CONTENTS | SEPT | 2018
06 06
SPOTLIGHT
10 12
Vaccine Safety: Examine the Evidence
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OUTDOOR SPACES
18 20
Protecting Your Trees from Monsoon Storms
22
HAPPY HOUR
14 20
Vaccine Philosophy: Immunizing Parents Against Misinformation
GOING PLACES
It Was An Unexpectedly Charming Day Fall Is Coming, Really!
CRAFT
Unicorn Slime Recipe The Best White Wine You’ve Never Heard Of
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SPOTLIGHT
Vaccine Philosophy: Immunizing Parents Against M By Eliza Agrest Varadi, MD, IBCLC, FAAP Eliza Agrest Varadi, MD IBCLC, FAAP, a 2018 recipient of the Centers for Disease Control and Prevention Immunization Champion Award, is the American Academy of Pediatrics (AAP) Section on Early Career Physicians District IV Representative. Dr. Varadi is also a 2017 President’s Award recipient from the South Carolina chapter of AAP and Founder of Pelican Pediatrics in Charleston, SC.
I walk into the cozy lilac Breastfeeding Room in our pediatrics office, where I meet a prospective couple for their “meet and greet” appointment. The mom, seven months pregnant and glowing, is sitting in the comfortable breastfeeding recliner next to her husband. After giving an overview of our practice, touching on topics such as what to expect the first few weeks after birth, nursery safety and how to reach the doctor after hours, I ask if they have any questions. “What is your vaccine philosophy?” asks the mom. “Philosophy? My philosophy is science and evidence-based medicine,” I respond. “I advise vaccinating on time to protect your child, your neighbor’s child, and your community.” The couple considers my response. “What about all the information out there? All the stuff you read about on the internet?” the mom asks. I admit to the couple that I avoid reading internet blogs, where fiction often sounds so realistic and convincing, but I know parents may have questions after coming across misguided anti-vaccination messages.
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I tell them I also know that vaccines have been proven safe and effective, and that poorly conducted research claiming otherwise has been thoroughly disproved and retracted. I know that delaying or spacing out recommended immunizations, or skipping them, does absolutely nothing but expose the child and everyone around them to dangerous illnesses. And, I tell them, I know from personal and professional experience what happens when children catch one of these preventable diseases. It feels just like yesterday that I was sitting in room #2 in the Pediatric Intensive Care Unit with my then 2-year-old daughter, a chest tube draining the pus from her left lung. Outpatient antibiotics failed to help her recover from what appeared to be a pneumococcal pneumonia. It was that same intensive care unit where I trained just three years earlier.
Misinformation
The doctor taking care of my daughter at the time had been one of my attendings. “Just think about it this way,” he said. “Before the pneumococcal vaccine, we would see 10-15 of these pneumonias a month here. Now we see about 5-10 a year. Isn’t that great?” It is great, I thought, except when your child is one of the 5 to 10 children. I remember looking at my daughter, simply miserable with that chest tube in her side restricting her movements. I’d done all I could to protect her, getting her immunized on time, but she was one of the unfortunate few who catch the disease anyway. How could any parent knowingly put their child at risk for this? Or an even worse disease, like meningitis? It is unfathomable to me.
>>>>
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SPOTLIGHT
One of my patients had pneumococcal meningitis just last year. He came from a country where the vaccine against it is not routine, though he had all his other vaccines. He received his first pneumococcal vaccine in my office just a few weeks prior. He was due to come in for his second just a few days after he ended up catching the disease. Imagine how many children could have caught it sitting in the same waiting room as him, had I not insisted all my patients vaccinate. Then those children would expose other kids in their homes, schools or daycares.
“This is why it’s so important for both of you to get you TdaP shot,” I tell the parents. “Oh, and so should any grandparents or other close family members, as well.”
So, I tell the couple about my daughter’s experience, and the patient with pneumococcal meningitis.
Yes, I replied.
