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HEALTH • MEDICINE • WELLNESS • HEALTH • MEDICINE • WELLNESS • HEALTH • MEDICINE • WELLNESS • HEALTH • MEDICINE • WELLNESS • HEALTH • MEDICINE • WELLNESS • HEALTH • MEDICINE • WELLNESS • HEALTH • MEDICINE • WELLNESS • HEALTH • MEDICINE • WELLNESS • HEALTH • MEDICINE • WELLNESS

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TO FLOSS OR NOT TOThat isFLOSS the question You heard or read the news story a couple weeks ago: there is no clinical proof that flossing reduces the risk of cavities or improves gum health.

Seriously?

Friends and readers, this too shall pass. It will pass in the same way that one week we’re told that research proves coffee is the greatest elixir of health ever, and the next week it’s no better than drinking poison.

Round and round she goes, where she stops no one knows.

In the world of flossing (the former world of flossing?) the debate once raged: should you floss before brushing or after?

If you’re a floss-first-thenbrush aficionado, conduct this simple experiment: brush first, then floss. You’ll be amazed how often brushing leaves food particles behind that are removed by flossing. There is the clinical proof the news reports couldn’t find. It’s simple logic any third-grader would understand.

For the record, the American Dental Association continues to endorse flossing. +

AUGUST 19, 2016

WEIGHT

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F RE E! But the fact that it may not be easy doesn’t mean hy is losing weight so difficult? Or more it’s impossible. Countless people have lost weight correctly, why is it so hard to lose weight and kept it off. and then not gain it back?

S I E What’s the secret to success? And why do so Earlier this year researchers from M 3 OF 1/ many fail? the National Institutes of Health (NIH) Part of the answer lies with science, part of it evaluated contestants from Season 8 (2009) of with simple human nature. the TV show The Biggest Loser. The sad findings One of the surprises that arose from the findings were that despite the admirable successes on the AN AMAZING of the NIH study was something that should show itself (which is taped over a period of several TRUE TALE by Ryan Heckendorn the monkey off the back of people who beat months), regaining most or all of the lost weight 10 take cents themselves up after regaining lost weight.

— and more — is the norm.

After The Biggest Loser competition ended, One contestant began the show weighing 444 the study found that resting metabolism for the pounds. Although he slimmed down to a relatively participants — the amount of calories they burn svelte (for him) 289 pounds, the follow-up study while doing nothing — had dropped, and dropped six years later found him tipping the scales at 450 dramatically. One of the contestants, for example, pounds. Another started the show at 442 pounds, How is Examiner reader Ryan was burning 800 fewer calories per day than went to 234 by the end of the competition (that is Heckendorn doing, one year would be normal for someone his size. Others a 208-pound loss!), but was back up to 390 pounds after he went from 257 pounds experienced a similarly steep drop. This was a six years later. down to 172? See page 16. surprise, since the expectation was that a crash These were obviously highly motivated people. program like The Biggest Loser would cause only a temporary drop No one could call someone a slacker who dedicated months of in metabolic rate. Instead, it was long-term. their life to weight loss, and who successfully shed more than 200 Obviously, a body burning 800 fewer calories per day means pounds. that, all other things being equal, a diet to maintain the lower But it doesn’t take an NIH study to reveal that weight loss weight would have to be reduced by a corresponding 800 calories followed by weight gain is common. Most of us know someone every day. That’s a lot, especially when you consider the “ideal” who has been there, done that. In fact, we ourselves are often that someone.

Please see WHY SO HARD? page 16 +

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AUGUSTA MEDiCAL EXAMINER

AUGUST 19, 2016

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LOOKING FOR A DOCTOR? SEE PAGE 15

You can’t. You just can’t help the way you think you might be able to. You tried for years and it did no good except helping them get drunk and high longer. Many if not most of you reading this column are enablers or provokers – that’s why this subject captured your attention! So, if you keep doing what you’ve always been doing, you’ll keep getting what you’ve always been getting. Nowhere but frustration.

So here are a few ideas of how to help your addict/alcoholic friend/family member — and yourself: • Get a life! I once asked a lady who was obsessed with her addicted son and husband, “If I gave you $2,000 and a free rental car, what would you for yourself this coming weekend?”

She thought for a long time and replied, “I haven’t a clue!” Her life had been so wrapped around her ill family members for so long that she had lost herself. Your recovering loved one would love nothing more than to see you LIVE! Get a hobby, take some trips, join a book study group, find a church, and start looking out for #1!

• Don’t crowd or smother your friend/relative! In a group session when I hear a Smother-Lover speaking, sometimes I go to their chair and literally stand in front of them, place my arms on the back of the chair, and get as close as I physically can without touching them and ask “How does this feel?”

NOBODY likes it! Most say they want to push me away.

Nobody likes to feel suffocated. That’s how the one in recovery probably feels when it comes to you trying to control and protect them in early recovery. You will pay a high price for this behavior if you continue it. Give them some space. Let them show you what they can do.

