"Adventures" in Health Care 4

 

May 19, 2026

An "adventure" in health care (American style), part 4

Gary Engstrand

 

Prologue

              A friend who’s been following this story, wrote to me, “I suppose that after the radiation treatments are over, your life will continue on more or less as before, and that the mental load of the experience will recede.” I certainly hope he’s right!

              I must also confess that I am unsure I would be composing this narrative if the prognosis were grim. Because it is not, and I can be optimistic about the outcome because my doctors have said cure is the goal, I can write somewhat cheerfully and even inject a small bit of humor—such as it is—from time to time.

              A couple of friends commented that I am getting excellent care. “It does sound though like you are able to get the very best people to work with” and “Sounds like you are in good hands.” Others have offered similar assurances. Am I? I don’t know. Who does? What patient, untrained in medical sciences, can really judge the competence of the physicians treating them? I have been impressed with the expertise that I perceive in the physicians (and nurses!) that I’m working with, but I could easily be misled. I *am* impressed that Dr. Hirtz, the oncologist, cites studies to support his treatment choices.

The Process Still has Stress

              And here I thought that once the radiation treatments and hormone therapy were under way, I’d get to the end of the process and be done. Once again, silly me.

              Every two weeks I have lab tests, through the end of July. The primary concern is liver and kidney function. I’m not clear which of the activities poses a potential threat, and maybe it’s more than one. I was aware before this all started that ibuprofen taken over the long term can cause damage, so I’m not thrilled about taking 1200 mg per day. Fortunately, that comes to an end when the radiation treatments are finished on May 29. In the meantime, however, I get to worry about collateral damage to organs. The worst outcome is damage such that I need a transplant, but I console myself by recognizing that thousands of men have gone through this process and not needed an organ transplant as a result. 

              I have had the first lab test and the numbers were fine. So so far my kidneys and liver are faring well. Phew.

              The second continuing stressor is the PSA tests. One comes next Friday. I asked Dr. Hirtz, “would you expect to see a drop in the PSA number at that point?” He would like to see a number below 10 (down from 27), which will be due almost entirely to the hormone therapy. The radiation takes several months to have an effect.

              I ask another question: What if the number is only 20 or 21? Then he would have to reconsider the treatment regimen. A number declining only slowly is problematic.

              So once again I have the opportunity to worry about numbers.

Questions to the Oncologist

              I don’t know how many people pepper their physicians with questions. I do.[i] I suppose the amount and intensity of questions varies directly with the seriousness of the affliction the physician is treating. Over the course of the last three weeks I asked about many things (not all of which I’ll bother recounting).

-- Did the delay in getting to treatment, between the December 30 PSA of 13 and the start of radiation on April 22 with a PSA of 27, allow the cancer to spread more than would have been the case if the treatment had begun a month or more earlier? Nothing to be done about it if so, but I was curious.

              It is likely there was some growth in the cancer over that time.

Sigh. I wondered about that. Had I been home, I suspect the diagnosis and treatment would have moved much more quickly.

-- I noticed on the Mayo website a caution about interaction effects between abiraterone and Flomax. Is that a concern? I recall a conversation I had with (my daughter) Krystin’s psychiatrist about a dozen or more years ago. Krystin had been on a number of drugs related to her diabetes and at one point ended up in the psychiatric ward of the hospital because she was hallucinating. I spoke with the psychiatrist and wondered whether this incident was provoked by drug interactions; Krystin was not the type who hallucinated or otherwise suffered from psychiatric issues. The psychiatrist agreed that it might have been the case; he changed her drugs and poof!, the hallucinations vanished. He also commented to the effect that “once you get beyond two drugs, maybe three, we have no idea what the interaction effects are, and anyone who says we do is lying.” I don’t think I’ve had any interaction effects so far, but I’m not thrilled with the idea of adding yet another drug (Flomax) to the pharmaceutical cocktail I already have to consume (prednisone, ibuprofen, Orgovyx, abiraterone, calcium supplement, multivitamin, simethicone).

There can be mild interaction between the two drugs; the first can block the action of the second, and it may be necessary to take a higher dose of the latter. But it is common for prostate cancer patients to be on both and a higher dose is not a problem.

-- I asked a couple of questions related to Metamucil and simethicone.

It’s your call, adjust them as you think needed.

-- I told Dr. Hirtz, the oncologist, that I had a dumb question (he interjected “there are no dumb questions”): Why not just one treatment to zap the cancer? Rather than 18 or 26 or 45?

The reason is that high enough doses to kill the cancer quickly would harm the surrounding cells and organs. Normal, non-cancer cells can recover day to day from the radiation; cancer cells cannot and accumulate damage over the course of treatment. The number of doses of radiation depends on the status of the disease; it varies by patient. As for Dr. Larson’s (in Florida) conclusion that he would order 45 treatments, it is possible to have a longer treatment period but there doesn’t seem to be any medical advantage to stretching out the treatments and they are just more of an annoyance for the patient. The longer treatment schedule was usual but the more modern approach is a shorter period.

Fine with me! Fewer is better, although the daily regimen of treatments is not a problem; they are 10 minutes away and I’m done and home by 8:45 a.m. except when the nurse and Dr. Hirtz want to see me, which is every Wednesday. I like those Wednesday sessions; I have an opportunity to ask all my questions!

-- I am glad the expectation is “cure.” If that prognosis should change, however, I want to know. I feel strongly about this; there’s a history in my family. My mother was diagnosed with cancer in early July (1989) and died at the end of September. It was determined that she had uterine cancer that had spread to the lymph system and lungs by the time it was diagnosed. I was privy to all her medical records and discussions, and I asked a couple of colleagues on the Medical School faculty for an evaluation. The gist of their reaction was “it’s weeks, not months.” Her doctors never told her that it was terminal (and, to be fair, neither she nor my father ever asked or pressed the issue, because I suspect they did not want to know). However, at one point they lied to her: she asked if she’d be able to attend an annual event with my father a year hence, and they said she would. I knew that was untrue and it made me angry that they lied. The situation made conversation difficult and there were likely last things my mother would have wanted to do and conversations to have, but those things never happened. I want to know so that I *can* take care of last things and have a few conversations. I hope, however, that this issue is entirely moot!

If I am going to die of prostate cancer, which is highly unlikely, it will be years in the future. There’s no need to prepare my will now.

I had already been assured (and reassured) that this cancer is not terminal, and I wasn’t asking for the third time. But I wanted to emphasize the point about being informed.

-- It is normal for patients to begin to feel fatigue as the radiation treatments progress. So I asked: There is fatigue and there is fatigue. Is the possible fatigue from radiation like one feels with the flu or a bad cold, when all you want to do is lie on a sofa the entire day? Or is it fatigue like not enough sleep or overdoing the gardening and one simply needs a nap?