“Vaccines have so successfully reduced the number of infectious diseases striking U.S. children, people often forget how serious they can be. As we talk with parents about the sound science behind vaccines and the immunization schedule, we also need also to share our stories about children who’ve caught these dangerous illnesses.” I also tell them about one flu season when I witnessed 2 healthy teenagers die from the flu after several weeks on a ventilator. Neither had been vaccinated. I tell them about the 1-year-old patient who barely survived the flu having to go on ECMO. He was not fully vaccinated. And I tell them about an 8-week-old boy with pertussis I treated a few years ago. The baby was too young to be vaccinated, and likely caught pertussis from an unimmunized family member. With each of the baby’s violent coughing spells, which left him exhaustedly gasping for air, we would all gather--doctors, nurses, respiratory therapists—to debate whether we should intubate or not.
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After an awkward pause, the mom shows me a copy of a delayed vaccination schedule circulating on the internet. “So, you don’t think we shouldn’t separate vaccines as suggested in this popular schedule and instead get everything on time?”
“And please remember to get your Tdap vaccine and ask all family members to get it. You can get it here in our office, the pharmacy across the street, your doctor’s office or the health department. Oh, and since your due date is in September, make sure y’all get the flu shot as soon as it comes out.” Vaccines have so successfully reduced the number of infectious diseases striking children in the United States, people often forget how serious they can be. As we talk with parents about the sound science behind vaccines and the immunization schedule, we also need also to share our stories about children who’ve caught these dangerous illnesses. In this way, we help immunize parents against the epidemic of misinformation circulating on the internet. I guess you could say that is my vaccine philosophy.
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SPOTLIGHT
Vaccine Safety: Examine the Evidence By the American Academy of Pediatrics (AAP)
The American Academy of Pediatrics, an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. For more information, visit www.aap.org and follow us on Twitter @AmerAcadPeds.
The safety and effectiveness of vaccines are under constant study. Because vaccines are designed to be given routinely during wellchild care visits, they must be extraordinarily safe. Safety testing begins as soon as a new vaccine is contemplated, continues until it is licensed, and is monitored indefinitely after licensure.
Over the past decade, questions have been raised regarding a relationship between autism and vaccines. Along with general safety concerns, parents have wondered about: • Too many vaccines overwhelming the immune system • The measles, mumps, rubella combination vaccine (MMR) • The preservative thimerosal, which was never present in MMR but was present in several vaccines used in the 1990s—it has since been removed from all routinely used childhood vaccines with the exception of flu.
The American Academy of Pediatrics (AAP) works closely with the Centers for Disease Control and Prevention (CDC) to make recommendations for vaccine use.
Research has been conducted on all of these topics, and the studies continue to find vaccines to be a safe and effective way to prevent serious disease. This article lists those studies and provides links to the publications to allow parents—and all those who administer or recommend vaccines—to read the evidence for themselves. These studies do not show any link between autism and MMR vaccine, thimerosal, multiple vaccines given at once, fevers or seizures. Note: This is not an exhaustive list—vaccine safety studies are constantly being conducted and published and may not be reflected here. Please examine the evidence for yourself. If you have any questions, speak with your pediatrician. Studies About General Safety & Number of Vaccines https://www.healthychildren.org/English/safetyprevention/immunizations/Pages/Vaccine-StudiesExamine-the-Evidence.aspx
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GOING PLACES
It Was An Unexpectedly Charmin By Irene S. Levine. Contributed by Ford’s World Travel with offices in Sun City and Sun City West. Ford’s Travel consultants have a combined 350 years of global expertise to help you plan your next vacation. Call: 623-933-8256 or visit: fordstravel.com.
Navigating Europe’s capital cities and quaint villages aboard a river cruise offers a harmonious balance of thoughtful planning and surprising delights. Irene S. Levine reveals the best of both worlds she discovered on a recent river cruise.
