Fowler Fends Off Crowd for Honda Crown

It wasn’t easy, but then it never is for Rickie Fowler. Fowler broke a long streak of ineptitude at the PGA level. After watching his four-stroke lead fall to one, Fowler responded with back-to-back birdies to salt away the Honda Classic Crown.

It’s his first win in 13 months, a time frame that has seen his contemporaries like Dustin Johnson, Jordan Spieth, and Justin Thomas take their games to a new level.

“Whether I’m talked about with those guys or not, I just want to play the best that I can and keep pushing myself and, ultimately, just keep trying to put myself in position to win and start collecting more of these,” Fowler said, tapping the trophy.

Fowler’s last win came at the 2015 Deutsche Bank Championship. He shot a 1-over 71 on Sunday but that was still enough to edge the closest competitor by four strokes. The win earned him $1.152 million and 500 FedEx Cup points

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Parc East – by Trillium Development

Coming soon to Port Coquitlam is Park East by Trillium Developments. Park East will be centrally located on the corner of Atkins and Shaughnessy, a short walk to the Main Village with its all it shops and services, as well as the West Coast Express.

Park East will be consist of 57 condos consisting of one bedroom, one bedroom plus den, two bedroom, or two bedroom plus den, with size ranging from 446 square feet to 1077 square feet. Each suite at Parc East will be designed with quartz counters, stainless steel appliances, and large islands in the Kitchen, with laminate flooring throughout.

Amenities include a gym, furnished amenity room that includes a lounge area with kitchenette, and an outdoor entertaining space, as well as outdoor play area for the kids (little kids, not the big kids, thats what the lounge is for 🙂

Sales expected to start in the late winter of 2017 or early Spring with price to starting the mid 200’s. Register with us to be kept up to date with floor plans, and vip sales.

 

 

 

 

 

E. & O. E. This is not an offering for sale. An offering for sale may only be made after filing a Disclosure Statement under the Real Estate Development Marketing Act

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The Arden

 

The Arden is coming soon to Port Coquitlam  The Arden will be a boutique building with just 22 executive size suites with Quartz countertop, stainless steel appliances and laminate flooring.  The Arden will sure be a great spot for first timers or down-sizers.

Pricing is expected to be:

1 bedroom from high $200’s

1 bedroom + dens from Low $300’s

2 bedroom 1 bathrooms from Mid to high $300’s

2 bedroom 2 bathroom over $400,000

Completion anticipated to be Fall of 2017.  Previews start soon, register with us today to get access to this development and many others

 

 

 

E. & O. E. This is not an offering for sale. An offering for sale may only be made after filing a Disclosure Statement under the Real Estate Development Marketing Act

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Parents: As more states legalize marijuana here’s what you need to know and do

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Recreational use of marijuana was just legalized here in my home state of Massachusetts, and this has led to a lot of interesting conversations as legislators, regulators, and businesspeople try to figure out how to best implement this change.

But the most important conversations about marijuana, in Massachusetts and throughout the country, may be between parents and children.

This week the American Academy of Pediatrics (AAP) released a clinical report to help pediatricians and parents talk to teens about marijuana. As it has become legalized in more states, research has shown that fewer teens think of smoking marijuana as risky.

This is often what I hear from teens in my practice. They don’t think of marijuana as a dangerous drug — and the fact that its use was legalized seems to have reinforced the impression that it’s safe.

But it’s not safe.

Marijuana can:

• impair short-term memory, concentration, attention span, and problem-solving, all of which can get in the way of learning and can also lead to accidents and injuries
• lead to lung damage from inhaling the smoke
• increase the risk of long-term psychiatric problems such as depression or psychosis
• cause long-term problems with memory and executive function, even after use of marijuana has stopped
• lead to addiction — experts say that 9% of those who experiment will become addicted. This number is higher (17%) for those who start in adolescence and even higher (25% to 50%) in teens who smoke marijuana daily.
• cause growth and learning problems in babies whose mothers smoke during pregnancy.

Just because something is legal doesn’t mean it’s safe. Cigarette smoking is legal, and is linked to many serious health problems. Drinking alcohol is legal, and leads to alcoholism, many health problems, and many serious accidents and injuries.

It’s really important that parents talk to their teens about the risks of marijuana use. It’s also really important that parents be mindful about how their own use of marijuana sets an example and sends a message. Here are the main points that the AAP wants parents to know.

• Because marijuana affects the brain, and because teen brains are still developing, marijuana is particularly dangerous for teens.
• Teens who use marijuana regularly can develop serious mental health problems.
• While marijuana has been legalized in many states for use by people over 21, it’s still illegal for teens, so using it can lead to having a criminal record, which can affect getting into schools or getting jobs.
• Driving under the influence of marijuana is like driving drunk: it’s dangerous and should never happen.
• The smoke of marijuana is toxic, both to the person smoking it and the people around them.
• If parents use marijuana in front of their teens, their teens are more likely to smoke it too. Think before you light up.
• Another thing to think about before you light up: marijuana can impair your ability to make safe judgments for and about your children.
• If parents have any marijuana products, especially things like edibles, they should keep them safely away from children (this is particularly true when there are small children at home).

It’s so important to think about this as a parent — and to talk with your teens, not just once but often, in an ongoing way. Make sure they have the information and strategies they need to make the best and healthiest choices. Make sure that you are making the best choices yourself when it comes to marijuana use, because as a parent, your choices are about more than just you.

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Brooklynn

Much like Maplewood Village and Lions Gate Village, Lynn Creek/Seylynn is undergoing a transformation into a walkable, transit oriented hub.  Brooklynn by Wanson Developments will be the next development to come up in the Lynn Creek/Seymour Village centre. Brooklynn will be a mixed use building consisting of ground floor retail and 63 1, 2 & 3 Bedroom condos.

More information and sales are expected to be released in March of 2017, register with us today to be kept up to date on this development and may others like it coming to the North Shore.

 

 

 

E. & O. E. This is not an offering for sale. An offering for sale may only be made after filing a Disclosure Statement under the Real Estate Development Marketing Act

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Cedar Reach at Maplewood

After the very successful development of Loden Green by Guildford Developments and Maplewood Place by Anthem, as well as the Northwood Estates Rental suite and shopping centre,  Maplewood Villages is rapidly becoming a hot spot in North Vancouver. Cedar Reach is the newest development coming soon to the area.  Cedar Reach will be modern collection of homes featuring 163 One, Two, and Three bedroom homes in the heart of Maplewood Village.  Within a short stroll to Northwood Shopping centre, including Strong’s Market, Deep Cove Brewing. banking and liquor store, Cedar Reach will be designed with West Coast architecture and storage space for all your gear to fully enjoy the outdoors its surrounded by.

If you’d like to receive more information on this development or any other coming to the North Shore, register with us today to be kept up to date.

 

 

 

E. & O. E. This is not an offering for sale. An offering for sale may only be made after filing a Disclosure Statement under the Real Estate Development Marketing Act

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Belle Isle by Citimark Developments

Lions Gate Village was approved under the new OCP a couple years ago, we are now seeing the changes coming with Park West slated to begin sales in the coming months, as well as Larco’s rental community, but Belle Isle will be the first ground oriented townhome development, when all phases are completed will include 164, 1, 2

, and 3 bedroom townhomes and garden flats.