              It is fatigue that a nap will usually take care of.

I liked that answer! And as of today, I’m no more fatigued than usual in life.

-- Am I immunocompromised due to either the radiation or the medications? I ask because we were planning to babysit our 15-month-old granddaughter one Sunday, but that Saturday she started coughing and had a runny nose, so both we and my son and DIL agreed it probably wasn’t a good idea for us to have her. I don’t want to be sick during this treatment (of course, I don’t want to be sick, period!).

I am very mildly immunocompromised. Not enough even to wear a mask in public, but I should avoid sick people.

-- I know a couple of guys, my vintage, at various stages of going through prostate cancer treatment. One of them (being treated at Mayo), is on shots for hormone therapy; a shot every six months. Is that the plan for me, once the radiation is done, or will I be on six pills for 18 months to 2 years?

The hormone shots are a less aggressive approach to cancer and are used with patients who have lower Gleason scores. Orgovyx is a newer drug that is highly effective and I will be on the two drugs for 18 months or more because he wants to treat the cancer aggressively.

Not what I wanted to hear but I’m all in favor of aggressive treatment, even if I do have to take 4 large pills every morning and then wait two hours to eat anything.

-- “Metastatic” is a frightening word. I have metastatic cancer, and it took me awhile to figure out (I believe correctly) that the term simply means a cancer has spread beyond its point of origin. When I first did some reading about prostate cancer, and treatments for metastatic cancer, I was considerably alarmed. I gather, however, that there are degrees of metastasis: a little, some, a lot, and that mine is probably “some” but not “a lot.” Is that right?

              That is correct.

-- I haven’t weighed recently but it seems like I’m eating more than usual. I’m slender enough that I can afford to gain (I lost about 15 pounds as a result of abdominal surgery in June 2024, was down to about 135 pounds, and never fully regained the weight). I am concerned, however, that any weight gain will go right to my middle ☹. Does/can one gain weight on this treatment regimen?

On average, patients gain about 10 pounds over the course of treatment. Keep exercising.

I need to talk to a trainer about the best exercises to minimize midriff expansion  ☹

-- A friend of mine, my age, related that his physician doesn’t recommend PSA tests for men over the age of 70. I observed that if I had not had regular PSA tests for many years as part of my annual physical, including last December, I would now be dying because I have no symptoms and would have no reason to raise any question with a physician. By the time I would realize there was something wrong, it would be too late; the cancer would have spread beyond the point where it could be successfully treated. It is only all those magic numbers and pictures that revealed the disease.

Neither I nor my colleagues in oncology would concur with that recommendation. You will have PSA tests for the rest of your life.

That’s hardly bothersome. I have regular blood panels for my annual physical that could include a PSA test; if I have to go in one additional time per year (i.e., PSA tests every six months) it would not be a big deal.

              A friend commented that it’s interesting that there is such reliance on the PSA test, generally regarded as among the more unreliable tests in the medical armamentarium. The National Cancer Institute has this to say about it: “False-positive test results are common with PSA screening. About 6%–7% of men have a false-positive PSA test on any given screening round, and only about 25% of men who have a biopsy due to an elevated PSA level are found to have prostate cancer.”

My assumption is that for a competent physician, the test is simply a warning sign and suggests further examination is required. My urologist in Florida commented that before the biopsy and MRI, he would not declare that I had cancer, and that’s one reason the first thing he did was order a second PSA test. When that came back even higher, then the process of further examination kicked in.

A Digression on Word Choice

I asked a writer friend “in your mind, does the word ‘journey’ imply volition, choice? Does one choose to go on a journey, or can a journey be involuntary?” He wrote back. “Yes, I think so, though perhaps not always a preferred choice, but yes, a choice at some level. Which is probably why the popular use of phrases like ‘my cancer journey’ ring somewhat false to my sensibilities. Is that what you think too?”

Another friend also wrote. “To me the use of the word ‘journey’ is a tiresome metaphor. My credit union wants to help me ‘blaze a trail’ on my ‘financial journey.’ Yuk. But at least that's more intentional than experiencing a disease and treatment that one did not choose to have.

Kathy came across this in The New York Times a couple of weeks ago, originally 5/16/24 but reprinted early this May. Excerpts:

When Did Everything Become a ‘Journey’?

Changing our hair, getting divorced, taking spa vacations — they’re not just things we do; they’re “journeys.” The quest for better health is the greatest journey of all.

“Journey” has decisively taken its place in American speech. The word holds an upbeat utility these days, signaling struggle without darkness or detail, and expressing — in the broadest possible way — an individual’s experience of travails over time.

It’s often related to physical or mental health, but it can really be about anything. . . . [Someone with a chronic disease] In the chronic disease community, she said, “journey” is a debated word. “It’s a way to romanticize ordinary or unpleasant experiences, like, ‘Oh, this is something special and magical.’” Not everyone appreciates this, she said.

“Journey” had fully entered medical speak by the 2010s. Many cancer patients recoiled from the “battle” language traditionally used by doctors, as well as by friends and relatives. In “Illness as Metaphor,” Susan Sontag had noted back in 1978 that “every physician and every attentive patient is familiar with, if perhaps inured to, this military terminology.” But now, opposition to the notion of disease as an enemy combatant reached a crescendo. To reflexively call an experience of cancer a battle created “winners” and “losers,” where death or long suffering represented a failure — of will, strength, determination, diet, behavior, or outlook — on the part of the patient. [Well, there is a winner and loser. . . .]

“Journey” seemed less judgmental, more neutral.

For some people, talking about cancer as a “journey” gave them a sense of control and camaraderie — buddies traveling the same path — but others used the term to convey their exhaustion. Having cancer “is like trying to drive a coach and horses uphill with no back wheels on the coach,” one man wrote. Patients used “journey” to describe just how passive they felt or how reluctant to bear the burden of their disease. Separately, patients have told Semino [who studies the use of words] how much they hate the word “journey,” saying it trivializes their experience, that it’s clichéd.

I agree with those patients. I’m not on a journey. I have been facing an ordeal, a trial, a stressful period in my life that I can’t wait to be over with.

              I also dislike the military analogy, in part because I have read too many obituaries with “courageous battle with cancer” as the description of how the person died and in part because the analogy is inapt, in my view. The way I think of it is that the physicians are administering treatments to kill the cancer cells. The right term to use here is “mass murder”: that’s the objective! Mass murder of errant cells. (The same descriptor could be used when taking an antibiotic to deal with a bacterial infection: mass murder of the invading alien bacteria!)