• Ask your friend how you can help! What a novel idea!

See YOUR BRAIN page 5

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AUGUST 19, 2016

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AUGUSTA MEDiCAL EXAMINER

The

PROFILES IN MEDICINE

T

Advice Doctor

presented by Queensborough National Bank & Trust Co.

Double Feature

he face you see here is a familiar one around Augusta. But when you think of Dr. Bill Karp, is it as a doctor? Or as a jazz musician?

Both careers have a long history for Dr. Karp.

Born in Brooklyn in 1944, Karp stayed in-state for his Bachelor of Science degree in chemistry, then journeyed to The Ohio State University where he earned a Ph.D. in Physiological Chemistry and did postdoctoral research in perinatal nutrition in 1970.

The Ohio school was well-respected for research Karp was interested in: nutrition, specifically fetal and neonatal metabolism of fats and lipids.

When Dr. Alex Robertson was recruited from Ohio State to chair MCG’s Department of Pediatrics, he in turn recruited Karp to organize the department’s clinical research efforts.

Karp imagined his sojourn in Augusts would last two years or so.

It has been 45 years. So

Bill Karp, Ph.D., D.M.D. far.

The move to Augusta was a good one for Karp in several ways.

“My fi rst wife died in Ohio when I was 24,” he recalls. “Coming to a new place was a fresh start for me.”

Fortuitously, he rented an apartment on Hickman Road where, directly across the hall, lived a healthcare professional named Nancy who was a physical therapist and holder of a doctorate in health

education from UGA. It wasn’t long before Bill and Nancy were husband and wife.

Later, when Dr. Judson Hickey was recruited from the University of Kentucky School of Dentistry to create a MCG’s School of Dentistry, Karp became the director of its Nutrition Consult Service and its Nutrition Course (for MCG’s schools of Dentistry and Allied Health) for the next 20 years. Simulataneously, that’s where his D.M.D. was earned.

Now a Professor Emeritus, Karp is anything but retired. “I give Continuing Education and Continuing Medical Education courses all over the U.S. and Canada,” as well as at Augusta University for various student populations (OT, PT, RT, Dental Hygiene, Dietetic Interns and others).

“I’ve spoken in every major and minor city in the United States,” he says. “Do you how many cities that is?”

Please see PROFILES page 6

Editor’s note: this is the fourth installment in a monthly series presented by Queensborough National Bank & Trust and the Medical Examiner profiling exceptional physicians and others of note in Augusta’s long and rich medical history.

P R I VAT E B A N K I N G Queensborough Private Banking provides professionals and executives with a comprehensive approach to

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+ Dear Advice Doctor, I’m turning to you because I’m at my wit’s end about a situation in my family. My sister has always been very competitive and jealous, but it seems to get worse as time goes by — something I wouldn’t have thought possible just a few short years ago. The problem is I just got a job at the same place where she works — in a position higher than her. She has had a bee in her bonnet ever since she found out.

I don’t start for a two weeks, though. Do you think I would be wise to decline the job offer and keep seeking employment elsewhere?

— Hoping for Peace, Preparing for War Dear Hoping, This is one of those situations that can go from 0 to 60 in literally seconds, and you are justified to be concerned. Bee stings are a common source of allergic shock — called anaphylactic shock or anaphylaxis — and the reactions can range from itching and mild skin irritation to a life and death emergency. For some people, a bee in their bonnet — if it stings — can cause their tongue and airways to swell to such a degree that breathing is impossible.

Although prevention is the best course of action (perhaps lose the bonnet), there are other options available. One course of action for those with an identified severe allergy are usually advised to carry an epinephrine autoinjector at all times. A medical alert bracelet is also a good idea so that if the person cannot communicate, bystanders and emergency responders will know the source of the problem.

Finally, there are immunotherapy treatments available that are very effective at desensitizing people who are severely allergic to insect bites. Ask your doctor – soon! + Do you have a question for The Advice Doctor about love, life, personal relationships, career, raising children, or any other important life topic?

Send it to News@AugustaRx.com. Replies will be provided only in Examiner issues.

flexible, time-sensitive and highly competitive

DAVID D. BULLINGTON, JR.

Let CLIFF ECKLES and DAVID BULLINGTON help you plan and manage your unique financial needs.

AUGUSTA

financial services.

E. CLIFFORD ECKLES, JR.

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AUGUST 19, 2016

AUGUSTA MEDiCAL EXAMINER

#27 IN A SERIES

Who is this?

OLD NEWS

+

POINTS OF INTEREST TO FORMER KIDS

by Trisha Whisenhunt, Senior Citizens Council

A

T

he earliest installments of this series were subtitled, “Important People You’ve Never Heard Of.” As time went on and some very well-known medical pioneers were profiled here, that definition didn’t always apply. But it would certainly fit the esteemed medical scientist pictured above. Although he’s known as the founder of an entire branch of biology and medicine — endocrinology — his name is hardly well-known.

In fact, he had two last names: the one he was born with and the one he died with.