Belle Isle will be centrally located in a new community within walking distance of Park Royal, a 15 minute drive to downtown and quick access to bus routes directly downtown, or anywhere on the North Shore

To be kept up to date on this development or any on the North Shore register with us today.

E. & O. E. This is not an offering for sale. An offering for sale may only be made after filing a Disclosure Statement under the Real Estate Development Marketing Act

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Bad bug, no drugs: The real end of antibiotics?

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In September 2016, a woman in her 70s died of septic shock in Reno, Nevada, from an infection which was fully resistant to 26 different antibiotics. She had spent much of the previous two years in India, where she was treated for a hip fracture. The hip became infected, and after several more hospital stays, she returned to her home in Nevada.

Within weeks, she was desperately ill, and back in a hospital in Reno. A sample from her hip wound revealed a strain of the bacteria Klebsiella pneumoniae which was not sensitive to any antibiotics. It was even resistant to a drug called colistin, an old-fashioned, somewhat toxic, and rarely used antibiotic that is considered the last line of defense against antibiotic-resistant bacteria. Before she died, the patient was isolated and kept in a private room. There is no indication that her resistant bacteria had spread to other patients in the hospital or in the Reno area.

How these bacteria outsmart antibiotics

The Klebsiella bacteria that killed her had a powerful enzyme that breaks down antibiotics, known as New Dehli metallo-beta-lactamase (NDM), because it was first found in a patient who had travelled to that Indian city. Indian politicians have disputed the link between their capital and a deadly superbug, and the local tourism board and chamber of commerce probably aren’t too thrilled about it either. In any case, it is probably unfair to focus too much on the Indian origin of this resistant bacteria. Klebsiella bacteria with a slightly different, but equally fearsome form of antibiotic resistance known as KPC have already become entrenched in the United States, as well as in Brazil, China, Israel, Colombia, and Italy.

The vast majority of cases of resistant Klebsiella infection in the United States involve patients who have been hospitalized. But alarmingly, highly resistant bacteria have started to percolate down into the community. A recent outbreak of NDM-positive Klebsiella in Colorado involved patients without health care exposures. A woman in Pennsylvania presented to a clinic in May 2016 with a urinary tract infection with bacteria resistant to colistin, which she had probably picked up during a recent hospital stay.

Is it the end of antibiotics as we know them?

Hand-wringing about antibiotic resistance has been around almost as long as antibiotics. Newsweek somewhat prematurely proclaimed “The End of Antibiotics” in 1994, and the New England Journal of Medicine bewailed the rising tide of antibiotic resistance as early as 1960. All the way back in 1945, scientists had discovered it was relatively easy to create antibiotic-resistant bacteria by exposing them to very small amounts of antibiotics, and then gradually increasing their degree of antibiotic exposure. In retrospect, this shouldn’t be so surprising. Penicillin and cephalosporin antibiotics are derived from molds, which used these compounds for millennia to suppress competition from bacteria. So bacteria, in turn, have developed ways to neutralize and break down antibiotics. Overuse of antibiotics has favored the spread of bacteria carrying these resistance mechanisms.

Another sobering development is that the antibiotic pipeline is drying up, with dim prospects of new drugs coming along to replace the old ones that are losing potency. The economics of antibiotic discovery are bad. Many pharmaceutical corporations have gotten out of the business of developing new antibiotics altogether. The cost of bringing new drugs to market can ratchet up into the billions. The anticipated payoffs are small, as infectious diseases practitioners only use new and powerful antibiotics when absolutely necessary, in an effort to have them retain their effectiveness for as long as possible.

Here’s what you can do

You can take a number of steps as a patient, a consumer, and a citizen to help keep the flood waters of antibiotic resistance from breaking through the levee.

Don’t press your doctor to prescribe antibiotics if they believe it is unnecessary. Taking antibiotics increases your risk of acquiring drug-resistant bacteria, kills off your beneficial gut bacteria, known as your “microbiome,” and exposes you to the potentially deadly bowel infection, Clostridium difficile colitis.

About 80% of the antibiotic use in the United States is in agriculture, not medicine. In particular, low doses of antibiotics are added to livestock feed in factory farms to prevent infections and promote growth. This constant, low-level antibiotic exposure is an excellent way to create drug-resistant bacteria. At least some of these bacteria probably work their way up the food chain to affect humans. You can support the responsible use of antibiotics in agriculture by only purchasing meat raised without antibiotics. And consider calling your congressperson to ask their support for greater public funding for new antibiotic discovery.

And while this sounds bleak, there are other things you can do as a consumer and as a patient to help. You can start by paying attention to the food you eat and by not pressing your doctor for unnecessary antibiotics.

Listen to Dr. Ross’s podcast on antibiotic resistance. 

 

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Fowler Hones in on Honda Classic Title

American Rickie Fowler continued to dominate the course at the PGA National in Palm Beach Gardens, Florida, firing a Saturday 65 to open up a 4-stroke lead at the Honda Classic.

In his career, Fowler is a staggering 0-for-8 when he’s either been in the lead or within a stroke of the lead entering the final round. If he blows this one, he’ll be certifiable.

“I know I have the lead, and it’s nice to go out in front,” Fowler said. “But you still have to play, and especially around this place, it can jump up and bite you at any time.”

Fowler improved on his opening two rounds of 66 with a 5-under 65 to reach 13-under. His closest competitor is England’s Tyrrell Hatton, who was 4-under for the day and is 9-under for the tournament.

Fowler had a bogey-free round on a day where three other men in the top 10 matched him at 5-under, and American Brandon Hagy nailed a 6-under 64 to climb 47 spots into a tie for eight.

Hatton could have been double-digits under par after a string of three of birdies on 12-14, but he bogeyed 18.

Emiliano Grillo, Sean O’Hair, Garry Woodland, Martin Kaymer, and Wesley Bryan are tied for third at 7-under.

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Dustin Johnson Takes Over as World No. 1

Dustin Johnson’s win at the Genesis Open last Sunday propelled him into the no. 1 spot in the Official World Golf Rankings, the 20th man to hold that spot.

In his last 50 events, Johnson has five wins and an impressive 30 Top 10 finishes. He knocked Jason Day out of the top spot after the Australian had resided there for 47 straight weeks. Day fell to No. 2 and Rory McIlroy to No. 3.

Also in the top 10, Sweden’s Alex Noren flip-flopped places with Patrick Reed to take over at No. 10.

Johnson is the first player not named Day, Jordan Spieth, or Rory McIlroy to hold the No. 1 spot since August of 2014, when Adam Scott held it for 11 weeks. Since then, McIlroy has held the top spot for 56 weeks, Spieth for 26 weeks, and Day for 51 weeks.

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Dustin Johnson Cinches Genesis Open Title

Looking quite like Tiger Woods in his prime, Dustin Johnson cruised to a 5-stroke victory at the Genesis Open on Sunday by shooting a final-round 71.

By shooting 66-66-64 in his first three rounds, Johnson guaranteed it would take an epic collapse coupled with a record-breaking round for him to fall short.

So even though Belgium’s Thomas Pieters fired a 63 on Sunday, he got no closer than five shots. Johnson was 3-under through nine holes, all but sealing the win even as he bogeyed three holes over the past 10.

The victory took Johnson to No. 1 in the Official World Golf Rankings, moving him ahead of Jason Day who had held the position for just shy of a year.