When you envision your vacation, you rarely imagine it in the rain, but a brief downpour during our walking tour of Bruges, Belgium, didn’t dampen our spirits. We had just finished exploring the city’s architectural and historical gems when our local guide handed out oversized umbrellas, pointing out cafés on the main shopping street where our small group could escape the rain. My husband and I stumbled into a cozy restaurant. Chatting with locals, we ordered what turned out to be the best mussels we had ever tasted — accompanied by Belgian beer, of course. Just as it was time to rejoin our group, the sun added a glimmer to the
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rooftops of the medieval buildings, cobblestone streets and winding canals that created the sensation of stepping into a fairytale. It was an unexpectedly charming day, but also perfectly befitting our seamless, eight-day voyage — an ideal balance of complimentary guided activities and free time to seek out local experiences, and we never had to worry about a single detail. Our 164-passenger ship sailed smoothly as we slept and docked close to city centers and villages waiting to be explored. Though we gravitated toward active excursions, others expressed appreciation over small-group options that appealed to gentle walkers, as well as to “late-starters” who preferred to remain on board a little longer. For us, a true highlight was the 80-acre Keukenhof gardens in the western Netherlands, where we meandered through the gardens and pavilions with seven million tulips and hyacinths in bloom. We especially enjoyed having access to two dozen bicycles on board our ship, which we used to traverse the historic Dutch town of Willemstad on our own.
As we mingled with other guests, we heard tales of other enchanting European river cruise excursions, from strolling the sloping hills and cobblestone streets of Budapest on a Danube cruise to sipping crisp Alsatian wines in the French village of Colmar on a Rhine cruise. Indulgent bliss followed us back on board, where our chef made meals decadent and varied, and we could choose among multiple dining venues. At The Chef ’s Table restaurant, we watched the chef in dazzling action from our 24-seat table. He plated specialties such as marinated salmon accented with a lemon, pepper and mango salsa, followed by a perfectly grilled beef tenderloin
ng Day... and porcini potato, each course paired with an exquisite wine. We somehow managed to save room for a chocolate tart with a millefeuille of red currant and mascarpone. Personal touches and memorable moments extended throughout our trip. Before dinner each evening, Rolf, our multilingual cruise manager, briefed us on the history, culture and customs of upcoming destinations. We felt taken care of — by him, the welltrained crew and the knowledgeable local guides — all of whom not only met our needs but also anticipated them. At breakfast, I even teased one server that she was spoiling my husband by bringing him oatmeal already topped with brown sugar. Each evening, we retired to our twin-balconied stateroom that had all the amenities of a five-star hotel, including a marble bathroom with multi-jet showerheads. Passing up the television shows and movies on the high-tech infotainment system, my husband spent every night glued to the closed-circuit bow camera so he didn’t miss any of the picturesque views on shore.
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OUTDOOR SPACES
Fall Is Coming, Really! By Anesia St. Clair Anesia is a licensed contractor and owns Pure Patio, a design center and retail store in Goodyear, Arizona.
Here we are in the thick of our monsoon season, enjoying the diversity of our daily weather. Unless you have a pool, it’s safe to say not a lot of time is being spent out in your back yard right now. There are a few things you can be doing now to maintain what you have and prepare for our wonderful fall. If you have your patio furniture cushions covered, bagged, or stored in the garage, check on them. You want to make sure there’s no mildew, insects, rodents, or smell causing a problem. We have high humidity right now, and that can lead to discoloration and an attractive environment for unwelcome visitors. If you have patio umbrellas outside that are cranked down and tied closed, or wrapped in a cover, they will become very smelly this time of year. Open up umbrellas and let them dry after the rain. Once temperatures cool and you’re comfortable doing some work outside, you’ll want to clean the fabric. If your umbrella is made of Sunbrella material, it’s recommended to wash with a diluted bleach solution if you find a mildew smell in it. Check any outdoor fabric for bird droppings and remove as soon as possible to prevent staining. When droppings are dry, you can scrape them clean with the edge of a credit card. Spot clean with a fabric cleaner or solution of very diluted dishwashing soap. Keep sticks and leaves off of your hardscape areas. Organic material that is left in place and then rained on may begin to decompose and discolor your patio. Keep your hardscape areas blown off and hose off from time to time.