Born as Edward A. Schäfer on June 2, 1850 in Hamburg, Schäfer moved to London as a young man and became a naturalized British citizen. By age 18 he was a student at University College London, studying under the noted physiologist William Sharpey. In 1873 Schäfer became the fi rst so-called Sharpey Scholar. The following year he was appointed Assistant Professor of Practical Physiology and then in 1878, at only 28 years of age, was elected to the Royal Society, the world’s oldest organization (founded in 1660) for promoting and recognizing scientific knowledge, fostering international research cooperation and promoting public interest in science.

Among Schäfer’s pioneering medical milestones: he discovered and demonstrated the existence of the adrenal glands and adrenaline; coined the word “endocrine” for the secretions of ductless glands; and also coined the word “insulin” after identifying it in the pancreas as the single substance most directly connected to diabetes.

Schäfer’s career was marked by many honors, as prestigious medals and degrees were awarded to recognize his contributions to medicine and the understanding of how the human body functions. He was knighted in 1913. A textbook he authored in 1885, Essentials of Histology, was still in print sixteen editions and nearly 70 years after its publication.

Schäfer also in 1861 demonstrated an early version of CPR which became the gold standard technique for artificial respiration in drowning cases for nearly 50 years.

Perhaps the most poignant aspects of Schäfer’s career were in his personal life. He outlived three of his four children, two of the deaths being sons lost in World War I combat. His oldest son had been named John Sharpey Schäfer in honor of his beloved college professor and doctoral advisor. Upon his death, Schäfer legally changed his name (in 1918) to Sharpey-Schafer.

The change had three reasons: in remembrance of his son, to perpetuate the memory of his teacher William Sharpey, and also because at the time, according to Sharpey-Schafer’s 1935 obituary in the British Medical Journal, “anyone with a German name was regarded with suspicion and hostility.”

A measure of the high regard of his colleagues was a gift given to him upon his retirement in 1933, a leatherbound volume containing 29 scientific papers published by his past and present research assistants. Each contributor personally signed the book, which required it to be sent around the world before being presented to Sir Edward Sharpey-Schafer. +

WHAT TO DOWNSIZE FOR RETIREMENT

re you close to retirement and looking forward to finally doing the things you want to do instead of what you have to do? Along with that comes the list of the things to pass on to your children or let go. This can be a difficult task because of emotional attachment or finances. Many people decide well in advance to ask their children what they would like to have. Some items you never thought your kids would want may have sentimental value to them. Ask them before discarding things you think are worthless.

The 12 most common areas to downsize: Sell the large home and buy smaller. If you are beyond the point where the family congregates for holidays, it may be time. Renting is another choice, as is assisted living.

Pay off any outstanding debt. Now would be a good time to pay off credit cards and other debts. For some this may not be an option but if it can be done, it is a good way to begin the next chapter of your life.

Purge your clothes closets.

The rule of thumb is, if you haven’t worn it in the last year, get rid of it. You can have a yard sale, hand it off to family and friends or donate to your favorite local charity.

The added benefit of this last suggestion is you can claim a portion of the value of your clothes on your taxes.

Clear out any off-site storage unit. Not only will this be one less thing to have to deal with when the time comes, it will also save you the rental fees.

Get rid of your unused exercise equipment. Has your treadmill become a clothes tree? Enough said.

Kitchen gadgets. The question you need to ask yourself is: when was the last time I plugged it in?

Can you do without that second car? The

average yearly cost of keeping and maintaining a car can be expensive. If you have more than one, taking a hard look at whether or not you can manage with just one vehicle may be the way to go.

Childhood memorabilia (in other words, memorabilia from your children). Pass it on. You may want to keep a few very special things, perhaps one or two per child but for the most part, let the kids have it.

Pare down the furniture. A smaller house will of course, mean less furnishings.

Sort through your books, magazines and DVDs. Donating to your local library is a sound option.

Your fi les. Other than the last 7 years of tax papers and other legal documents, why are you holding onto it?

Holiday decorations.

This can be an emotional area. Again, passing these memories onto the children is the best answer. Keep just a small portion for your future expression of holiday cheer.

It’s never easy to let go, but once done it can be very liberating.

The sooner you start the easier it will be. +

MYTH OF THE MONTH Eating before you drink keeps you sober This falls into the same category as “flossing doesn’t prevent tooth decay.” If you just think about it for a few minutes, it makes no sense.

Neither pizza nor bread nor any other food is going to process alcohol you’ve consumed and prevent it from entering your bloodstream. This myth probably comes from the immediate buzz people get when drinking on an empty stomach.

That is not their imagination.

Drinking with food or on a full stomach, by contrast, does slow down or delay the absorption of alcohol into the bloodstream, but does not prevent it or reduce it.

Eating before drinking, by slowing down alcohol’s departure from the stomach to the body, can sometimes prevent a hangover. The opposite,

however, eating after drinking, does nothing to slow down the body’s absorption of alcohol or + prevent hangovers.