Pieters and Scott Brown tied for second.

Johnson won just one day after announcing he and fiance Paulina Gretzky are pregnant with their second child. It’s Johnson’s 13th PGA Tour title, fifth inside the last two calendar years.

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Finding the tick in time could save you from Lyme!

“Doesn’t it typically happen during the summer?” asked a worried lady that had walked into my clinic in November with a growing circular rash on her wrist. She was referring, of course, to Lyme disease, that scourge of outdoor enthusiasts. While the peak season for Lyme disease is indeed summer, the ticks that transmit it are active March through December. And, while this may be off-season for the ticks, it is a good time to catch up on how to stay safe in the not-so-distant spring.

What is Lyme disease, and how do you treat it?

Lyme disease is caused by a bacterium called Borrelia burgdorferi which is spread to people through the bite of infected black-legged ticks, also popularly known as “deer ticks.” Early symptoms include a typical enlarging red rash (“bullseye rash”) at the site of the tick bite. This is common, but not everyone with Lyme disease gets this rash. Other signs of Lyme include flu-like symptoms (fever, fatigue, and headache). If left untreated, over time the infection can lead to Bell’s palsy (paralysis or weakness of facial muscles on one side), meningitis (inflammation in the brain and spinal cord), heart rhythm problems, and joint pain and swelling. Additional symptoms can include headaches and stiff neck, tingling and numbness (often in the hands and feet), and rarely, inflammation of the eyes.

The diagnosis is usually based on a person’s symptoms, the presence of the typical rash, and a history of likely exposure to infected ticks. Lab tests for Lyme disease do not turn positive until three to four weeks after the infection. Usually doctors do not wait for the results of these tests during the early stage of the disease, to begin treatment.

Once diagnosed, Lyme disease can be successfully treated with a few weeks of oral antibiotics. Doxycycline is the antibiotic prescribed to all but pregnant women and children, who usually get the antibiotics amoxicillin or cefuroxime. For people with severe heart or neurological symptoms of Lyme, intravenous antibiotics are usually necessary.

Here’s what you can do to keep from getting Lyme disease

As always, prevention is superior to cure. Right now, there is no Lyme vaccine available for people. There is a Lyme vaccine available for dogs! However, it does not protect against other tick-borne diseases, hence preventive measures against ticks are still necessary. Most dogs exposed to Lyme disease do not have symptoms. Some develop fever, lack of appetite, lameness, and joint swelling. Therefore, staying safe requires preparation and vigilance. The ticks that transmit Lyme disease are tiny, and you can’t feel it when a tick attaches to you. They may even make their way into your home by attaching themselves to pets. Here are some steps to follow to remain safe.

• Avoid wooded and bushy areas with tall grass and stick to the center of trails when hiking.
• Wear light clothing to make ticks easier to detect.
• Wear long pants tucked into socks to keep ticks on the outside of clothes.
• Use DEET or a permethrin-based tick repellent on clothing and outdoor gear.
• Pesticides like permethrin, fipronil, or amitraz may be used on dogs. These are available in the form of powders, impregnated collars, sprays, or topical treatments.
• Do remember to never use tick repellents that are intended for dogs on a cat! Cats are extremely sensitive to a variety of chemicals.
• When back home, shower or bathe as soon as possible and carefully inspect the entire body to remove any attached ticks. It takes up to 36 hours for the bacterium to be transferred after the tick bite. Prompt removal of the tick will reduce the chance of infection.
• Tumble dry clothes on high heat for at least 10 minutes to kill ticks.
• Carefully examine children and pets after outdoor activity.

 If you find a tick along for the ride, here’s what you need to do

Use thin tipped tweezers to grasp the tick as close to the skin surface as possible. Pull the tick straight upward with steady even pressure to remove the tick with the mouthparts intact. Squeezing the tick will not increase the risk of infection. Adult ticks are a lot more difficult to remove intact. If the mouthparts break off, the chance of getting Lyme disease is the same as if you hadn’t removed the tick at all. After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water. Watch for signs and symptoms of Lyme disease for up to 30 days.

See your doctor within 72 hours of the tick removal and if the tick removed was swollen. You may benefit from preventive antibiotics. This is especially important if you live in (or have visited) an area where deer ticks are common.

Create a tick-free zone around your home

Need a little more motivation to mow the lawn or rake the yard? Remember that ticks lurk in tall grasses, brush, and weeds around homes and at the edge of lawns. Remove any old furniture, trash, or mattresses from the yard that may give the ticks a place to hide. Place a three-foot-wide barrier of wood chips or gravel between lawns and wooded areas and around patios and play equipment to restrict tick migration into recreational areas. Stack wood neatly in a dry area (this discourages rodents that carry the ticks). Keep playground equipment, decks, and patios away from yard edges and trees, and place them in a sunny location if possible.

Lyme disease is a painful but preventable condition. When you enjoy the outdoors this year, pay close attention to your environment and follow the steps mentioned above to stay safe and keep your family and your pets safe too!

References

Gary P, Wormser, Raymond J et al. The Clinical Assessment, Treatment and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by Infectious Disease Society of America, Clinical Infectious Diseases, November 2006.

Tick Borne Diseases of the United States: A Reference Manual for Health Care Providers, Third edition, Centers for Disease Control and Prevention, 2015.

Tick Management Handbook: An integrated guide for homeowners, pest control operators, and public health officials for the prevention of tick-associated disease, The Connecticut Agricultural Experiment Station, 2007.

Meryl P. Littman, Richard E. Goldstein, Mary A. Labato, Michael R. Lappin, and George E. Moore. ACVIM Small Animal Consensus Statement on Lyme Disease in Dogs: Diagnosis, Treatment, and Prevention [PDF, 13 pages]. Journal of Veterinary Internal Medicine, March 2006

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Home sleep studies may help identify sleep apnea

What if I need a sleep study? If you are one of the approximately 35% of Americans who snore, perhaps this has crossed your mind. You have read on the internet or watched a newscast about sleep apnea, a condition associated with an increase in heart attack and stroke risk. Loud snoring, daytime sleepiness, fatigue, and observed pauses in breathing at night are the most frequent symptoms. A sleep study is necessary to make the diagnosis.

To many people, the thought of a sleep study raises visions of being restrained in a bed with wires attached everywhere and complete strangers watching you, in other words, “Big Brother on steroids.” They frequently tell their doctors that they never will be able to sleep under such circumstances, and sometimes they are correct. A number of studies have shown that the first night of sleep in a laboratory may not be representative of a person’s usual sleep pattern. Fortunately, there is a solution: a home sleep study.

Increasingly, driven by the necessity to reduce health care costs, health insurance companies have been requiring that limited home sleep studies be done to confirm the diagnosis of sleep apnea. In addition to being less expensive, these studies allow the patient to sleep in his or her familiar home environment. A major disadvantage is that brain wave activity is not recorded, which means that important sleep information isn’t captured. In addition, because the study is not directly observed by a technician, the quality of the signals may be inadequate. So it’s been unclear whether the treatment outcomes of those studied with a home test are the same as those who are studied in a sleep laboratory.

In a recent large study of patients suspected of having sleep apnea, effectiveness of treatment for patients who were diagnosed using information from replicated home sleep studies was compared to those diagnosed with data from a sleep laboratory. The investigators found that improvements in sleepiness and quality of life were the same. These results are reassuring, and add to the increasing amount of information indicating that home sleep studies may be used to confirm the diagnosis of sleep apnea in most patients.

