Parkinson's disease. N Engl J Med 2001 Mar 8 344. Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJM200103083441002 [15] Sawamoto, N., Doi, D., Nakanishi, E. et al. Phase I/II trial of iPS-cell-derived dopaminergic cells for Parkinson’s disease. Nature 641, 971–977 (2025). Retrieved from: https://www.nature.com/articles/s41586-025-08700-0#citeas [16] Tabar, V. et al. Phase I trial of hES cell-derived dopaminergic neurons for Parkinson’s disease. Nature  641, 978–983 (2025). Retrieved from: https://www.nature.com/articles/s41586-025-08845-y [17] Schuepbach WMM, Rau J, Knudsen K, et al. Neurostimulation for Parkinson's disease with early motor complications. N Engl J Med  2013; 368(7): 610–622. Retrieved from: https://www.nejm.org/doi/10.1056/NEJMoa1205158 [18] BRAIN Initiative Research Leads to FDA Approval of Adaptive Deep Brain Stimulation for Parkinson’s Disease. NIH. March 06, 2025. Retrieved from: https://braininitiative.nih.gov/news-events/blog/brain-initiative-research-leads-fda-approval-adaptive-deep-brain-stimulation [19] Stanslaski S et al. Sensing data and methodology from the Adaptive DBS Algorithm for Personalized Therapy in Parkinson's Disease (ADAPT-PD) clinical trial. NPJ Parkinsons Dis. 2024;10(1):174. Published 2024 Sep 17. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11408616/ [20] Tian X et al. Efficacy and safety of magnetic resonance-guided focused ultrasound for Parkinson’s disease: a systematic review and meta-analysis. Frontiers in Neurology. Volume 14 – 2023. Retrieved from:   https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2023.1301240/full [21] Streumer J et al. Does spinal cord stimulation improve gait in Parkinson's disease: A comprehensive review. Parkinsonism & Related Disorders. Volume 109, 2023.Retrieved from: https://www.sciencedirect.com/science/article/pii/S1353802023000548 CME article: " New Treatments for Parkinson's Disease"

Our   critique explores the limitations of plastic recycling and the health hazards of plastic exposure. It delves into the challenges of recycling, including low recycling rates, contamination, and the deceptive practice of mass balancing . by Stuart M. Caplen, MD updated 9/26/24 Worldwide production of plastic, according to the United Nations Environmental Program, is about 430 million metric tons per year.[1]  This compares to 2 million metric tons of plastic produced in 1950.[2]   About 9% of these plastics are recycled, 12% incinerated, and 79% deposited in landfills or disposed of into the natural environment in places such as rivers, seas or oceans.[3]   Some of the sources of environmental plastic may not be obvious.  It is estimated that plastic from tire wear is responsible for about 8.6% of the plastic content in the oceans.[4]  Each year, laundering clothing made of artificial fibers is estimated to release 500,000 metric tons of plastic microfibers (the equivalent weight of about 3 billion polyester shirts) which end up deposited into the waterways and oceans.[1,5]  However, by far, the largest amount of plastic deposition comes from plastic waste.[1]  It is estimated that by the year 2050 there may be more plastic by weight in the ocean than fish.[6] 99% of plastics are made from fossil fuels.[2]  There are several potential health issues which may be caused by exposure to plastics.  Chemicals in plastic can leach out which represents a problem with food packaged in plastic or processed with plastic tubing.  Aluminum beverage cans and aluminum dishes may have a plastic coating, as may cardboard containers.  Some of the compounds in plastics have been linked to a number of serious health issues .[7]   In addition to chemicals leaching from plastics, another potentially serious health problem is related to microplastics (extremely small plastic fragments or fibers), which enter the food chain.  Microplastics have been found in many food and environmental items such as fish, meat and chicken, fresh fruits and vegetables, tap water, bottled water, rice, sea salt, and honey.[7]  Microplastics are now also present in the environment in places such as ocean water, ground water and in the soil.[7]  Research on the effects of microplastics on human health is at an early stage, but ingested or inhaled microplastic fragments or fibers have been detected in human brains, hearts, lungs, kidneys, livers, intestines, testes, bone marrow, hip and knee joint synovial membranes, atherosclerotic plaques, and feces.[7]  In one study, subjects who had plastic particles in their carotid artery atherosclerotic plaques had a 4.5 times higher risk of having a stroke, myocardial infarction or death in the next 34 months compared to those that did not.[8]  With respect to infants, microplastics have been found in breast milk, polypropylene infant feeding bottles, infant feces, and placentas indicating humans now may possibly be exposed to plastic microparticles for their entire lives.[7]  More research on harmful effects of plastic exposure and the deposition of microplastics in the body is needed. Given that modern societies are using vast amounts of plastics which can leach potentially toxic chemicals into food and the environment, as well as produce microparticles that can be absorbed into bodily organs, can we recycle our way out of this plastic dilemma?  Recycling holds the promise of decreasing the one-use plastic culture, but recycling has a number of problematic issues.  