— by F. E. Gilliard, MD, Family Medicine 4244 Washington Road, Evans, GA 30809 706-760-7607

AUGUST 19, 2016

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AUGUSTA MEDiCAL EXAMINER

WHAT EVERYBODY OUGHT TO KNOW res?

ABOUT LIVING HAPPY

k good eno r skin can ugh cer? son.”

T

o k

here are many things the reasonable and prudent man or woman should always do. Here are a few all them.

• If your mother is still living and you haven’t spoken to her in the past 24 hours, either call or go see her immediately. Fathers don’t require such close attention.

Therefore, his rule is 48 hours.

• If you have a dog or a cat and have not petted them in the past 24 hours, you’re falling down on your job as leader of the pack. Make restitution immediately. A snack and a pat will work wonders.

• If a gentleman is approaching the door at a public establishment at approximately the same time as a lady, he should pause and let her walk in first. Nothing like age, ethnicity or sexuality should play any role in this decision. It is a matter of displaying good manners and good upbringing that would make your mother proud.

Besides, if the man barges in first, it is very likely the lady behind him will begrudgingly suppress the thoughts of her discontent. That is no fun for either. On the other hand, if

the lady walks in first, it is somewhat uplifting to both the man and the lady, not to mention he gets to watch a wonder of nature walk before him. I’m not ashamed to say that I admire the undulations of a well proportioned lady walking before me. I think God intended for man to inspired by that.

• If you have a handicap tag and park in a designated handicap space, before walking across in front of an oncoming car, have the decency to limp ... and wave appreciatively ... to the driver that did not run over you.

• If you’re being dropped off in front of a grocery store, always walk in front of your car, not behind it. It is a matter of self preservation.

The driver of your car is the only one in the parking lot that you know for sure will not run over you.

• When you eat in restaurants and add a tip to your credit card, round up to the dollar above your preliminary total. This makes accounting easier for the establishment and the credit card company as well for paying your bills. I never sign a credit card for an awful

HE

T

t s e B amount of cents.

• Contrary to your instinctive impulses, if gasoline prices are falling, buy only the amount you need the next couple days.

The price will be lower next time. If prices are generally rising, failure to take every opportunity you get (within reason) to buy more gas will cost you because if you wait, the price will be higher tomorrow.

• Walking on a sidewalk or in a parking lot, the man should walk on the side of the traffic. This is just good manners and being concerned for the well-being of your lady. Failure to do so is a sure indication that you were not reared by a good Southern Mother.

• If a law enforcement official tell you to stop, stop.

And don’t wise off. Answer the questions that you’re asked truthfully. And you will not get shot. If you notice on the news, the vast majority of the conflicts between police and civilians are preceded by someone running off at the mouth. Or running. Or both Not once have I ever seen or heard of a motorists at a traffic stop being shot if he simply handed over his drivers license and kept his mouth shut.

• In my lifetime, I have eaten a lot of bad food. Also I have eaten a lot of good food.

I prefer good food over bad food. But regardless, when I eat good food, I do not eat more good food simply because it is good food. Some people seem to believe there are less calories in good food than there are in bad food, so they gorge on good food. A bulging waistline is

• To be happy in a longterm relationship, avoid anyone who says he needs you. That means this person has a problem and wants you to be the solution and to “fix” it for him. You cannot “fix” someone else’s problem.

Instead of someone who needs you, find someone who wants you.

• If you are not happy with your life, it is not the fault of the government, your wife/ husband/kids, or anyone else. So fix yourself. And live happy. + Bad Billy Laveau is a formerlyretired MD who wields a pointed sense of humor - and now, tongue depressors too. He speaks and entertains at events for audiences not subject to cardiac arrest secondary to overwhelming laughter and glee. BadBilly@knology.net or 706306-9397.

F REE T AKE-HO ME CO PY!

+

YOUR BRAIN… from page 2 Don’t assume...and we all know what that stands for. Remember: as a general rule, give out no money. It’s a trigger to relapse for most people. Remember: every time you do something for someone else that they could and should be doing for themselves is a statement to them that they are incapable of doing it for themselves. That’s enabling at its finest. There are ways to help that don’t involve money: transportation to recovery meetings, being a listening ear, etc., etc.

• Realize that nobody wants to hear your advice! Unless they ask for it...and even then be very careful! Unsolicited advice, however true, is classic Parent-to-Child communication style. What we’re striving for now is Adult-to-Adult communication style – like you’d speak to a peer at work and not to your child.

• Know that it’ll take you as long or longer to heal than them. It takes 3 things to have a meaningful relationship: TAR!

e n i c i d ME

evidence of continuous poor menu choices. To live happier, one must make good menu choices. Fortunately in this country, there is little if any cost difference between good foods versus bad foods.

Trust, Admiration, and Respect. Addiction annihilates these attributes, and the closest analogy I can think of to make the point is that healing from the ravages of your loved ones’ addiction is like healing from an illicit affair. The lies, the subterfuge, the deceit, the shock when it becomes apparent are all roadblocks to your trusting again. It takes years, not months. It’s earned gradually over a long period of time.