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Time to ramp up the pest control efforts. Our humid weather can bring about an abundance of crickets and scorpions, as well as other pests. When you start seeing them in the house, call your pest control company for service. They can quickly multiply so try to be very proactive on this one. Consider turning off your irrigation system during our rainy season. You may be surprised how wet the soil remains for a period of time after it rains. Roots like to dry out completely between watering events. If you’re irrigating over the top of rain, the roots are too wet. Many of our plants and trees are planted too deep into the ground. This practice combined with overwatering can lead to rot and a clean break right at the base. Prune your shrubs that need downsizing one more time before fall. They still have time to grow back and bloom (if applicable) before their growth slows down significantly. If you wait too long, you may suffer from colorless shrubs this winter. It’s best to complete any sizeable pruning now and then add a minor nip-tuck in another month if necessary. Some species that are in their prime bloom season may be left alone for now. After the blooming is complete, you can shape them this fall since winter isn’t their season for blooming. >>>>
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OUTDOOR SPACES
Fertilize your Bermuda grass one more time. Apply a balanced N-P-K blended fertilizer that you find at your local home improvement store for a continued green lawn. Once it’s September, refrain from fertilizing anymore. You don’t want to stimulate any more growth too close to dormancy. If you’re planning to overseed with winter rye, you want the Bermuda to be weakened when you scalp it. You’ll fertilize after your winter rye germinates and it will overtake the lawn quickly. Lastly, we frequently experience blowing dust at this time of year. It’s very fine and coats over everything. Consider hosing your house, perimeter walls, walkways, and driveways. Keep your air conditioner units clean as well. It’s easy to forget how dirty everything is until you clean it. You’ll smell the thick odor of dirt as you clean and you’ll surely notice the vibrant, clean colors when you finish. We have one more month of toasty weather. We should notice a change with breaks under 100 degrees and cool nights by the end of September. Taking a few steps now to get ready can help you get excited for our perfect seasons!
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Consider turning off your irrigation system during our rainy season. You may be surprised how wet the soil remains for a period of time after it rains. Roots like to dry out completely between watering events. Roots like to dry out completely between watering events. If you’re irrigating over the top of rain, the roots are too wet.
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OUTDOOR SPACES
Protecting Your Trees from Monsoon Storms By Anesia St. Clair Anesia is a licensed contractor and owns Pure Patio, a design center and retail store in Goodyear, Arizona.
Our recent storms have brought the heart-breaking loss of many trees in our communities. To give your trees the best chance at surviving high winds, there are a few things you can do: • Water deep and infrequent to encourage a deeper root system. Most trees prefer 70-80 gallons per watering, and the roots should completely dry out between waterings. Add up the number and capacity of your drip emitters in order to know what your ideal watering time should be. • Place your drip emitters near the tips of the roots, which are approximately beneath the ends of the widest branches on the canopy. • On young trees, resist the temptation to prune the branches along the lower trunk. Leave branches on the trunk all the way to the ground for one or two years after planting, then gradually remove and shape from there. This will promote a thicker, stronger trunk. • Remove the center nursery stake that runs up the trunk of the tree at planting time. Stake with two or more stakes at about 10:00/2:00 angles, starting a foot or more away from the base of the trunk. A center stake will keep the tree trunk unnecessarily weaker. • Do not allow staking wire or tubing to become tight around the trunk. Allow plenty of space for the tree to sway in
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the wind, which helps it develop strength. Done correctly, stakes should be removed after two growing seasons have passed. • When pruning, remove no more than 25% of the tree at one time. This will allow wind to pass through the tree while discouraging dense re-growth. It also helps prevent sunburn. When you look at the trees in the natural desert and realize that they survive on rain water only, no fertilizer, no pruning, and no staking, we might question how beneficial our maintenance practices are. Of course we like our trees to look much more neat and tidy than they do in the natural areas, but less can be more to some degree.
CRAFT
Unicorn Slime Recipe By Vanessa Coppola Visit www.seevanessacraft.com for more crafts and recipes.