It is currently more expensive to recycle plastic than to use virgin plastic in products.[9,10]  Different types of plastics cannot be mixed when recycling so they need to be sorted, which is a time-consuming process.[10]  Another issue with recycled plastics is that new chemicals may be introduced into the plastic when it is recycled.  When toxic substances are stored in plastic containers, the plastic can absorb some of them.  If that plastic is then recycled, those substances may be incorporated into the new plastic products which may then leach out.[11]  Recycled plastics are not generally as structurally sound as virgin plastics[12] and more chemicals appear to leach out of recycled products than virgin plastic.[11]  In addition, the environment around plastic recycling plants may become contaminated with plastic components.[11]    Although the worldwide rate of recycling is estimated to be about 9%, in 2021 the estimated recycling rate of plastic products in the U.S. was only 5%-6%.[9]  Greenpeace did a survey of 375 plastic recycling facilities in the U.S. in 2022 and found only two types of plastics were accepted by 100% of the facilities, polyethylene terephthalate (recycling code 1), used in items such as water bottles and salad covers and high-density polyethene (recycling code 2), used in plastic milk and detergent bottles.  Polypropylene tubs and containers, used for products such as yogurt containers  (recycling code 5), were only accepted by 52% of the facilities.  After that there was a steep drop-off with items such as plastic cups accepted by 9% of the facilities and plastic bags, plates, and cutlery being accepted by 2% or less of the recycling facilities.[10]  In 2022 only an estimated 60% of U.S citizens had access to municipal collection for polyethylene terephthalate and high-density polyethene bottles, and only 29% had access to municipal collection for polypropylene tubs and containers.  In that same year the actual capacity of the U.S. to process plastic waste was estimated to be only 21% for polyethylene terephthalate refuse, 10% for high-density polyethene refuse and less than 5% for polypropylene tubs and containers.[10]  As a result, most plastic products are either not eligible or not able to be recycled and most of the items intended for recycling end up in landfills, or in some locations, incinerated.[9,10]   In traditional recycling, called mechanical recycling, the plastic is shredded and then melted into pellets to be reused.[11,12]  However, a newer process called chemical recycling, or pyrolysis, uses heat, solvents and pressure to break down plastic to molecular components and then recombines them to make different products from the plastics.  An advantage of pyrolysis is that it can process types of plastics which are currently not accepted by standard mechanical recycling facilities, such as smaller plastic items and bags, which can jam mechanical shredders.[12] One best-case estimate for the near future, is that given current capabilities in pyrolysis facilities, pyrolysis could only produce 0.2% of new plastic used per year.[13]  In the pyrolysis process,15%-20% of plastic waste is recycled as plastic with 80%-85% of the plastic made into other products such as diesel fuel, hydrogen, methane, and other various chemicals.  In comparison, 55%-85% of plastic is recycled with mechanical shredding and therefore 15%-45% of the material becomes waste needing disposal.[13]   While it is theoretically possible to assign recycled material percentages to the plastic pellets created in mechanical shredding, it is virtually impossible to know with pyrolysis exactly how much of the recycled materials are in each product.  One straightforward  approach is to use a proportional method where all of the end products are given a recycled material percentage based on the weight or volume of the material produced.  However, that method is not used in pyrolysis, and mass balancing has become the standard method of calculating recycled plastic percentages in products.  Mass balancing is based on the principle that the number of molecules of recycled material going in must equal the number of molecules coming out of the process.  However, using this method has allowed recyclers to assign recycled plastic percentages to products that may not be true percentages.  Reasons for doing this may be that higher percentages of recycled plastic in high-grade plastics may be more profitable because using recycled plastic is now a sign of corporate environmental responsibility, and higher percentages are more desirable.[12,13] To explain mass balancing, let’s say a recycling facility makes four products recycling a combination of virgin and recycled plastic by pyrolysis; high-quality plastic, low-quality plastic, petroleum-based products and fuel.  Enough recycled plastic is added, so that each of the four final products actually contains about 25% recycled materials.   Four products of pyrolysis each containing 25% recycled materials With mass balancing, as long as the final total is 100%, the percentage of recycled plastic can be shifted among products.  For example, if the manufacturer decides to label the low-quality plastic, which actually has 25% recycled materials, as having zero recycled materials, that percentage can be shifted over to the high-quality plastic.  Mass balancing allows the recycler to claim that the high-quality plastic was made of 50% recycled materials when it actually contained only 25%.  