Although a home sleep study can be used to confirm a diagnosis of sleep apnea in the majority of patients, some really should be studied in a sleep laboratory — these include persons with underlying heart or lung disease and certain chronic medical conditions, as well as those who are suspected of having sleep disorders other than sleep apnea. Most importantly, home sleep studies can be incorrect and miss the diagnosis of sleep apnea, or underestimate its severity. If a home sleep study suggests the presence of sleep apnea, then it makes sense to go ahead and treat it. However, if the home sleep study is negative, a laboratory sleep study should be performed.

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Unlocking the lock jaw: Temporomandibular Joint (TMJ) dysfunction

The temporomandibular joint (TMJ) is one of the most heavily utilized and underappreciated joints in the human body. Mechanically, the TMJ is what allows you to open and close your mouth, and to a lesser extent, extend and move your jaw from side to side. Functionally, it facilitates eating, talking, and facial expressions. Without a TMJ, McGruff the crime dog would not be able to “Take a bite out of crime,” and Jaws would have never become a savage predatory superstar of the deep blue sea.  Just kidding. We all know from “Shark Week” that sharks do not actually have a TMJ, but you get the idea.

Structurally, the TMJ is a complex joint that involves multiple muscles working in concert with uniquely shaped cartilage to allow for the powerful actions of chewing, as well as the fine movements involved with speech. Like so many parts of the human body, the TMJ usually only receives attention when something goes wrong.

The grind of grinding

Grinding of the teeth, also known as bruxism, is a very common problem. For many people this occurs at night during sleep (nocturnal bruxism).  Since it occurs during sleep, many people are unaware that they’re even doing it, but the noise generated can be unbearable for a sleep partner. People with nocturnal bruxism often wake up the next morning with tightness and soreness of the jaw muscles.  Bruxism over time can cause destruction of tooth enamel, the formation of gaps between teeth as teeth start to shift, and damage to the TMJ joint. Some people who suffer from bruxism are first diagnosed during routine dental visits when enamel destruction is noted.

Snap, crackle, pop

A number of studies have shown that TMJ dysfunction can exacerbate headache disorders, and that successful treatment of TMJ dysfunction can improve the headache disorder. As a headache specialist, I routinely evaluate the TMJ. During the examination, I palpate the joint, while the patient makes different jaw movements. I can often feel, and at times hear, the dysfunction in the joint. These problems are usually due to the misalignment or damage that has occurred to the tendons, ligaments, and/or cartilage involved with jaw movements. When severe, the TMJ can painfully “lock,” and the person is unable to move their jaw until the joint is realigned, which can at times require surgery. These issues can occur in association with bruxism, excessive jaw clenching, jaw trauma, and at times without any clear cause.

My night…guard in shining armor

A very common treatment for TMJ dysfunction is the use of a nightguard, which is a plastic mouthpiece that covers the teeth, and prevents enamel on enamel contact. A nightguard is usually fitted to the upper (maxillary) teeth. In general, a dentist fabricates custom nightguards.  Although usually more expensive, custom nightguards are a better choice than over-the-counter versions for a number of reasons. Custom night guards tend to be thinner and more comfortable. In addition, custom night guards are molded specifically to a person’s teeth and bite. If a nightguard doesn’t fit well, it can actually cause shifting of teeth and worsen TMJ symptoms. Although bruxism has never been a significant problem for me, I wear a nightguard to prevent enamel wear and shifting of teeth. After using a nightguard for a number of years, I tell patients that not wearing my nightguard is like not putting on my seatbelt after I get in the car. It is a disruption in my routine, which can at times leave me feeling restless.

Injecting conversation

Other treatments for TMJ dysfunction include injections directly into the joint and jaw surgery. One of the less invasive and less painful treatments is the use of botulinum toxin (Botox). Cosmetically, Botox works by relaxing the muscles that, when overactive, can cause wrinkles. Similarly, when injected into jaw muscles, they relieve tightness, pain, and wear on the TMJ. Two of my patients had very large jaw muscles from constant clenching over the years, and with Botox injections the contour of their faces changed. One of these patients said, “I hated having these big jowls. My jaw line is much smoother now, and my pain is essentially gone.” Regarding side effects, another one of my patients asked, “Dr. Mathew, does injecting Botox in the jaw muscles cause any side effects?” I advised her, “Injecting too much Botox can cause jaw weakness when chewing something tough like steak, which can be a good thing.” She responded, “How can jaw weakness be a good thing?” I replied, “If you are experiencing jaw weakness, it will be difficult for you to complain about me.”

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Parents: How to manage injuries at home—and when you need to go to the doctor

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It’s a fact of life: kids get hurt. We do everything we can to keep them safe, but shy of sticking them in bubbles, which would be a bad idea for all sorts of reasons, the reality is that injuries happen. Luckily, most injuries can be managed quite well at home. Here are some tips on how to do that — and how to know when you shouldn’t.

Cuts and scrapes

The vast majority of cuts and scrapes just need a good washing (plain old soap and water is fine — use a washcloth if there is any dirt or other debris) and a clean bandage. Change the bandage daily with a washing (taking the bandage off before a bath or shower is often enough) and check out the area. If it looks at all red, a little antibiotic ointment can be helpful, but usually isn’t necessary (and can contribute to antibiotic resistance, so should be used sparingly).

Get medical attention if:

• the edges of a cut gape open — that usually means stitches are needed.
• you can’t stop the bleeding with pressure—with one caveat: cuts on the lip or in the mouth bleed a lot, but usually don’t need medical attention. Try some ice (or a popsicle) and wait a little while. If it’s not stopping, call your doctor for advice.
• a cut or scrape is looking redder, or has spreading redness or pus, despite the antibiotic ointment.
• your child develops a fever.

Animal or human bite

The first thing to do with any bite is to wash it really well. Often bites can cause puncture wounds that can be deep, so use lots of soap and run the water over it to clean it out as best you can.

Humans, it turns out, have dirtier mouths than dogs or cats — so any human bite that breaks the skin warrants a trip to the doctor.

While not all animal bites need a trip to the doctor, it’s a good idea to call the doctor for advice any time it happens, especially to sort out if there could be any risk of rabies. If your child is bitten by someone else’s pet, ask about rabies vaccination and get the contact information for the pet’s owner. Being able to confirm that the animal is vaccinated, or being able to quarantine the animal, could save your child a bunch of shots.

Bumps and bruises

The vast majority of these just need some ice and plenty of hugs. Get medical attention if:

• Your child has a bad bump to the head and is vomiting, acting sleepy or having trouble doing ordinary things. It’s worth a call to the doctor for any bad bump to the head, actually, so that you can run through what happened and decide together what to do.
• The bump is near or on the eye socket, and there is redness of the eye or any trouble moving the eye or with vision.
• Your child has a lot of pain despite the ice and hugs, or acts sleepy or is worrying you in some other way

Eye injuries

If your child gets something small in his eye, or gets something sprayed into his eye, rinse it out very well with lots and lots of water (if you have contact lens solution, that works well too). If after the rinsing your child feels fine and the eye doesn’t look red (or looks barely red), you’re all set. But if it still hurts or the eye looks very red, head to the doctor. You should head to the doctor immediately if what gets in the eye isn’t small, or if there is any bleeding or if your child complains of any trouble seeing.