• Accept that there are a lot of things you’ll never know. And that’s ok. The idea behind our anal-y-zing is that if we can rationally understand it the pain won’t hurt as badly.

Some true growth is evidenced when you can accept the past and the person without the need to know. Acceptance is freedom from pain and anxiety. Claim it for yourself!

• If the addict is a family member, enter into a contract with them! That’s what I’ll cover next time! Things are about to get interesting. +

Tell a friend about the Examiner!

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AUGUST 19, 2016

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AUGUST 19, 2016

AUGUSTA MEDiCAL EXAMINER

PROFILES… from page 3

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Karp has been Principal or Co-Principal Investigator in dozens of clinical studies, has published more than 50 articles in medical journals, in addition to contributing articles and chapters in publications ranging from American Baby magazine to Augusta’s erstwhile Verge magazine, in which he wrote a regular column on diet and nutrition.

Yet despite a dozen-page C.V. that focuses exclusively on medicine, many people know Bill Karp only as a jazz vocalist. He’s not a doctor; he’s an artist.

Earlier this year, he posed a question in a TEDxAugusta presentation: is it “Art AND Science”? Or is it “Art OR Science”?

For Bill Karp, it’s definitely art and science. As he mused during his TEDx talk, “We all know what a brain looks like from the outside. We certainly all know what a

brain looks like on drugs, don’t we? A fried egg, right?

But! Have you ever wondered what a brain on jazz looks like?”

It probably looks a lot like the guy in the photograph on page 3.

He has been performing as a jazz vocalist since age 4, originally in and around Brooklyn and Manhattan, and then through the Catskills and its many resorts, and now in Augusta, where Augusta Magazine readers have used the annual Best of Augusta poll to install him atop the 2015 “Best Jazz Vocalist” category. The 2016 reader poll comes out in late September/early October.

His next big gig comes on the Augusta Common this Sunday, Aug. 21 at 7:30 p.m., where he’ll sing with the Augusta Big Band Aggregate (ABBA).

Karp’s jazz performances and his public speaking

engagements generate a modest income, 100% of which — an amount approaching $20,000 just within the past several years — he has given away within the CSRA to support organizations like the American Heart Association, nutritional and dietary education, and children’s education, such as Summerville’s Imagination Station.

Obviously what he does is not about the money. In fact, as a counterpoint to the [Fill In the Blank] for Dummies series, the Karps wrote a book entitled Nutrition for Smarties. The 258-page book is available for free download at his website (wbkarp.com).

It’s loaded with exactly the kind of information you’re looking for because people just like you and me asked the questions posed in the book’s Q&A format: Are school lunches healthy? Are

organic foods worth the extra cost? Is red meat bad?

What about bacon? Which is better: brown rice or white rice? Can fast food be healthy?

It’s all pretty standard stuff for a clinician who is President of the Georgia Nutrition Council, Vice Chairman of the Columbia County Board of Health, an elected member of the American Society for Clinical Nutrition and the American Society of Nutritional Sciences, among numerous professional affi liations.

And you thought he was just a jazz singer.

If Dr. Karp could use these pages for a super-quick Continuing Education lecture for Medical Examiner readers, what would it be?

“Data shows that the more fruits and vegetables you eat and the less meat you eat, the healthier you will be. And move, move, move!” +

WE’RE BEGGING YOU We’re never too proud to beg. What we’re begging for is Medicine in the First Person stories. With your help, we’d like to make this a feature in every issue of the Medical Examiner. After all, everybody has a story of something health- or medicine-related, and lots of people have many stories. Send your interesting (or even semi-interesting) stories to the Medical Examiner, PO Box 397, Augusta, GA 30903 or e-mail to Dan@AugustaRx.com. Thanks!

“The cause was a mystery for a long time.”

“And that’s when I fell.” nearest hospital “He doesn’t remember a thing.” “The was 30 miles away.”

“I was a battlefield medic.” “He was just two when he died.”

“OUCH!”

“It was a terrible tragedy.” “She saved “I sure learned my lesson.”

“I retired from medicine my life.” “It seemed like a miracle.” seven years ago.” “We had triplets.”

“It was my first year “I thought, ‘Well, this is it’.” NOTHING SEEMED of medical school.”

“They took me to the hospital by helicopter.” TO HELP, UNTIL. . “It took 48 stitches.”

ambulance crashed.”

“Now THAT hurt!” “The “My leg was broken “I’m not supposed to be alive.”

“This was on my third day in Afghanistan.” in three places.”

“I lost 23 pounds.” “Turned out it was just indigestion.”

“At first I thought it was something I ate.” “The smoke detector woke me up.”

Everybody has a story. Tell us yours.

Here’s our “No Rules Rules.” We’ll publish your name and city, or keep you anonymous. Your choice. Length? Up to you. Subject? It can be a monumental medical event or just a stubbed toe. It can make us laugh or make us cry. One thing we’re not interested in, however: please, no tirades against a certain doctor or hospital. Ain’t nobody got time for that.