---

[i] With one exception: When I arrived at the ER early on a Saturday morning in June 2024, after a night of intense stomach pain, was given dilaudid and had a CT scan, the ER physician returned to the room with a surgeon, who told me I needed surgery and needed it that day. I said “ok.” No questions. I asked many later, but not at the time.

"Adventures" in health care 3

 

April 26, 2026

An "adventure" in health care (American style), part 3

Gary Engstrand

Prologue

              This entire narrative, all chapters, charts a series of psychological ups and downs. A couple of people I know describe these events as a journey. I demur. “Journey” elevates it to a psychological and literary level that is unwarranted. Kathy says it’s a trial, which is more accurate. In my view, it’s the story of many involuntary interactions with the health care establishment with an occasional dash of humor—and nothing more.

              I began writing this chapter with this: I am becoming somewhat weary in mind.

              As an indication of my state of mind, an anecdote. A number of my friends know that one of my retirement hobbies is doing paint-by-numbers: I send a photo to a small company that transforms them into a canvas with paints and sends me back a kit. I then paint it. I had promised one couple a painting of their son’s engagement at the Eiffel Tower and promised another couple a painting of their two grandsons. I was thinking seriously about telling both couples that I wouldn’t be able to deliver on my promise because I could run out of time. I have one more to do (of three) of my granddaughter Svea and I wanted to be sure I could finish it.

              Yes, the foregoing even though two physicians had already assured me that the cancer was not terminal. My (faulty) reasoning was that it seemed like each time there was more information, the cancer was getting worse, so I was getting gloomy about what evaluation might come next.

              I’m glad to say that I was wrong. I don’t have to renege on my promises and I can finish the Svea triptych. Following good conversations with both the nurse who deals with urology radiation and my radiation oncologist (whom I will call Dr. Hirtz), I was relieved.

What I have not mentioned before is that the people with whom I’ve been dealing—primarily nurses and physicians, both in Florida and Minnesota—have been wonderful. The *process* sucks but the *people* have been great.

Into the Treatment

              The first anecdote illustrates two propositions. (1) Sometimes the availability of information on the web is a curse. (2) It is dumb to jump to conclusions on the basis of what one reads on the web, even from a trustworthy source.

One of the two drugs that is part of the hormone therapy is abiraterone (a name I have a heck of a time remembering, and the pharmacist who called me to go over its use said they just call it “abi”). I was to pick up my prescription the day after she called (April 22, same day as my first radiation treatment). I googled it. Here is some scary language from the Mayo Clinic on abiraterone:

Abiraterone is used in combination with prednisone to treat patients with metastatic castration-resistant prostate cancer (prostate cancer that is resistant to medical or surgical treatments that lower testosterone and has already spread to other parts of the body) and metastatic high-risk castration-sensitive prostate cancer.

I read this language the evening before my first radiation treatment (and abiraterone pickup day). My reaction was “holy sh*t, if this is what they’re prescribing for me, the cancer must be worse than I’ve been led to believe.” I had already read a fair amount, and the constant repetition of the phrase “advanced prostate cancer” was alarming, since it applied to me.

              Of course I managed to fret for the evening and the next morning before I went in for the first treatment. Dr. Hirtz had told me he would see me after the first treatment and then every two weeks. So at this meeting with him, I asked about abiraterone. Dr. Hirtz explained that yes, they do use it as part of a strategy in dealing with cancer that has greatly metastasized. But they also use it in less drastic cases, in combination with another hormone therapy drug to try to ensure that any cancer cells floating around cannot grow; its use in my case does not mean I have “metastatic castration-resistant” cancer. Phew. And I felt like kind of a dope for getting all exercised about it.

* * *

              Prior to seeing Dr. Hirtz at this time, I had formulated a few questions. Once I got beyond my scare about abiraterone, I went on to the others, and the first one was the most important.

-- What is the probability that I will be alive in 5 years, assuming no other cause of death? 1 in 2? 1 in 20? 1 in 50? Are you going for a cure?

It is highly unlikely that I will die in the foreseeable future from prostate cancer. He said, at least a couple of times, that he is going for a cure and expects to achieve it, between the radiation and the double-barreled hormone therapy. Even with a roughly 33-40% chance of recurrence, which would be 5-10-20 years out, there are treatment regimens that control it like a chronic disease. Dr. Hirtz said “you’re young, you will do fine.” I smiled at him. He conceded that I’m not 50 but pointed out that I’m not in my mid-80s, either.

               Maybe it’s true of many patients with serious cancer, but I wanted to be continually reassured that it’s not terminal. Dr. Hirtz is the third physician who told me that, so I guess I can quit asking the question. Hence my comment at the end of the prologue that “I was relieved.”

              I have said on occasion that I’m less concerned about *when* I die than I am about *how* I die (e.g., no thank you Alzheimer’s or a variety of dementia). This intersection with cancer has made it clear to me that “when” is not now! A friend of mine read my story and wrote “I remember seeing a desk sign that said ‘Dear Cancer, thank you for reminding me what is important in life. You can go now.’ It is true that all we are doing is forestalling the inevitable (as your friend pointed out), but in the forestalled time, we get to enjoy this wonderful planet, be surrounded by loved ones and friends, go on new adventures or re-create old ones . . . definitely a worthwhile time!” Yep, and why I want *it* to go now and not me.

-- My wife and I go regularly to a fitness club. Should I exercise as usual, including cardio, weights, leg push, planks, etc.? Are there specific exercises I should avoid?

No, and exercise remains a good thing to do. But I may have less stamina as the treatments progress over the next five weeks. That made me chuckle. I didn’t have that much stamina to start with!

-- Does alcohol affect treatment outcome? Part of our daily ritual is the cocktail hour. We don’t drink a lot, but does any alcohol have an adverse effect on treatment outcome?

No, just everything in moderation.

-- What is the level of fatigue on average from the hormone therapy and radiation? What factors influence how fatigued I will be? I assume naps are okay.

It varies a lot. Some people experience almost no side effects, some are constantly tired. Take a mid-day nap. Since I’ve been doing that pretty much daily since I retired, this will not be a change in habit for me! Fatigue is more likely to be noticeable by the third or fourth week of treatment. I’m going to be an optimist and assume I won’t be tired. I don’t want my social schedule disrupted any more than necessary because of this stupid disease.

-- What is your interpretation of the PSA of 27 after 13 in December and 17.7 in February?

The cancer became more aggressive, although it still hasn’t spread too much beyond the prostate. But that is why he is taking a more aggressive approach to treatment. I didn’t ask—maybe will—whether all that ditzing around in Florida, waiting two or three weeks for appointments, gave the cancer more time to become aggressive. Not much I can do about it if it did, but that would lend credence to the proposition that health care is better in Minnesota.