Is it broken?

Almost every parent ends up asking this question. Most of the time, the answer is no. Take a good look at the area, and have your child try to move the injured part of the body. If it’s the leg or foot, see if they can bear weight.

Get medical attention if:

• there is severe pain, especially if your child feels dizzy or nauseated.
• the part of the body looks crooked or otherwise different from usual.
• there is severe swelling.
• your child has trouble moving the injured part of the body, or can’t bear weight

If none of these are true, use ice on the area and have your child rest. But if things aren’t getting better, call your doctor to see if an x-ray might be a good idea to be sure you aren’t missing a smaller fracture.

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A primary care doctor delves into the opioid epidemic

Our nephew Christopher died of a heroin overdose in October 2013.¹ It had started with pain pills and experimentation, and was fueled by deep grief.² He was charismatic, lovable, a favorite uncle, and a hero to all the children in his life. His death too young was a huge loss to our family. I have always felt that I didn’t do enough to help prevent it, and perhaps, in a way, even contributed.

Good intentions with unintended consequences

My medical training took me through several big-city hospitals where addiction and its consequences were commonplace. Throughout all of it, great emphasis was placed on recognizing “the fifth vital sign,” i.e. pain, and treating it.

I distinctly remember as a medical student wearing a little pin with the word “PAIN” and a line across it. One was considered a bad doctor if they didn’t ask about and treat pain. And so, treat we did. This medical movement, combined with the mass marketing of OxyContin and a swelling heroin trade, has created the current opioid epidemic.⁴

It generally starts with pain pills: Percocet, Vicodin, Oxycodone or OxyContin, either prescribed or given or bought. Quickly, a person finds that she or he needs more and more of the drug to get the same effect. Almost overnight, they need the drug just to feel normal, to stave off the horror of withdrawal. Street heroin is cheaper and easier to come by than pills, and so, people move on to the next level. Just like Christopher.

Recent data from the Centers for Disease Control (CDC) and the National Institute for Drug Abuse (NIDA) show that deaths from overdose of opioids have been rising every year since 1999.^5,6 (OxyContin came to market in 1996). Deaths from heroin overdose have recently spiked: a 20% increase from 2014 to 2015.⁷ And most recently we’re seeing fentanyl, an extremely potent synthetic opioid, where even a few small grains can kill.

So, if we doctors helped everyone get into this mess, we should help them get out of it, no?

Needed: Treatment that works

As the opioid epidemic has exploded, so has the demand for treatment. But treatment is almost impossible to come by. The U.S. is short almost 1 million treatment slots for opioid addiction treatment.^{8, 9} And not all treatments offered are that effective.

The “traditional” treatment of detoxification, followed by referrals to individual therapy or group support (think Narcotics Anonymous), may work well for some, but the data suggest that there are more effective approaches. In fact, a growing body of evidence very strongly supports medication, combined with therapy and group support, as the most effective treatment currently availabe.^10,11,12

“Detox” followed by therapy has consistently shown poor results, with more than 80% of patients relapsing, compared to treatment with medications, with only 15% relapsing.^10,11 Medications, specifically methadone and buprenorphine, can help prevent withdrawal symptoms and control cravings, and can help patients to function in society.^10,11,12 Suboxone (a combination of the drugs buprenorphine and naloxone) has many advantages over methadone. It not only prevents withdrawal and controls cravings, but also blocks the effects from any illicit drug use, making it more difficult for patients to relapse or overdose. In addition, while methadone can only be prescribed through certified clinics, any primary care provider who completes a training course can prescribe Suboxone. That means treatment for opioid use disorders could be much more widely available.

Basically, treatment with medications, and especially Suboxone, is effective, and safer than anything else we have to offer. Yes, relapses can occur, but far less frequently than with traditional treatment.^10,14,15 And death from heroin overdose? Far, far less.¹⁶

Biases against treating opioid use disorder with medications

Despite their effectiveness, there is stigma associated with treating substance use disorders with medication. I admit that I had my own doubts as well. People say, as I did, “Oh, you’re just replacing one drug with another.” But a lot of hard science has accumulated since 2002, when the FDA approved Suboxone for the treatment of opioid addiction.¹⁷

Think about it. Is shooting street heroin that’s cut with God knows what, using needles infected with worse, really the same as using a well-studied, safe, and effective daily oral medication? Some may claim “Oh, you’re just creating another addiction.” Would you tell someone with diabetes who depends on insulin that they’re “addicted”? Then why say that to someone with opioid use disorder who depends on Suboxone? This is literally the reasoning that played out in my head as I have learned about treating opioid addiction, or, more correctly stated, opioid use disorder.

Stepping up

I’ve decided that it’s time to do something. There’s a great need for doctors willing and able to treat opioid use disorder. In 2016, surgeon general Vivek Murthy issued a strident call to action to all U.S. healthcare providers, asking them to get involved.¹⁸

This issue has been on my mind and soul since Christopher’s death, so I started educating myself, and contacted our hospital’s substance use disorders specialist with my motivation and concerns. In the few months since then, I’ve taken the training course to become a licensed prescriber, and am working with the team to begin treating a small group of patients.

In my 16 years of clinical training and practice, I have witnessed all of this firsthand: the blatant, medically rationalized over-prescription of pain meds, the stigma and undertreatment of opioid use disorder, and the unnecessary, premature death of a really good kid. I’m just starting off on this, and I’m still learning, but my hope is to keep another family from experiencing unnecessary loss. (For more information see Medication-Assisted Treatment for Opioid Addiction)

Take the online course OpioidX: The Opioid Crisis in America. This course challenges common beliefs about addiction and the people who become addicted to opioids. Through an increased understanding of the biology of addiction, the course aims to reduce the stigma around addiction in general, and help people discover the multiple pathways to evidenced-based treatment. A variety of Harvard Medical School clinicians and health policy experts explain these topics and you’ll hear stories first-hand from those who have experienced addiction, or whose lives have been touched by this the opioid epidemic.

Sources

1. Generally Medicine: Ripped from the family
2. Generally Medicine: Drugs, Violence, and Tragedy in our Family
3. Mularski R.A., White-Chu F., Overbay D., Miller L., Asch S.M., Ganzini L. Measuring Pain as the 5th Vital Sign Does Not Improve Quality of Pain Management. Journal of General Internal Medicine, 31 May 2006.
4. http://ift.tt/1TKZuTn
5. http://ift.tt/2a4GZLD
6. http://ift.tt/1Q7O9ZO
7. http://ift.tt/2i0mNwN
8. Jones, C.M., Campopiano, M., Baldwin, G., and McCance-Katz, E. National and state treatment need and capacity for opioid agonist medication-assisted treatment. American Journal of Public Health, August 2015.
9. http://ift.tt/1Lsul2U
10. Wakeman S.E. Using Science to Battle Stigma in Addressing the Opioid Epidemic: Opioid Agonist Therapy Saves Lives. American Journal of Medicine, May 2016.
11. Bart, G. Maintenance medication for opiate addiction: the foundation of recovery. Journal of Addictive Diseases. October 2012.
12. Connery H.S. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harvard Review of Psychiatry, March/April 2015.
13. Mattick, R.P., Breen, C., Kimber, J., and Davoli, M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 6 February 2014,
14. Mauger S., Fraser R., Gill K. Utilizing buprenorphine-naloxone to treat illicit and prescription-opioid dependence. Neuropsychiatric Disease & Treatment, 7 April 2014.
15. Colson J., Helm S., Silverman S.M. Office-based opioid dependence treatment. Pain Physician, July 2012.
16. Schwartz, R.P., Gryczynski, J., O’Grady, K.E. et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. American Journal of Public Health, May 2013
17. Subutex and Suboxone Approval Letter. U.S. Food and Drug Administration (October 8, 2002). fda.gov.
18. Murthy V.H. Ending the Opioid Epidemic — A Call to Action. New England Journal of Medicine, 22 December 2016.