AUGUST 19, 2016

AUGUSTA MEDiCAL EXAMINER

Southern Girls Eat Clean Marinated Mushrooms

A Healthy Spanish Tapas Dish

One of our favorite things to do on a Sunday evening is to have a light meal with several different tapas. It reminds me of the time we spent in Spain a few years ago. These Marinated Mushrooms are perfect to serve as an appetizer.

Very flavorful, but still healthy and clean. This dish has a very light, lemon dressing that also will make for a perfect accompaniment to grilled fish or chicken.

On our trip to Spain in 2008, we fell in love with the very relaxed atmosphere there. It is the most beautiful country and I love the Spanish lifestyle.

Tapas in Spain were usually marinated salads made from fresh vegetables, meats such as prosciutto or chorizo, fresh cheeses, olives and fresh breads. Lovely Spanish wine or Sangria was served with these yummy Tapas. We enjoyed the late dinner hour and sampling small bites of different flavors, all of which were very light and tasty.

Give this recipe a try. Have some marinated mushrooms and transport yourself to Spain.

Marinated Mushrooms

Ingredients: • 1 lb. of organic button mushrooms • 1⁄4 cup of freshly squeezed lemon juice • 1⁄4 cup of organic coldpressed extra virgin olive oil • 1 Tbsp. of white balsamic vinegar • 1⁄2 cup of organic fresh flat leaf parsley, coarsely chopped • 2 cloves of garlic, crushed • 1⁄4 tsp. of crushed red pepper • 1⁄4-1/2 tsp. of Real Salt or sea salt • 1⁄4 tsp. of cracked black pepper

Instructions: 1. With a damp paper towel, clean mushrooms and then slice them thinly. Place into a mixing bowl.

2. Chop the parsley and place in the bowl with the mushrooms.

3. In a separate small bowl, whisk together lemon juice, olive oil and white balsamic vinegar.

4. Add crushed garlic, red pepper, salt and pepper to the lemon juice and olive oil and whisk again to mix all ingredients together well.

5. Pour dressing mixture

over mushrooms and parsley and toss to coat mushrooms.

6. Serve immediately at room temperature or if you prefer, chill slightly. + Alisa Rhinehart is half of the blog southerngirlseatclean. com She is a working wife and mother living in Evans, Georgia.

Visit her blog for more recipes and information on clean eating.

Many prescriptions = many trips to the pharmacy UNTIL NOW. Ask your Barney’s pharmacist 798-5645 about the simplicity of MedSync! (706) barneysrx.com Peach Orchard • Grovetown • Furys Ferry • Wrens • Louisville • Serenity

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AUGUST 19, 2016

AUGUSTA MEDiCAL EXAMINER

Looking for Likes in all the right places.

Pharma cy 4 11 Very little if anything about healthcare is inexpensive, and that includes medicine. Tiny pills can command large prices. Over-the-counter medications may be less expensive, but are they also less effective? Find the answers to lots of your drug store questions in this column written

by Augusta pharmacists Chris and Lee Davidson exclusively for the Medical Examiner.

TIME FOR SCHOOL!

I

Please Like the Examiner at facebook.com/AugustaRx

Thanks for reading the Medical Examiner!

t’s time for the children to go back to school and that brings trips to the doctor and pharmacy. Parents must get their kids seen by the doctor and some medicines that have been put on the back shelf for the summer once again come to the forefront of the daily routine. Let’s talk a little bit about some of the different types of medicine that you may need to get in step with school being back in session.

The start of the school year might bring to mind the need for medicines to help the some kids focus and learn in the classroom. Medicines for Attention Deficit Disorder, or ADD, are the first ones that see an increase with the start of school.

A lot of parents take their kids off these medicines for the summer and will restart when classes resume. For the most part, these medicines require a new prescription from your doctor each month. This requires coordination with the doctor’s office to get the prescription written and ready for pick-up. The prescription must then be taken to the pharmacy and filled.

Pharmacies will probably be struggling to deal with the increased demand for these medicines the first month of school.

Another medicine that will inevitably see an increase is for treating head lice. It happens to just about every classroom sooner or later. The first line choice for head lice is the over-thecounter medicine permethrin. It is available as the brand name Nix and its various generics. Insurance companies that cover over the counter treatments for head lice will cover this medicine as first line therapy, but often insurance will cover only prescription medications. If Nix does not work for the particular strain of head lice involved then a prescription medicines will be the only option. There are a few prescription treatments, which include Ovide and spinosad as the most often used options. These will be used if necessary. Any chronic itching of the scalp should

be checked, since these pests can spread like wildfire through a family or a classroom. Look for live bugs in addition to the eggs, called nits. These are tiny white sacks that are attached to the base of hair strands.

To prevent a head lice infestation use the following guidelines: do not allow any head-to-head contact or share any items that come in contact with the head, such as combs and hats. If the problem does show its ugly head treat all affected people and be sure and check all affected and other family members one week after treatment to ensure complete eradication.