Recycled plastic pellets with a minimal amount of recycled plastic can theoretically be sold as having 100% recycled materials as long as all the other products produced in that group were listed as having zero recycled materials.[12,13,14]   Using mass balancing, one product is assigned zero percent recycled materials by the recycler allowing another product, such as high-quality plastic, to be sold as containing 50% recycled materials even though it actually only contains 25%. According to the New York Times , a recycling company can also build a balance sheet of recycled credits that later can be used on other products.  Thus, due to mass balancing and the ability of the recycler to randomly assign recycling percentages to plastic pellets, product manufacturers and consumers may not know how much of the product was actually made from recycled plastic.[12]  There are currently no standards for mass balance certification in the U.S.[12]   Given the large amount of plastic being manufactured, the low percentages of plastic actually being recycled, and the inefficiencies and economics of the recycling process, it seems unlikely that recycling will ever be able to solve either the problem of environmental plastic pollution or human exposure to plastic.  It is already known that chemicals which can leach out of plastic into foods can potentially cause significant health issues .  While research into human microplastic exposure is still emerging, it is clear from the data gathered so far, that humans are both being exposed to and are absorbing some microplastics.  It is possible that once more studies are completed, it may be determined that absorbed microplastics are a slow-motion health crisis, which may take decades to manifest in individuals.  It does not seem likely that plastic particles, made from petroleum products, which are accumulating in various organs would be beneficial to human health.   It may turn out that the only way to significantly reduce human exposure would be to remove plastic products from both the food chain and food packaging.  The question is whether in the future, society would be willing to make the significant changes necessary to accomplish that goal.  If you found this article interesting you may also want to read   the article The Effects of Plastics on Human Health  . Author’s note: A thank you to Dr. Theodor Feigelman for editing this article.  References [1] Everything you need to know about plastic pollution. UN Environment Programme. 25 Apr 2023. https://www.unep.org/news-and-stories/story/everything-you-need-know-about-plastic-pollution [2] Azoulay D et al. Plastic & Health The hidden Costs of a Plastic Planet. Ciel. February 2019. Retrieved from: https://www.ciel.org/wp-content/uploads/2019/02/Plastic-and-Health-The-Hidden-Costs-of-a-Plastic-Planet-February-2019.pdf [3] Geyer R et al. Production, use, and fate of all plastics ever made. Sci. Advances .3,e1700782(2017). Retrieved from: https://www.science.org/doi/10.1126/sciadv.1700782 [4] Breaking the Plastic Wave. PEW Charitable Trusts 2020. https://www.systemiq.earth/wp-content/uploads/2020/07/BreakingThePlasticWave_MainReport.pdf [5] A New Textiles Economy: Redesigning Fashion’s Future, The Ellen McArthur Foundation. 2017. https://emf.thirdlight.com/file/24/uiwtaHvud8YIG_uiSTauTlJH74/A%20New%20Textiles%20Economy%3A%20Redesigning%20fashion%E2%80%99s%20future.pdf [6] The New Plastics Economy: Rethinking the future of plastics & catalysing action. Ellen McArthur Foundation. 2016. Retrieved from: https://emf.thirdlight.com/file/24/RrpCWLER-yBWPZRrwSoRrB9KM2/The%20New%20Plastics%20Economy%3A%20Rethinking%20the%20future%20of%20plastics%20%26%20catalysing%20action.pdf [7] Caplen, SM. The Effects of Plastics on Human Health. FibonacciMedicine. Last updated 8/21/24. Retrieved from: https://www.fibonaccimd.com/post/the-effects-of-plastics-on-human-health [8] Marfella R et al. Microplastics and Nanoplastics in Atheromas and Cardiovascular Events. NEJM. VOL. 390 NO. 10. March 6, 2024. Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJMoa2309822 [9] The Real Truth About the U.S. Plastics Recycling Rate. Beyond Plastics and The Last Beach CleanUp. Bennington College. May 4, 2022.  https://static1.squarespace.com/static/5eda91260bbb7e7a4bf528d8/t/62b2238152acae761414d698/1655841666913/The-Real-Truth-about-the-US-Plastic-Recycling-Rate-2021-Facts-and-Figures-_5-4-22.pdf [10] Circular Claims Fall Flat Again 2022 Update. Greenpeace. October 2022. Retrieved from: . https://www.greenpeace.org/usa/wp-content/uploads/2022/10/GPUS_FinalReport_2022.pdf [11] Forever Toxic, The Science on Health Threats from Plastic Recycling. Greenpeace. May 2023. Retrieved from: https://www.greenpeace.org/usa/wp-content/uploads/2023/05/GreenpeaceUSA_ForeverToxic_ENG.pdf [12] Creswell J and TabuchiIs  H. Your Water Bottle Really Made From Recycled Plastic? The New York Times. Aug. 26, 2024. Retrieved from: https://www.nytimes.com/2024/08/26/business/energy-environment/tritan-renew-plastic-bottles-recycled.html [13] Song L. Selling a Mirage. ProPublica. June 20, 2024. Retrieved from: https://www.propublica.org/article/delusion-advanced-chemical-plastic-recycling-pyrolysis [14] Daphne T, Ahmed N. Mass balance for plastics: Different methods that advance chemical recycling. Circularize. May 22, 2024. Retrieved from: https://www.circularise.com/blogs/mass-balance-for-plastics-different-methods-that-advance-chemical-recycling