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Dustin Johnson Adding Second Caddy to Family

Dustin Johnson didn’t just take the 36-hole lead at the Genesis Riviera Open on Saturday; he and wife Paulina Gretzky announced there’s a new member of the family on the way.

Accompanied by the couple’s French bulldog puppy Perla, Gretzky appeared on Instagram holding up a photo of a sonogram of “Baby Johnson #2” and holding her already noticeable baby bump.

This will be the couple’s second baby, following son Tatum Gretzky Johnson, who turned two a month ago.

The pair have been engaged since 2013 but never married. Fatherhood has been grand for Johnson, who has won four titles since Tatum’s birth on January 19, 2015, including the 2016 US Open.

Paulina Gretzky is the daughter of Wayne Gretzky, the greatest player in NHL history.

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Trump International Opens in Dubai

While their father yells at the media, Eric and Donald Trump Jr. were having a bit more fun this week, travelling to Dubai to open the Trump International Golf Club in Dubai.

There’s been plenty of questions of who will run Trump’s various business units once he took office. US Presidents are forbidden to be involved in the business world or have any holdings therein while serving as Commander in Chief.

The golf club is being run by billionaire Hussain Sajwani, owner of DAMAC Properties, which developed the course.

It’s the 17th golf course opened by Trump’s organization across the world. It is a 7,300-yard, par 71 course inside the 42 million square foot Damac Hills master development.  Gil Hanse, who designed the 2016 Olympic golf course, is the course architect.

The club has a 30,000 square foot clubhouse – the biggest in Dubai, along with four restaurants, a state-of-the-art gymnasium, an infinity swimming pool, a pro shop, a golf academy, a double-sided driving range, chipping facility, and putting greens.

Restaurants include: Fifth Avenue, an imitation of Manhattan in the 1920s; The Terrace, which features American fare; The Ninth Sports Cafe, a sports bar with TVs all over the place and an extensive display of liquor; and Cabanas, which has an outdoor feature surrounded by water that makes you feel like you’re floating above the course.

 

 

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Dustin Johnson Ahead at Riviera

Rain has dictated much of the action at the Genesis Riviera Open this weekend, but it hasn’t deterred Dustin Johnson from taking a 1-stroke lead through two rounds.

The top five player is 10-under after consecutive 66s to take a 1-stroke lead over Pat Perez and Cameron Tringale with the third round due to start Sunday.

Johnson finished strong  in Friday’s Round 1 with four birdies on the back nine including back-to-back on 17 and 18. He replicated the feat in Saturday’s Round 2, recording birdies on 15, 17, and 18.

If he wins the title, he will take the No. 1 spot in the world rankings away from Jason Day, who has held it for almost one year.

“I want to win this tournament,” Johnson said. “Whether I get to No. 1 or not doesn’t affect me at all.”

Torrential rain and fog have severely diminished the tournament’s watchability. Play started an hour late due to fog on Thursday, then Friday’s second round was washed out by rains and wind. Two more hours of rain delayed Saturday’s play.

The best round on Saturday came courtesy of American Cameron Tringale, who fired a 7-under 64 to climb from 30th to a tie for second. Tringale started the day with three straight birdies on holes 3-5 and wound up with seven on the afternoon.

Pebble Beach champion Jordan Spieth is currently tied for 17th at 5-under after shooting 69-68.

The cut was set at even par. American Bubba Watson, a two-time winner and the defengding champion,

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New imaging technique may help some men avoid prostate biopsy

Men who have high levels of prostate-specific antigen (PSA) in their blood face troubling uncertainties. While it’s true that prostate cancer can elevate PSA, so can other conditions, including the benign prostate enlargement that afflicts many men as they get older. PSA levels also vary normally from one man to the next, and some men have unusually high levels even when they’re perfectly healthy. To rule out cancer, doctors might recommend a biopsy. Yet prostate biopsies pose risks of infection, and they can also miss cancer in men who truly have the disease. Most prostate biopsies are guided by transrectal ultrasound, an imaging technology that allows doctors to see the gland while taking tissue samples (called cores) with specialized needles. Tumors may not show up on ultrasound, however, so the biopsy needles might never hit a cancerous target.

A more precise way to investigate elevated PSA results

In January, British researchers reported results from the multi-center PROMIS study showing that a different imaging technology, called multi-parametric magnetic resonance imaging (MP-MRI), could allow some men with high PSA levels to safely avoid a prostate biopsy altogether. “If my MP-MRI was negative, I would not have a biopsy,” said Mark Emberton, M.D., director of the Division of Surgery and Interventional Science at University College London, and a co-author on the study. “And I would do that confidently.”

An MRI machine uses a very large magnet, a radio-wave transmitter, and a computer to construct detailed pictures of structures inside the body. MP-MRI is an advanced form of the technology that allows specially trained radiologists to detect prostate tumors. They can also gauge how aggressive the tumor is by looking at how tightly the cells are packed and how blood and water molecules flow through them.

Here’s how the study worked

During the study, researchers looked at how well MP-MRI performs at detecting prostate cancer compared to two different kinds of biopsies: a standard biopsy guided by transrectal ultrasound (TRUS-biopsy), and a “template prostate mapping” (TPM) biopsy that samples the entire gland at 5-millimeter intervals. TPM biopsy is the “gold standard” for diagnosing prostate cancer, but doctors rarely use it because it’s so invasive. If MP-MRI had failed to detect a prostate cancer identified with TPM biopsy, then the result would be recorded as a false negative.

The study enrolled 576 men with PSA levels ranging up to 15 nanograms per milliliter. MP-MRI correctly identified prostate cancers that were confirmed with TPM biopsies 93% of the time. That’s a significant improvement over TRUS-biopsy, which only picked up about half the prostate cancers detected with TPM biopsy. MP-MRI was also effective at identifying men who did not have clinically significant prostate cancers, recognizing them correctly 89% of the time. The results helped to confirm that MP-MRI is better at picking up aggressive tumors than it is at detecting low-grade cancers that might never be harmful during a man’s lifetime. Dr. Emberton emphasized that the cancers missed by MP-MRI were nearly all low-grade. “MP-MRI missed none of the high-grade, dangerous cancers and TRUS-biopsy missed many of them,” he said.

Promising, but proceed with caution

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org said the new study helps to show that MP-MRI provides important diagnostic information in a non-invasive way that protects men from infection and other biopsy-related complications. But he cautioned that all diagnostic methods employed today carry some risk of missing prostate cancers that are truly present. “Moreover, the radiological skills needed to interpret MP-MRIs correctly are in short supply,” he said. “And the technology’s cost must also be considered as its use becomes more widespread.”