Include all pillowcases and other bedding and other items that may have comes in contact with the hair.

Another item that may become more important as the school year proceeds is a vitamin program. This may seem strange to say but as any pharmacy or doctor can tell you, colds and infections, both viral and bacterial, will increase when school is in session.

Boosting the immune system early on in the back-to-school process will help kids fend off these extra infections and prevent missed days from school. A vitamin regimen is great preventive medicine, and can provide a boost for the immune system and health in general.

For kids in particular, it can supplement the diets of those who are picky eaters or whose favorite foods are fast foods. Ask your doctor or pharmacist for their recommendation for your child.

Here’s to staying healthy throughout the 2016-2017 school year. But remember if the unforeseen happens the pharmacy will be there for you. + Questions about this article or suggestions for future columns can be sent to us at cjdlpdrph@bellsouth.net Written for the Medical Examiner by Augusta pharmacists Chris and Lee Davidson (cjdlpdrph@bellsouth.net )

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AUGUST 19, 2016

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AUGUSTA MEDiCAL EXAMINER

Ask a Dietitian I

Voted “BEST BARBER SHOP” in Augusta Magazine many times!

Daniel Village Barber Shop 2522 Wrightsboro Road

736-7230

ARE ALL MILKS CREATED EQUAL?

by Danielle Dunnagan, MS, RD, LD

Lactose-free Milk This milk lies within the dairy milk family and is produced for individuals with an intolerance to the sugar found in milk, also known as lactose. When the body cannot fully break down lactose, symptoms such as bloating, gas, or stomach cramps may occur. Nutritionally, lactose free milk is essentially cow’s milk with the lactose removed.

It has 90 calories per serving, 0 grams of fat, 13 grams of carbohydrates, 8 grams of protein, and 30% daily value of natural calcium. Many who follow a lactose-free diet are able to tolerate small amounts of dairy. Try products such as lactose-free milk, yogurt,

Head to toe service: Jerry will shine your shoes while we cut your hair.

We’re on Wrightsboro Rd. at Ohio Avenue.

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Augusta Mall

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Please see MILK page 15

ASK ABOUT THE $1.99 SMOOTHIE OF THE DAY!

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fat free milks. Most labels will list calories per 8 ounce (1 cup) serving and fluctuate between 149 and 86 calories per serving; the higher the calories, the higher the fat content. Flavorings such as chocolate, strawberry, or vanilla are added sugars and increase total calories and carbohydrates per serving.

Nevertheless, dairy milk is not alone in the milk beverage market. Milk substitutes are also available and aim to be nutritionally similar.

Comparing the labels is the most effective way to stay informed about what your milk provides. Here are the facts on a few of the most common types of milk or milk substitutes in the market today.

That feeling you get when you see someone in traffic who really needs a haircut...

Ohio Ave.

Gone are the days where the milkman delivered milk to our doorstep without having to choose which type, brand, or flavor. Today, grocery stores are lined with an unbelievable assortment of milk and milk beverages, each looking or tasting different from the next.

The convenience of so many brands and flavors provides us with a popular public predicament: Are all milks created equal?

According to the Dietary Guidelines for Americans, children and adults ages 9 and older should include 3 servings of dairy in their food intake each day such as milk, cheese, or yogurt to name a few. A serving of dairy should provide about 6 to 9 grams of protein and ample amounts of calcium, a naturally occurring mineral needed for optimal bone health.

Dairy milk in particular provides a number of essential nutrients including potassium, phosphorus, vitamin A, vitamin D, vitamin B12, riboflavin, and niacin. It also packs 8 grams of protein per 8 ounce serving and provides around one third of our daily calcium needs. Calories and fat content are what differentiates whole milk from low fat and

AIKEN: 803-226-0034 AUGUSTA: 706-922-1611 EVANS: 706-855-1616

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AUGUST 19, 2016

AUGUSTA MEDiCAL EXAMINER

Kid’s Stuff NOTES FROM A PEDIATRIC INTERN

by Caroline Colden, M.D.

THE HPV VACCINE

THE MONEY DOCTOR BACK TO BASICS

With everyone heading back to school, this is a great time to get back to the basics of financial planning. Many people make financial decisions and then forget to revisit and re-evaluate them as their situation changes over time. Today this is easy to do as technology allows people to put most things on auto-pilot. The old saying “out of sight, out of mind” certainly applies, and we have found that thinking through the items below on a regular basis can help save thousands of dollars over time.

Income / Savings – Starting early and saving 15 to 20 percent of your income is prudent. Each year the IRS releases updated contribution amounts for the different types of tax advantaged accounts (401k, IRA, Roth IRA, HSAs, FSAs, etc.). Maximizing the appropriate accounts given your situation is one of the most important tax planning items you will do each year. You will want to make sure you increase your contributions each year to take advantage of the increase in limits.