School’s back in session, and soon you may be hosting a sleepover, birthday party or other kid-filled get together. Craft up a batch of unicorn slime to keep them busy! This recipe only requires two ingredients and you won’t believe how easy it is to make. Mix and match glue colors to personalize. INGREDIENTS Elmer’s Classic Glitter Glue (pink, purple and aqua) Liquid Starch (5 tablespoons per 6oz glue bottle)
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INSTRUCTIONS Step 1 Pour one bottle of glue in a mixing bowl. Step 2 Add 5 tablespoons of liquid starch into the glue, mixing in between each tablespoon with a fork, until your glue starts to look like slime. Step 3 Remove the slime from the bowl, leaving behind any excess liquid, and start kneading and squishing with your hands. If it’s still too slimy, add a little more liquid starch. Step 4 Keep kneading and squishing until the slime is smooth and stretchy. Step 5 Repeat steps 1-4 for the remaining bottles of glue. Mix the colors together and play!
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HAPPY HOUR
The Best White Wine You’ve Nev By Michael Apstein You can find more reviews from Michael Apsteine and other talented writers at www.winereviewonline.com.
Although the Romans cultivated Ribolla Gialla and the Venetians supposedly used the wine made from it to settle debts, I could not have written this column 30 years ago because much of the area where it is grown was in then-Communist western Yugoslavia, now Slovenia, and off limits to Westerners. Furthermore, quality wine was not a focus under the Communist regime and growers were forced to sell most of their grapes to the government co-op, which turned them into an anonymous blend. The epicenter of Ribolla Gialla or Rebula, as it is known in Slovenian, is the small Collio area of northeastern Italy spilling over into the Brda (pronounced ber-da) region of Slovenia. There, among the steep hillsides (collio, as they are called in Italian and brda in Slovenian) the grape thrives. The Slovenians, finally unshackled, were able to bring the wine back to its former glory. It’s a fascinating area of winding roads, a unique sedimentary soil, locally known as opoka (in Slovenia) or ponca (in Italy), and vineyards etched into the hillsides, the combination of which provides excellent drainage and limits the vines’ natural vigor. Valeria Simčič, who along with her husband Marjan, owns the top Brda estate, Marjan Simčič, emphasizes the importance of elevation, noting that Rebula planted in the plains or even lower on the slope results in high yields, which in turn, results in dilute, innocuous wines.
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Whether in Italy or Slovenia, the topography is the same with the shuttered border-crossing military outposts the only reminder of the political divide of the past. The remaining difference is that the Italian version is labelled Ribolla Gialla (yellow ribolla, pronounced, ree-bow-la jala) and the Slovenian one, Rumena Rebula (yellow Rebula) or more usually, simply Rebula. Growers frequently own vineyards in both countries, which presented a problem for those on the Slovenia side in the past because they needed special government permission to take their tractors across the border. The current difficulty for both the Italian and Slovenian producers is how to label a wine made from grapes grown in two countries, since many producers’ own vineyards on both sides of the border. There are basically two styles of Ribolla Gialla depending on how the winemaker decides to make the wine. The crisp and lively “classic” style results from traditional white winemaking practice of pressing the grapes and fermenting the juice, in the absence of skins, in stainless steel vats. A denser--some would say richer or more complex, others might say heavier--style results when the winemaker treats these white grapes as though they were red and uses the traditional red-wine process of fermentation of the juice in contact with the skins in oak vats for days to weeks. In the extreme case, exemplified by Radikon and a few other producers, the juice and skins ferment together for months, resulting in orange- or amber-colored wine.