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The underappreciated health benefits of being a weekend warrior

Follow me on Twitter @RobShmerling

What do you think of when you hear the term “weekend warrior”? Maybe it’s a person who exercises intensely on the weekend but is otherwise sedentary. I tend to think of an overweight, middle-aged guy resolving for the 100th time to get in shape. But because he only has time to work out over the weekend, that’s when he does it — or overdoes it.

Woe betide the weekend warrior

Weekend warriors with back pain, a pulled muscle, or other “overuse” injuries are a common sight in doctors’ waiting rooms after they’ve tried to do too much in too little time. That’s why most experts recommend regular exercise most days of the week rather than just on weekends.

A new study’s new take

Despite the injuries commonly associated with the weekend warrior, a new study finds that weekend warriors may be on to something. As published in JAMA Internal Medicine, weekend warriors who met recommended exercise guidelines (including those who exercised just once or twice a week but did so vigorously for at least 75 minutes, or at moderate intensity for at least 150 minutes) had a reduced risk of death from cardiovascular disease, cancer, or other causes.

Here’s some more specific information about this study:

• More than 63,000 adults in England and Scotland were surveyed about their health and physical activity between 1994 and 2012.
• Nearly two-thirds of study subjects were considered inactive — 11% were regularly active and about 4% were “weekend warriors.” The rest were “insufficiently active,” meaning they were not inactive but did not meet recommended activity guidelines.
• Data regarding their deaths from any cause, cardiovascular disease, and cancer were also collected over this time period.

Compared to less active adults, weekend warriors had a 30% lower risk of death from any cause, a 40% lower risk of death due to cardiovascular disease, and an 18% lower risk of death due to cancer. While regular exercisers had lower death rates than weekend warriors, the differences were quite small.

Some caveats

Of course, a study of this sort can only describe an association between exercise and death rates, but it cannot prove that the exercise actually caused the health benefits. It’s possible that something other than exercise — perhaps a difference in diet not captured by the surveys — accounted for the lower death rates among the weekend warriors. Activity levels were self-reported and could be inaccurate. In addition, 90% of the study population was white. If other ethnic groups were included, the results might have been different. Other information not included in this study would be of interest, including the type of sedentary activities (such as sitting), effects on other health outcomes (such as mental health, arthritis, or diabetes), and rates of injuries related to physical activity.

Still, this study is among the first to suggest that weekend warriors may get a similar benefit from their schedule of exercise as those working out more regularly. This study also supports current exercise guidelines that recommend 75 minutes of vigorous exercise per week or 150 minutes of moderate intensity exercise per week.

So, what does this mean for you?

In my view, this study is important. In the past, weekend warriors were encouraged to change their ways lest they wind up injured. And it has long been assumed that you can’t get much benefit by exercising just once or twice a week rather than daily or most days of the week. This new study should make us rethink that assumption.

If you’re a weekend warrior, the results of this study should be reassuring. But I see at least two important challenges:

• The weekend warriors in this study met or exceeded current activity guidelines — they probably exercised more, and more intensely, in one or two days than many people who work out only over the weekend.
• Injuries are particularly common among weekend warriors; unfortunately, this study did not collect information on the risk of injury among weekend warriors. Experts generally agree that warming up, stretching, and not pushing too hard, too fast are important preventive measures.

Perhaps the most important conclusion of this study is that inactivity is way too common and being active is what matters, not how often you exercise each week.

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Charles Darwin, Chagas’ disease, and the killer kissing bugs of California

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It is possible, although very unusual, to get Chagas’ disease in the United States. The medical journal Open Forum Infectious Diseases recently reported a case of Chagas’ disease acquired in California. A healthy 19-year-old student from the greater Los Angeles area donated blood, and tested positive for Chagas’ disease. (Blood donations in the United States are routinely screened for Chagas’ disease, as it is estimated that 300,000 Latin American immigrants in the United States have been infected with Trypanosoma cruzi.) He had never traveled to Latin America; his infection probably came from a kissing bug bite in his sleep during one of several camping trips in southern California. Tests showed no evidence of heart damage. He had a good response to four months of treatment with the anti-parasitic drug nifurtimox, although this drug gave him temporary side effects of anxiety and depression.

Kissing bugs are found in much of the United States. However, only kissing bugs in the southwest United States are highly likely to carry Trypanosoma cruzi. Kissing bugs in California and Texas may be especially likely to spread Chagas’ disease. In one study, 28% of kissing bugs from southern California and 55% of kissing bugs from northern California were carrying Trypanosoma cruzi. In the borderlands of south Texas, 57% of kissing bugs are infected with Trypanosoma cruzi.

The major reason why the spread of Chagas’ disease is rare in the United States is housing. Housing standards in the United States are generally higher than in affected parts of Latin America, and it is rare for kissing bugs to invade homes here. However, it is possible for kissing bugs to gain entry to American houses that are dilapidated, as happened in one case of human infection in Louisiana after Hurricane Katrina.  Bed bugs, which can transmit Chagas’ disease in laboratory experiments, are common in some parts in the U.S., but there is little evidence that they are an important real-world source of infection with Chagas’ disease.

Keeping Chagas’ disease at bay

There is an urgent need for more research into the spread and treatment of Chagas’ disease in the United States. The drugs used to treat Chagas’ disease are not well tolerated, and they are not effective in patients who have already developed heart damage. At present, your risk of getting infected with Chagas’ disease in the United States is very low, especially if your house or apartment is in good shape, and you avoid camping outside in the open. However, some scientists are worried that Chagas’ disease may become more common in the future. Increasing development in areas where kissing bugs are found may bring them in contact with humans more often. As well, the kissing bugs that carry Chagas’ disease could spread northward with climate change. As Darwin might observe, it’s an evolving situation.

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2017 update to the immunization schedule for kids

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Every year, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) update the recommendations for immunizing children from birth to 18 years. This past week, the latest changes were published.

The changes are usually small, and this year is no exception. But they are important — and they are a sign of how these organizations, and all the scientists who study immunization, take immunization effectiveness and safety very seriously. There is ongoing research to be sure that vaccines do everything we want them to do. As that research is done, discoveries are made that change what happens when kids come in for their checkups and shots.

Sometimes the changes in the schedule aren’t actually changes. Sometimes the experts want to emphasize something about a vaccine that not everyone knows — and sometimes they tweak the way the schedule looks to make it easier to read and understand.

Here are the latest changes, reminders and tweaks:

• There are two for the Human Papilloma Virus (HPV) vaccine:
  • A reminder that it can be given as early as age 9-10, something many people don’t realize
  • And a reason to start early: if kids get the first dose of vaccine before their 15^th birthday, they only need 2 doses (6 months apart) instead of the previously recommended 3 doses. Anyone who starts on or after the 15^th birthday still needs those three doses
• The LAIV or nasal spray version of the flu vaccine is officially out of the schedule (since it was found not to work very well)
• Babies should get their first dose of Hepatitis B vaccine within the first 24 hours of life, if possible, to give the best protection in case of an undiscovered infection in the mother.
• Pregnant adolescents (like all pregnant women) should get a dose of TdaP vaccine between 27-36 weeks of pregnancy.
• A separate column was added to the schedule for 16-year-olds to emphasize that they should get a booster dose of the meningococcal vaccine.
• A new tab was added to help doctors know which vaccines are recommended for children with special health conditions. For example, children with sickle cell disease, chronic heart disease, severe asthma, as well as certain kidney and immune system problems should get the PPV23 version of the pneumococcal vaccine along with the one routinely given in infancy.