-- Is taking simethicone (aka Gas-X) a problem?

Not only is it not a problem, they recommend it, and suggest routinely taking it with every meal. OK, I will! I’ve already added more medicines than I’ve had in my entire life, so what’s another tablet?

              More generally, the treatments are high and low doses of radiation. High where cancer is clearly indicated by the PSMA PET scan, low where the scan is ambiguous and in the surrounding tissue where stray cancer cells might be lurking. 

              One of the treatments that Mayo offers is “PSMA-targeted therapy . . . PSMA+ metastatic castrate-resistant prostate cancer. A radiopharmaceutical, lutetium LU 177 vipivotide tetraxetan targets and sticks to cancer cells to precisely deliver treatment.” I asked the oncologist about that. Dr. Hirtz said it’s a study, and the drug, radioactive, is injected into the body to circulate to get cancer when it has spread many places. So it’s like brachytherapy, I asked? It is, in that it’s an injection, but it’s only used in seriously metastasized cancers. I told him I’d gotten the same answer from him and the two urologists about brachytherapy and had decided to tell the guy, the true believer advocate, to go fly a kite. I only did it in my mind, not in a message.

* * *

              The treatment itself: In the room with the radiation machine, I’m to lay on a narrow waist-level platform. It’s hard and there’s no padding, like lying on a blackboard. I asked what it’s made of; it’s carbon fiber. The machine is a linear accelerator, which sounded to me like something used in particle physics experiments. I’m told the machine costs upwards of $2 million.

              Lying on this “bed” of carbon fiber, there are four arms that stick out from a machine behind my head, one arm on each side and one on top and one on the bottom (under the carbon fiber). Two of the arms end in large white rectangles, perhaps 2’ by 3’, one has a large white hemisphere perhaps 3’ in diameter at the base, hovering above me, with what looks like an aluminum foil square in the center, and the fourth arm has a smaller white sphere about the size of a basketball. The white rectangles, one sort of above my chest and one sort of above my mid-section, are used for scans (not quite sure what they do). The large hemisphere is the instrument that delivers the radiation. The small white basketball takes the scans.

The four arms slowly rotate 360° around me; the carbon fiber slab doesn’t interfere with the scanning or radiation (understanding *that* is way above my pay grade). I just lie quietly, watching these shapes go around and around, scanning and radiating the full circle, for about 10 minutes. If you’ve been in an MRI scanner, you know you get the BANG BANG BANG BANG, WHIRR WHIRR WHIRR WHIRR, TAP TAP TAP TAP, RUMBLE RUMBLE RUMBLE RUMBLE (or something like that) all very loud and repeating several times. In contrast, the linear accelerator is almost completely silent, just these four arms with rectangles and balls slowly circling around me. It seemed a little weird, science-fiction-y, and I certainly have no sense that I’m being bombarded with toxic rays. Then I’m done.

* * *

              I don’t know what my co-pay on the drugs would be. The abiraterone on drugs . com is $71.95 for 30 tablets. The Orgovyx on the same site is $2,787.12 for 30 tablets. Minnesota Urology covers the cost of the drugs beyond what my insurance pays. I don’t know how they do it but I’m certainly not arguing with them.

* * *

              In normal social discourse it is unseemly to talk about bodily waste elimination systems. However, this is a story of cancer diagnosis and treatment, and liquid waste elimination suddenly became a part of the story after the second radiation treatment—at a bridge game with seven friends. After the second morning of radiation, that afternoon I could barely urinate, and what little I did also hurt coming out (maybe a ~4 on the proverbial 0-10 pain scale). I was a little frantic and frankly depressed, another emotional down, and I am here to tell you that when you cannot urinate, or only barely so, you don’t think about much else.

              I wrote later to the seven bridge players explaining why I was somewhat subdued and in the bathroom and on the phone (getting an urgent appointment with the urologist). One wrote back with a marvelous line: “I can identify with your discomfort and getting accustomed to the humbling stages of life.” Boy, he got that right.

              When I went in for the third radiation session, I groused (light-heartedly) to the lead technologist (a 50-something sweetie) that she’d really messed up my urinary system. She said, “so soon?” So not a surprise to her.

Immediately after that third session I saw the extremely knowledgeable and friendly nurse at Minneapolis Radiation Oncology; he said that my problem was common when going through radiation treatment for prostate cancer and he had solutions. One part of the solution was amazingly simple: take 600 mg of ibuprofen twice a day. The other part was a medication he prescribed, Flomax, which "helps relax the muscles in the prostate and the opening of the bladder,” says the Mayo Clinic. The Mayo website included this language:

Using this medicine [Flomax] with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

The first drug on “not recommended” the list?  Abiraterone. I don’t like that, but I gather it’s pretty routine to prescribe Flomax along with abiraterone for men with prostate cancer.

As with many—most—meds, there are side effects, but of course the frequency and severity of those effects varies a great deal across individuals. Some of them for Flomax, however, are serious.

              I have now gone from one pill a day a month ago (a multivitamin for seniors) to 15 pills per day after the third radiation treatment. Here’s the evening menu:

I suppose many people my age take a lot of pills, but this is a new experience for me, and not one I particularly wanted.

              I’m not sure I’ll take the Flomax, if the ibuprofen works well enough. At the least, I’ll ask about the potential interaction effects. I recall a conversation I had with (my daughter) Krystin’s psychiatrist about a dozen or more years ago. Krystin had been on a number of drugs related to her diabetes and at one point ended up in the psychiatric ward of the hospital because she was hallucinating. I spoke with the psychiatrist and wondered whether this incident was provoked by drug interactions; Krystin was not the type who hallucinated or otherwise suffered from psychiatric issues. The psychiatrist agreed that it might have been the case; he changed her drugs and poof!, the hallucinations vanished. The guy also commented to the effect of “once you get beyond two drugs, maybe three, we have no idea what the interaction effects are, and anyone who says we do is lying.” I don’t think I’ve had any interaction effects so far, but I’m not thrilled with the idea of adding yet another drug to the cocktail I already have to consume.

* * *

              I don’t know if there will be a “part 4.” I hope that I’m through whatever hiccups there are in the treatment process and it will play out as it’s supposed to through the end of May. I stay on the abiraterone and Orgovyx for 18 more months, but in the meantime I’m just fine. That’s the way the story is supposed to end! On the other hand, I didn’t think there would be a “part 2,” so who knows?

#115 Kids not want silver (and china)

 

 April 20, 2026

 Last winter I sent a message to a number of friends:

 * * *

A question for you: Do your kids ever have occasion to use sterling flatware and china when they invite friends for dinner? I realize that many of them may not *own* sterling or china, so this becomes hypothetical: Would they use it if you gave it to them?