ver Heard Of Saša Radikon credits his father for undertaking prolonged fermentation and aging in contact with the skins in the 1980s. As he tells it, his father, Stanko, wondered why the wines made in the usual way for white wines tasted so hollow when the grapes themselves had so much flavor. He concluded that by separating the juice from the skins, producers were discarding the best part. (At that time, grappa producers were paying higher prices for these discarded skins since they contained so much flavor.) Although many producers believe some skin contact enhances the flavor profile, few undertake such protracted skin contact as Radikon. Marjan Simčič, whose eponymous winery is one of the best in the region, has gradually reduced the amount of skin contact during fermentation over the last 20 years and has settled on 16 days, the same duration as for his red wines, though in weaker years he reduces it further. Even for his “classic” Rebula, he allows a couple of days of skin contact but emphasizes that is not to extract flavor from the skins, but only to allow the natural yeast--he never uses commercial yeast--to multiply and start fermentation smoothly. At the ends of this spectrum of styles--think Jermann and Radikon--the resulting wines are very different, which, ultimately, I think presents a major problem for the category. In short, there is simply no way for consumers to know what they are getting just by looking at the bottle. A potential solution is to expand what Al Bagatto, a top-notch restaurant in Trieste, does with its outstanding wine list. They put a barrel icon next to the Ribolla Gialla wines that were barrel-fermented. Producers could consider similar icons on their labels to alert consumers as to the style of the wine. Until then, consumers just need to remember individual producers and which wines they prefer. It’s no different selecting Rebula or Ribolla Gialla than any other wine: in the end, it’s producer, producer, producer. A third style of Ribolla Gialla, in the form of a sparkling wine, has been gaining in popularity, comprising about 7 percent of the Slovenian production to almost 25 percent of it over the five years from 2012 to 2017, according to Professor Denis Rusjan, of the University of Ljubljana. Whatever the style, even those that see little or no skin contact or barrel aging, the wines have a captivating and palate-caressing texture, offset and amplified by brilliant acidity. The best of them have a depth, complexity and richness not usually associated with Italian white wines. Though there’s an occasional Ribolla Gialla or Rebula that has a stated-alcohol of 14 percent, most of them, despite their richness, weigh in at 12.5 or 13 percent. They are substantial wines, in the best sense, capable of holding up to robust seafood stews but graceful enough not to overpower more delicate fish, such as branzino. In short, they are wines to savor, not to quaff.
classic style over the skin-contact barrel-fermented ones. Though that was generally the case, I was pleasantly surprised at the complexity, depth and balance of many of the wines that had seen skin contact and barrel aging. That style of wine benefits enormously from a year or two of bottle age that allowed the tannins--both from the grape skins and from the barrels--to integrate into the wine. That’s usually not a problem for consumers here in the U.S. because most of the wines commercially available on our shores already have a couple of years of bottle age. Indeed, a barrel sample of Radikon’s 2017 Ribolla Gialla was harsh and practically undrinkable, whereas their deeply amber 2011--the current vintage on the market--was balanced and glossy. In contrast, the classically-styled wines from the 2016 and 2017 vintages, such as Collavini’s 2016 “Turian” from the neighboring DOC, Friuli Colli Orientali, Jermann’s 2017 Ribolla Gialla labeled Vinnae (IGT Venezia Giulia), or Erzetič’s 2017 Rebula (Goriska, Brda) were deliciously refreshing now while conveying the unusual and welcome mouth-filling texture. I have listed below some producers who I can recommend. Many of them make a range of wines, from the classic to the barrel-aged extended skin contact style so until they put icons on the label, inquiring when you buy a bottle is a good idea to know exactly what to expect. Dolfo (their 2017 classic has purity, freshness and a welcome hint of bitterness in the finish), Erzetič (their 2017 classic Rebula has palate-awakening acidity the complements its richness), Ferdinand (a 2016 oak-aged Epoca was mineral-y and citrus-tinged, while their 2007 Epoca was mature and fresh), Gravner(like Radikon, known for orange or amber wine, may not be for everyone), Jermann (their vibrant and beautifully textured 2017 Vinnae is a blend of mostly Ribolla Gialla [90%] with Riesling and Friulano; the 2008, bottled under screwcap, has gorgeous development while maintaining freshness), Keber (similar style to Gravner and Radikon), Klet (a co-operative, but unlike the ones of the Communist era, this one focuses on quality), Radikon (as Saša Radikon is quick to point out, their wines are not to everyone’s taste), Edi Simčič (no relation to Marjan Simčič, it just happens that Simčič is a common Slovenian name), Marjan Simčič (their single vineyard bottlings under the “Opoka” label, are stunning and will convert those who have a prejudice against extended skin-contact wines), and Zanut (whose classic style combines power and grace). Ribolla Gialla or Rebula are not widely available, but they are worth the search. Except for Radikon’s whose extended aging creates extra expense, most of the Ribolla Gialla or Rebula cost less than $40 a bottle, retail.
My prejudice before tasting a range of them recently at a conference devoted to the grape held in Brda was that I would prefer the
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