The schedules, both for routine immunization and for catching up when kids get behind, can be found on both the CDC and AAP websites. Check them out, and let your doctor know if you have any questions.

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Snored to death: The symptoms and dangers of untreated sleep apnea

Sleep is a critically important component of human existence. On average, humans spend about 25%-35% of their lives sleeping. Sleep allows both the body and brain to rest and recover from the stress of daily life. As such, trouble sleeping can cause a range of health problems, and if left untreated dire consequences.

Longing for more sleep

There is a common misconception that there is an exact amount of sleep that the body requires. The necessary hours of sleep can vary, as some people can require as little as five hours or as much as nine hours to function optimally. In addition, too little or too much sleep can cause problems. The classic example is someone who sleeps in on the weekends. Although one may think getting more sleep than usual would leave a person feeling well rested, sleeping an extra 2-3 hours can actually cause the person to feel groggy and less rested.  For my migraine patients, both under and over sleeping can serve as triggers for more migraines. Naps can also be detrimental to sleep hygiene, as they often lead to poor sleep that evening.

Quality, not just quantity

Even if sleep duration is good, sleep quality can be quite poor. Sleep interruptions can fragment sleep. When a person goes back to sleep after an  interruption, it can take one hour to reach the restful part of the sleep cycle. Another interruption before reaching deep sleep will cause yet another delay in the cycle. People who wake up many times during the night can have some nights with zero hours of deep, restful sleep. Poor sleep quantity and/or quality can cause excessive daytime drowsiness (falling asleep while reading, or even driving), chronic fatigue, headaches, mood issues, irritiabilty, poor memory, and cognitive dysfunction.

Urine trouble

When discussing sleep interuptions, many patients will claim that they have to get up to use the bathroom, which is common, particularly for elderly patients. In reality, the bladder is rarely waking up a majority of these patients, and they instead are experiecing a spontaneous arrousal. After they wake up, they realize, “Ohh, there is some urine in my bladder…that must be the reason I woke up.” When there is disbelief, I suggest that the patient reduce fluid intake, and yet they still wake up with the same number of interruptions.

Raining cats and dogs

I fondly recall one patient who came to see me due to worsening headaches. She told me about how miserable she was from not only her daily headaches, but also from her constant fatigue and worsening memory. While we were talking, I could not help but notice the fur all over her black fleece and black pants. After making this observation, I asked, “Do you have a dog?” and she said, “Yes, I have two dogs and three cats.” I then asked, “Where do your pets sleep?”  She replied, “On my bed with me and my husband.” Given the PETential for sleep interruptions, I recommended that she stop sharing the bed with her pets, and keep them two closed doors away from the bedroom. Keeping them just outside the bedroom door would surely lead to clawing on the door and other noises that would interrupt her sleep. After following just this simple advice, she experienced a significant improvement of her headaches, fatigue, and memory. I, on the other hand, experienced a significant improvement of the amount of animal fur on the furniture and floor of my office.

Snore in trouble

Sleep apnea is literally when a person stops breathing during sleep. As a result, the brain undergoes repeated moments of suffocating. In popular culture, snoring is viewed as funny, and people often laugh when a snoring person lets out a sudden explosive snort. The reality is this loud snort is often the person gasping for air as the brain is not getting enough oxygen. Sleep apnea interrupts sleep for both the person and their bed partner. In the case of a female patient who’s husband refuses to get evaluated depite showing signs of sleep apnea, I often urge the patient to bring their husband with them to their next appointment with me. Whether it’s the patient or the spouse, I often hear the line “I have always slept this way.” When that happens, I explain that poor sleep is like alcohol. In our 20s drinking a six pack of beer would lead to a rough morning after, but the same six pack of beer in our 50s can require a week to fully recover. Likewise, recovering after an all nighter without sleep in our 20s tends to be much easier than trying to pull an all nighter in our 50s. That being said, younger brains tend to be more resiliant with toxic situations, like alcohol consumption and sleep dysfunction, than the same brains later in life.

If improvement of headaches, mood, energy, wakefulness, memory, and cognition are not movitvation enough, I also advise that untreated sleep apnea leads to an increased risk of stroke, heart attack, and dementia (brain damage). That usually gets people’s attention, and reduces the need for me to perform unnecessary surgeries like a husbandectomy to allow the wife with insomnia to get a good night’s sleep, and subseqently less headaches.

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Fabrizio Zanotti Rides Hot Hand to Maybank Title

There was no breaking of the dry spell for Masters champion Danny Willett, who instead saw Paraguay’s Fabrizio Zanotti race past him and the rest of the field to win the Maybank Championship, his second career title.

Zanotti eagled the 18th hole to shoot a dazzling 63, finishing 19-under par. The dramatic shot saw him hold off American David Lipsky by one stroke.

Zanotti shot a 9-under on Sunday with Lipsky at 5-under and Bernd Wiesberger third at 6-under to finish 17-under.

Willett wound up shooting a 1-over 73 and dropped into a tie for fourth.

Zanotti started the day in ninth place, shooting 70-69-67 over his first three rounds, but entering Sunday 6-under over his prior 19 holes.

He got hot three holes in with birdies on 3, 5, 6 and 8.  After a string of pars, he birdied 13, 15, and 17 before his fantastic eagle 3 on the 520-yard, par-5 No. 18 to grasp the title. His 10-foot eagle putt looked for a split second like it would lip out, but then dropped into the cup.

“It was probably the best round of my career,” Zanotti said. “It was a really good day, a really good week and I’m really happy.

“It was at the 15th where I thought I might be able to win, when I made birdie there. I thought, maybe I’ll have a chance if I make two more birdies, but I made a birdie and an eagle so it was great.

“To shoot nine under on the last day to win a golf tournament is incredible. I have been working a lot with my coach and with my team and I’ve been making some changes.

“This is because of all that hard work. I missed the last three cuts but I was hitting the ball well and was not unhappy. This week I just came here and tried to take it easy.”

 

 

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Spieth Cruises to Pebble Beach Title

Jordan Spieth played solid defense all afternoon to shoot a 2-under 70 and take the title at the AT&T Pro-Am by three strokes, finishing 19-under on Sunday.

It was his ninth win on the PGA Tour, making him just the second man since the end of World War II to win nine tournaments before age 24; the other is Tiger Woods.

In a bit of a quirk, it also gave Spieth a PGA win in every month of the season but August. His wins have come in : July, March, April, June, July, September January, May, and now February.

The lead was never less than three on Sunday, as he never made any mistakes, hitting 14 straight pars at one point.

“I don’t like boring golf,” he said. “But that’s what was needed today.”

Two-time champion Brandt Snedker made an early charge, birdying three holes through the first six to close the lead from seven to four. But he couldn’t keep up the pressure and finished fourth.

This is Spieth’s fourth top 10 finish in as many starts in 2017. He remains No. 6 in the world but could get as high as No. 2 with another win next week.

Ken Duke and Carson Daly won the pro-am.

Spieth is already tied for 13th in career PGA wins among active players with nine.  Also with nine PGA wins are Sergio Garcia and Bubba Watson

 

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