The background. I inherited two sets of sterling flatware, one set from my parents and one set from a great aunt and uncle, so they are family heirlooms of a sort. Elliott only knew my dad; the other three died before he was born, but he lives in my great aunt and uncle’s house (as did I for 30+ years). I recently reminded Elliott that he would inherit them. He wrote to me: “As much as it might pain you, I think you are better off selling all that silver and whatnot and investing the money. We have no space for it and we wouldn't ever use it anyway. Formal dinner parties like you grew up with are not a thing people do any more. Cleaning the silver is neither a cost nor time investment that anyone is willing to make.” Obviously, the sentimental attachment is nil.

What would your kids’ attitude be about using it?

I want to thank all who who took the time to respond to my query about sterling silver (and china, sort of). I append the responses, anonymized. Most of them confirm the conventional wisdom.

Elliott's view seems to be widely shared among our children. However, it is not only our children who are largely uninterested in sterling and china (and most of our other "stuff"!). Several of you wrote to tell me that *you* weren't interested in it: have it and don't use it or got rid of it. What struck me, however, was that several of you indicated your *grandchildren* are or might be interested! (Our granddaughter Svea, at 14 months, hasn't expressed an opinion yet about silver and china )

Obviously there's no right or wrong about keeping versus getting rid of sterling and china. I have kept both, from different forbears, and we use them off and on during the year. I find it fun to set an attractive table for dinner guests using our own items plus those from my parents and grandparents. At the same time, I recognize that all of our long-time friends would come for dinner even if we used paper plates and plastic utensils and glasses and many don't give two hoots if it's an attempt at an elegantly-set table.

My more general sentiment--clearly not widely shared--is that I find these things connect me with my parents and grandparents and great-grandparents. I didn't ask you about other items that may have come along from parents and grandparents and other relatives. Your answers about such items might have been different.

For example, I never knew my maternal great-grandmother (she died 30 years before I was born) but I treasure having her wicker sewing basket, the 19th-century (Danish) Bible in which she recorded marriages, births, and deaths, her letters to my grandmother, and her hand-painted pitcher given to her by one of her sons. And so on.  

The same with the wedding china and desk brass-and-glass grandfather clock: they give me a bond with my dad's parents, whom I can barely remember, as does my dad's mother's mother's 19th-century KJV Bible, in which she also recorded marriages, births, and deaths. She also died many years before I was born.

Similar items have fallen into my hands: my grandmother's painted flamingo plaster wall plaques (likely from the 1930s), a print that hung in my dad's parents' apartment for many years and prints that hung in my grandmother's house, art that hung in my parents' house, and on and on. 

I like having things that I know my forbears held and used and looked at. Maybe I'm just strange.

Gary

* * *

Here is what my friends wrote.

-- I believe they would have the same reaction to that question as Elliott. I have my mother’s and I have never used it. I am thinking about selling it as of late.

-- Yes, my daughter does use these things occasionally (as do I) at least in part because she also lives in a big old house and appreciated that part of growing up. I love seeing that—she actually sets up a coffee station and uses china cups and saucers and a coffee pot, etc. that goes with. They were given sterling flatware by a great aunt (I only have silver plate) and they inherited their china. I don’t know about my son and his bride. They have her grandmother’s china already. Definitely a matter of young adults’ personal preference.

(added response: correction - I think the price of silver has skyrocketed so I think the flatware is definitely worth the effort. The china is not worth anything much.)

-- My kids said: “Thanks but no thanks.” I gave them each a set of sterling anyway. They don’t use them and I hope they have sold them. I won’t ask. Neither of my kids want any heirlooms except the ones that have a sentimental value to THEM and can fit in their houses. (A few pieces of art, pieces of jewelry and some polished rocks.) This is not a generation that wants old stuff. And I don’t think it sells for much. You could try guilt by telling them you are hanging on to some things for your granddaughter….

-- Our kids aren't too interested -- must be dishwasher safe for them to want anything! BUT our granddaughter loves it all! However, she could very well change her mind when the time comes. I kept a teacup and saucer and some pieces of silver from my parents as a reminder. I think people "down South" are more interested in the silver and fine china for entertaining than midwesterners are.

-- In general, my kids seem to have no interest in silverware. But now that [my daughter] has become the host of family holiday gatherings, she has taken over our formal china and even found additional matching service pieces on the internet (the china is no longer made). They also are interested in the Christmas china.

-- It would be a mixed response. Our [one] son and his wife have dinner parties all the time and also our daughter. Our son in Mpls doesn’t entertain like that. Neither registered for sterling 30 years ago and really wouldn’t care to get the set I have. So I get where Elliott is coming from. Different times.

-- I think that mine, although older, would agree with Elliott. You can get a lot melting it down these days. I have a set that I haven't done yet because I have one VERY sentimental daughter who would have a hissy fit (but won't use it). I don't use it because I HATE polishing it.  :-)

-- All hypothetical! I never had sterling so I didn’t have any to give away. [One DIL] has china and maybe silver from her mother and grandmother which she uses. I still have our china which I still use. My granddaughters are the only ones who might be interested. And [one granddaughter] FaceTimed us 15 minutes ago so I asked her and she seemed enthusiastic about receiving it but I’d have to wait until she had a place of her own. Her mother doesn’t have a sentimental bone in her body. [Another granddaughter] might be interested in the years to come. [My sister] has my mother’s sterling silver. Our niece was interested in our cut glass stemware so that found a good home. Couldn’t find any takers for [MIL’s] silver plate serving pieces. I think Goodwill got them. 

I understand Elliott’s resistance to polishing silver.

Hard to let nostalgia go!

-- I think our kids would feel the same way about the sterling silver specifically and family heirlooms in general. My mom has all kinds of really nice things, from a grandfather clock to expensive figurines. I don’t know what we’ll do with all of it. Your son would probably love it if you sold the silver and invested it in a 529 plan.

-- Both my kids would respond exactly as Elliott did. I am not surprised at all by his response.

-- My kids don’t have any interest in either flatware or china — nor do antique stores or secondhand shops or Value Village or Bridging. No one. That includes me. I never used any of it. I had my own, my mother’s, my grandmother’s, and my great-grandmother’s — flatware and china. All gone.

-- Our kids are like Elliott and we also have 2 sets of sterling silver and several sets of bone china. We are hopeful that someday one of them might change his or her mind, so we are holding on to them for a while. Our kids don't want anything of ours

-- gave [my daughter] my Mom's china and she has never used it. I have china, silver flatware and crystal glasses and I never use them either. Primary reason - it all needs to be hand washed. Looks beautiful though!

-- Our kids would sell it! They would say exactly what Elliott said although not as kindly! We feel fortunate that, over 10 years ago, we gave the china to a niece. We wrapped it up and found containers for her to take it home that day (family reunion). Since several couples drink, we think one of the kids might want the glassware.

-- Sorry to say, but our kids would fall in with Elliott’s sentiments.  We have A LOT of stuff I’m pretty sure they will not want. Good luck! Please let me know if you have any good tips for dispensing with China and silverware.

--  Actually [my wife] and I never in our sixty years of marriage used the china, crystal, and silver we were given at our wedding.  We felt bad for the people who had spent all that money. And certainly, our kids don't do so! I haven't sold the silver, but this would be a great time to do so.

-- We have never had sterling flatware. We do have some silverplate that [my wife] inherited and another set we bought at a garage sale. We virtually never use it. There have been a few times we have hosted a holiday dinner for family when we got out [my wife's] inherited china and the silverplate. We don't do that anymore but we do have everyday dishes and utensils to handle eight without getting out the fancy stuff.

-- Our kids don't want any of it and (without asking them) I'm pretty sure they would answer like Elliott did. Same goes for any other "stuff" we have, including furniture.

-- When I inherited my mother's china and silver flatware NO ONE wanted them ... even the antique store. I finally sold her full china set for $50. She would be so disappointed. So, yeah, I don't think anyone uses china like they used to, including me. I guess it's an old fashioned idea. I even have an old silver tea set no one wants. May have to sell that for the silver as well.    

-- Unfortunately you are having a common experience for "our" generation as I talk with friends and siblings. Here is my experience:  

One son, partnered but not married and in a condo, has indicated that he does not need/want basically anything from us - he has pointed to a few furniture pieces that might work for him if we move. He and his partner have chosen stoneware that they like and have no space for any second set of dishes; she likes to cook and has all the kitchen equipment she wants.

The other son is married with two teenage daughters. His wife already has two sets of extra dishes (quality china, Waterford glassware, and silver items including flatware). It has sentimental value for her from family on both sides, and there is enough for both daughters to inherit. If we want to hand down one or two items -- that is the most they will take into their already packed basement storage area. Neither son is interested in the silver and the need to maintain it. 

Elliott is correct, I think, that only the very upper classes who have large houses with lots of storage, staff to maintain valuable household items, and the need to entertain regularly maintain and regularly use fine china and in the way you see displayed in upscale home decor magazines. On the other hand, my daughter-in-law does bring out one of her special sets at Christmas and Easter - and that may explain the tepid interest of our granddaughters at the moment. So, alternatively, you might keep your sets in storage and see what that granddaughter is thinking in 20+ years.

 

 

 

 

"Adventures" in Health Care 2

 

April 18, 2026

An "adventure" in health care (American style), part 2[1]

Gary Engstrand

Prologue

              I didn’t plan to write a “part 2” because I didn’t think there would be anything happening that I could make into an interesting read. Several friends asked me to do so, and as it turns out I can tell a few more stories. Unfortunately. So three days after the conclusion of “part 1,” I’ll start part 2. Not that the specific dates are of particular importance, even though I’ve put them in bold, but they demonstrate that Minnesota Urology and their colleagues in Minneapolis Radiation Oncology moved quickly after the PSMA scan.

              It has occurred to me more than once, as this course of diagnoses and evaluations has unfolded, that it is based entirely on what I might call magical numbers. I have no symptoms; I feel today the same as I felt a year ago. I suspect, however, that those magical numbers are going to lead to medical interventions so that I will NOT feel the same as I did a year ago.

Last December a sophisticated machine looked at my blood and said a number was high (the PSA). Another sophisticated machine took a picture of part of my body that supposedly meant something (the MRI). Later, in March, yet another sophisticated machine produced another set of numbers indicating disease (the Gleason scores). And in April another machine confirmed the information from the first three machines (the PSMA PET scan). But for all these machines, I would have no idea I have any illness. I could be the anti-machine equivalent to anti-vaxxers and deny there’s anything wrong with me. I certainly have no evidence personally that there is!

              A friend of mine who read chapter 1 echoed a sentiment that Sam expressed and that I shared. “Although I knew I most likely had cancer, when I read the word CANCER on the report, it nearly knocked me off my chair.” Yep. Who, me?

              M Health Fairview has long been the health care provider I have used—and generally been happy with. But they disappointed me on the cancer treatment. The first they could get me in for the PSMA PET scan was April 20; the two clinics I am using got the scan done quickly and the treatment started equally quickly. Who knows how long it would have taken M Health to finally get things moving after April 20?

              One thing I neglected to mention in part 1 was that Kathy was as worried as I was while we were in Florida (and still is, to the extent that I am). As I compose today (April 18), however, the stress levels are much lower. Kathy also went (goes) to almost all the appointments with me, which I want and very much appreciate. We discovered years ago that two heads are better than one at medical appointments; she asks questions that I forget or didn’t think to ask.

A Worrisome Sidetrack

              I managed to create considerable stress and worry for myself. I have a long-time good friend and former U of MN colleague who was recruited away from the U to run a research center in Boston; I’ll call her Emily. She’s a distinguished scholar and researcher and the U was dumb to let her get away. She’s been dealing with cancer herself. Anyway, she connected me with a friend of hers whom I’ll call Ron, who’s done extraordinary research on prostate cancer treatments (because both he and his brother had prostate cancer).

              Ron sent me a number of article citations and in several email messages vigorously advocated for brachytherapy in combination with external radiation rather than what my physicians were planning, only external radiation. (In short, brachytherapy consists of inserting radiation in the prostate, something the size of a grain of rice, whereas external radiation is what you’d expect, a machine that shoots beams at you.) This was not the treatment I was being prescribed and I began to wonder if my physicians were behind the times or something. This apparent discrepancy caused me considerable worry and stress for a couple of days. Back to being in Florida ☹

              Ron also set me up for a video call with the head of UCLA brachytherapy, a unit that is the leader in the field.

I gave my three physicians the materials that Ron had provided about brachytherapy.

The Minnesota urologist sent me a message:

“Generally brachytherapy has fallen out of favor, I don't see it used very often nowadays as external beam has evolved. With brachytherapy I worry that a high radiation dose near the bladder has higher likelihood of downstream side effects.”

The Minnesota radiation oncologist called me and talked to me for 20 minutes; I’m paraphrasing from memory:

He offered to slow down the treatment plan if I wished. (I said absolutely not.)

He trained at Mayo, which stopped using brachytherapy some time ago. He cited research (said he'd get me the citations) indicating that brachytherapy combined with external radiation did not offer better survival rates but did cause additional side effects.

Brachytherapy plus external radiation was the preferred approach in the past, but once they learned that they could safely use higher-dose external radiation, brachytherapy fell out of favor in the profession.

He encouraged me to get another opinion—the reason he offered to slow down the treatment plan—and said that *maybe* I could find someone who would do brachytherapy in combination with external radiation (i.e., he was skeptical anyone would do it). They do it only in rare cases now.

The Florida urologist also sent me a message:

"I would not combine [external radiation] with brachytherapy. LOTS of problems. I try to have those patients find a new urologist because they're very difficult to manage."

Given these responses, I thanked Ron for his efforts on my behalf and declined the video with the UCLA guy:

My take on these opinions is that it's the reverse of sticking by an outdated procedure; they have used it in the past and dropped it when they believed they had a superior treatment option.

I am comfortable with the treatment schedule that my oncologist has set up and I'm impressed with the thoroughness and care embodied in their treatment.

I'm going to close out this exchange now. But I do want to express my appreciation for your messages and research. You made me examine the treatment more carefully and ask my doctors to explain why they have chosen the treatment they did. In the end, I'll stay with what they have prescribed, but I feel better about it as a result of your communications. I thank you for that.

 Ron, however, was nothing if not dogged. He replied by asking about my hormone therapy and sent me three videos promoting brachytherapy—and suggested I send them to my physicians because they—the videos—"refute, with recent, real-world clinical science, everything they told you.” I found that response to be utterly tasteless and tacky after I told him I was signing off, I trusted my physicians, and comfortable with the treatment. Ron is not an MD; I’m going to take the word of a true believer versus the judgment of my three physicians? Nope.

I did not respond and I did not watch the videos because I’m not competent to judge medical evidence. When we first started exchanging messages, I thought he might be helpful; I concluded by thinking he’s a jerk.

My Boston friend Emily wrote a message, as part of my exchange with Ron, that was helpful by itself. 

Here is what I have learned about cancer treatment. You will not piss anybody off by asking difficult relevant questions. It is your LIFE. (I have had to learn to check my “Minnesota Nice”: be a good quiet patient and say thank you to the nice man saving your life.) I have found that providers appreciate intelligent probing questions. I am certain my level of care got upgraded when I was able to cite literature and ask for a rationale. I think there is a * by my name—get ready to provide rationale and alternatives because she has read the literature. Providers are human and they are looking for an easy road but when they see you will ask, they have to pause and reconsider.

So read the literature if you’re able. Of course, she’s a biological scientist, so that’s easy for her to say!

Into the Process

              I left off “part 1” with the PSMA PET scan (Prostate Specific Membrane Antigen, Positron Emission Tomography) No surprise, it found cancer. That was Wednesday, April 8. I was off for the weekend.

              Monday, April 13 was a morning meeting with the nurse who does the drugs and afternoon with the radiation oncologist. Two appointments the same day. Lovely.

The nurse told me about the two drugs I’d be taking: stop the testosterone! It feeds the prostate cancer—even if the cancer has spread beyond the prostate (which it has but, as I understand it, only a little). One of the drugs has side effects that are addressed by prednisone, so I have to take a drug to deal with the effect of a drug. Something doesn’t seem quite right about that picture.

The last I knew, I would have to take these drugs for a couple of years. I managed to make it nearly 75 years without ever taking any prescription drugs on a long-term basis. I guess that record comes to an end. Phooey. (I’ve never objected to taking whatever drugs a physician recommends, I’ve just never taken anything more than a week or two, such as an antibiotic. My long-time internist at the University once told me I was an oddball: a 70-year-old man who took no prescription drugs. I took that as a badge of honor. Like I had anything to do with it.)

Before meeting with the nurse about drugs, I had to do another lab test. The PSA was higher than ever. I don’t know what that signals but it can’t be good. I intend to ask when I go in to start the radiation.

The radiation oncologist had just barely enough gray/silver hair for me to know he’d been practicing awhile. I didn’t want someone just out of their residency. As I noted earlier, he told me that he’d done his training at the Mayo Clinic, which I took as a good sign.

He will use higher doses of radiation on the cancer but said that he also directs a lower dose at the surrounding tissues that might be at risk, in case there are any microscopic cancer cells lurking there. Sounds good to me, although I tend to think of radiation in general as scary (see below * * *). I asked him what the probability of a recurrence of the cancer is after this round of treatment; he said about one-third—but added quickly that “we can treat that, too.” Oh goody, a 33% chance of having the opportunity to do this all over again in the future.

* * *

One study I read, in Harvard Health Publishing, from the Harvard Medical School, gave me a few minutes’ pause. It reported on a Canadian study done in 1998-2000 that initially reported (after about six years) that there was no increase in secondary cancers—in other organs—from either brachytherapy or surgery (the other treatment option for prostate cancer). The data were drawn from men aged 62-66. (It didn’t look at brachytherapy versus external radiation.) A follow-up study of the same men, in 2024, reached a different conclusion (my emphasis in yellow):

This time, rates of new cancers in the pelvis - including the bladder and rectum - were higher in the brachytherapy group. Specifically, 6.4% of brachytherapy-treated men had secondary malignancies at 15 years of follow-up, increasing to 9.8% after 20 years.

Results from the study "should be considered when treating men with localized prostate cancer who have a long life expectancy," the authors concluded.

"I do believe that this study reveals a dark truth about radiation for prostate cancer that has been long suspected," says Dr. Anthony Zietman, a professor of radiation oncology at Harvard Medical School and Massachusetts General Hospital, and a member of the advisory and editorial board for the Harvard Medical School Guide to Prostate Diseases. "As the decades pass after radiation therapy of any kind - brachytherapy or external beam - the risk for radiation-induced malignancies rises.

"These malignancies are usually in adjacent organs like the bladder and rectum, or within the prostate itself. They may be very curable, and thus the survival rates are the same for radiation or surgically treated patients, but there is little doubt that, for these patients, they represent a 'sting in the tail' long after the radiation has been given and forgotten.

Zietman doesn’t distinguish between brachytherapy and external radiation; it appears that his point is radiation has risks, period.

I decided not to worry about radiation-induced malignancies just because it appears there is a 9.8% chance of such a malignancy 20 years after treatment. While I hope to live a reasonably long life, in 20 years I’ll be 94. I’ll take the 9.8% chance at that point.

* * *

Continuing progress, next I had a “radiation planning meeting” on Wednesday, April 15 to set up the sessions. I get 26 days of radiation, every weekday from April 22 through May 28. They gave me an 8:15 a.m. slot every day. I told them I’d be happy to come in at 7:00 a.m. (the University clinics open then), but they don’t start until 8:00. Darn. I want to get this done and out of the way every day.

              At the planning meeting I gained tattoos, for the first and only time in my life. I hate needles. I get all the vaccines and blood draws necessary but I close my eyes and look away when the needle goes in. I did so with my tattoos. I didn’t fully understand their use, but I have three dots at midriff level, one on my middle and one on each side; the radiology technician injected a small bit of ink, so they’re permanent. I think they triangulate with them.

              One of the joys of these daily morning radiation treatments is that I have to come in with a full bladder and empty bowels. That will be an interesting challenge. I can drink the prescribed 16 ounces in the hour before coming in, but. . . . I am impressed, assuming my gastroenterological state is satisfactory for the purpose of scans, that they do a new scan every morning before they administer the radiation. I’m not sure why, but if they need it, fine by me. What’s a little more radiation among friends?

              Part 3 will follow when there’s anything worth writing about.

 

             

 

---

[1] As was true in part 1, all the names used here are pseudonyms. Except for Kathy, where she appears.

#114 Time in Florida

 

                                                                                    January 31, 2026

                                                                                    Saturday afternoon

Hello everyone.

            The time we are spending in Naples marks the sixth year we have left Minnesota winters for the pleasant climate of southwest Florida. For most of my adulthood, I (silently, and only gently) sneered at the idea of snowbirds and spending time away from Minnesota in the winter. “I’m a hardy Minnesotan, I can keep on living here in the winter! You’re all wimps!” My, how one’s attitude changes as age and retirement creep up on you.

            Late last fall, while still able to sit on our porch, I asked Kathy what our frame of mind would be if we didn’t have the time in Florida to look forward to. I think we agreed we’d be depressed. All the years I was working I disliked the January and February period the most: the end of the holidays and seeing family and friends, short days—often dreary—and long nights, cold, snow, and ice, and a bleak landscape. When the option to leave became available, after Kathy retired in September 2020, we decided to go. (We had taken short breaks in Florida and Arizona before we retired, so we knew the value of warm and green, even if only in short bursts.)

* * *

            As for what’s been going on at the local level: I begin by noting that I have nothing insightful to add to the thousands of words that have already been written about the awful activities of ICE in my hometown of Minneapolis (and in the state of Minnesota). My hope is that those responsible will be subject to prosecution for (what appears to be) murder or abduction or assault or whatever appropriate statutes come into play. I am aware that state prosecution of federal officers has hurdles to overcome, but I’m alarmed at the possibility that ICE officers might be immune from prosecution for criminal acts.

            We have all learned that nothing that comes out of Kristi Noem’s office has any credibility.

            I am impressed that the Department of Homeland Security believes the Fourth Amendment is inoperative. “The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.” I hope the courts, and the Court, do not agree.

            I do not give much credence to conspiracy theories. If someone were to propose, however, that Stephen Miller and RFK Jr. are moles for China and/or Russia, I’d have to consider the possibility. Weaken the national research structure, weaken public health, weaken higher education, weaken the economy, destroy relationships with allies—what more could Messrs. Vladimir Putin and Xi Jinping want?

            As for the general situation in the country, I think the comparisons with Weimar Germany and the rise of the Nazis are overblown. I have seen Facebook memes with the ghost of Hitler smiling over Trump’s shoulder. Nah.

First, we have a free press, which Nazi Germany did not. Second, there is social media. Third, there is no group being targeted for concentration/extermination camps; I think that not even the vile mind of Stephen Miller envisages that happening. Yes, ICE is going after folks who aren’t white, but mass executions/genocide are not part of what’s happening. Deportation is not (mostly) murder. (And, ironically, the two people allegedly murdered in the Twin Cities were white folks. The alleged murders are a tragedy but symptomatic of a policing organization out of control and nothing greater than that in terms of lives lost.) Fourth, the legal system—the courts—is functioning and has imposed some barriers to ICE and the Trump administration (not nearly enough, IMO, but the courts still act with authority). Yeah, ICE seems like the Gestapo, but the legal system may impose significant costs on ICE (i.e., civil liability lawsuits, criminal lawsuits). Fifth, no demonstrations like what we’ve seen in Minnesota and elsewhere would have been tolerated in Nazi Germany. Those huge public outcries may be putting a brake on how far Trump is willing to go. Sixth, there would have been no vigorous dissenting political leaders (e.g., Gavin Newsom, J. B. Pritzker); Hitler’s Brownshirts, the Sturmabteilung, would have eliminated them.

I don’t downplay the significance of what’s going on here, and as all my friends know, I detest just about everything about this administration, but I think a realistic assessment says the comparisons with Nazi Germany aren’t accurate.

* * *

            Going from the depressing to the happy.

            I cannot compose one of these epistles without including Svea photos. Elliott & Martha & Svea visited us in Florida for a week; they returned home last Thursday.

My goodness, a (nearly) 1-year-old requires a lot of attention, and Svea received it all the time she was here. Maybe all infants are good-natured and smiley if they are treated well, and Svea certainly is both. Elliott & Martha were good enough to continue to do most of the parenting, but Kathy and I spent time with Svea as well.

This brief experience leaves me in awe of grandparents who must assume responsibility for their grandchildren when the parents are unable to care for them. I would be exhausted after about two days. That said, two days after they left, I miss her.

This townhouse has several mirrored walls and sliding glass doors; I will need to use about half a bottle of Windex to clean off all the little fingerprints.

            Climbing on grandma.

Feeding Cheerios to the ibises (white) and moorhens (black). Despite the look on her face, she found the birds fascinating.

Playing in the chair with grandpa.

* * *

            And one more positive note:

            For those of my vintage, recent research news about vaccinations has been encouraging. The New York Times reported on the “off-target” benefits (“meaning that the shots do good things beyond preventing the diseases they were designed to avert”). A recent meta-analysis of years of research: “the findings ‘are really very consistent,’ said Dr. Stefania Maggi, a geriatrician and senior fellow at the Institute of Neuroscience at the National Research Council in Padua, Italy. She is the lead author of a recent meta-analysis, published in the British journal Age and Ageing, that found reduced risks of dementia after vaccination for an array of diseases. Given those ‘downstream effects,’ she said, vaccines ‘are key tools to promote healthy aging and prevent physical and cognitive decline.’”

            I keep up with all vaccinations in any case, but I’m glad to learn they may also help forestall a cognitive decline. (I am hoping that regular attendance at the fitness center will take care of forestalling physical decline.)

            On that note, I’ll sign off. Stay warm if you’re in a cold place. And stay in touch.

            Gary