The key thing to remember when using tax advantaged accounts is that they have income limits and contribution deadlines. As your income changes it is important to re-evaluate your strategy because you may not be eligible for certain accounts or become eligible for other accounts. If you miss a contribution deadline you will miss out on the tax benefits and the planning opportunity.

Spending / Budget – After paying yourself fi rst (saving 15 to 20 percent), budgeting is the best thing you can do to maximize your dollars. Creating a budget will help you align your spending with your values, goals, and priorities. Tracking your expenses and being intentional about how much you spend across different categories is now easier than it has ever been thanks to the technology boom.

We encourage our clients to keep things simple and stick with one aggregation tool or use a simple spreadsheet. We also encourage setting up auto-pay and consolidating accounts as much as possible to keep things simple. The risk today with doing that is the “set it and forget it” temptation. This can cause people not to notice when expenses increase or when they are no longer aligned with your values, goals, and priorities. It is good practice to compare your budget each month to your bank statements and confirm the charges were as expected. It is also helpful to think through each expense once a year and confirm it still aligns with your values, goals, and priorities.

Insurance - One of the best tools to decrease risk is insurance. Thera are many different kinds of insurance including health, home, auto, umbrella, life, disability, long-term care, etc. which all have multiple options you can choose from. It is eye opening when you add up all the money both your employer and you spend on insurance each year. Most of the time the money you spend on insurance is well worth it and aligns with your values, goals, and priorities. The risk is that over time as your situation changes your insurance needs do too. We have found that shopping the market with an independent agent every few years is important and helps confirm that you do not have any gaps or uninsured risks. It also helps you confirm that the pricing on your current policies is competitive in today’s market.

Estate Planning – As life events unfold your estate plan must be revisited. Reviewing the documents will help make sure you have an up-to-date will, durable power of attorney, health care power of attorney, trusts, etc. You also want to make sure your beneficiary designations on insurance and retirement plans along with titling of property are updated and coordinated with your other estate documents.

Tax Planning – Taxes impact almost all our financial decisions and most financial planning strategies are used to navigate the current tax law as efficiently as possible. If you have not reviewed your 2015 taxes for future planning opportunities or talked with your financial planner and tax preparer about proactive measure you can take in 2016 now is the time to do that. We have found that the key to successful tax planning is doing it in the fall, which makes the spring much less stressful, and your tax preparer has more time and energy to focus on your situation.

Investments – The best answer to the question, “What changes should I make to my investments given the latest headline” - is often “Nothing.” However, during the year checking your overall allocation and rebalancing is prudent for risk management. For our clients, we make sure any investment decisions are coordinated with taxes and consider things like tax location, tax loss harvesting, and capital gain harvesting. These are important to think through each year.

We have found that reviewing each area of your financial plan on a regular basis is very important. Your fi nancial planner should be revisiting the basics with you and then be holding joint calls with your other trusted advisors (CPAs, estate attorneys, insurance agents, bankers, etc.) to make sure everything is coordinated and implemented. Financial planners can also help you take a deeper dive with detailed analysis in each area above and other areas including Please see MONEY DOCTOR page 11

One of the newest vaccinations a pediatrician can provide is the Human Papillomavirus (HPV) vaccine. It is offered to both boys and girls starting at ages 11-12, and most insurance companies will pay for the series until the patient is in their 20s. The HPV vaccination is a series of 3 shots given at designated intervals and it protects against the most common causes of genital warts and HPV-related cancers. Yes, it is the fi rst anti-CANCER vaccine we have available now to offer to children.

A common misconception about the vaccine is that it only protects against cervical cancer, and that only girls need to be protected. However, the HPV viruses most commonly responsible for cervical cancer can cause other types of cancer too, including cancers that can affect males as well (penile cancer) and both sexes (oropharyngeal or throat cancer). The virus is spread via close skin-to-skin contact, so sexual intercourse is not the sole means by which it can be transmitted. Most infections are cleared by young, healthy people in about 2 years, but a number of cases go on to later cause cancer. Many individuals can also become repeatedly infected, which increases the chance of sustaining long-term consequences.

The most ideal time to vaccinate patients against HPV is in the ages of 11-12 or early teenage years, as the immune systems can develop the most effective responses at that time. The vaccines have not been found to have any association with significant side effects or adverse reactions at this time.

Women should still undergo regular PAP screens every 3 years during their 20s and every 5 after that to detect any abnormal cellular changes in the cervix that could be early cancer. Studies suggest that the cancer-causing effects of HPV infection occur much later than initial infection and even after clearance by the body. This is due to manipulation of our bodies’ DNA by the virus which develops into the cancercausing cells. No treatments or cures for HPV infection exist at this time, so the best plan of action is to vaccinate against infection and prevent it from happening. +

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THE M.E. Blog: AugustaRx.com/news

AUGUST 19, 2016

11 +

AUGUSTA MEDiCAL EXAMINER

The blog spot From the Bookshelf — posted by Katherine Eby on July 25, 2016 at themighty.com

BEFORE YOU JUDGE THE MOM BUYING SODA IN THE GROCERY STORE One day my daughter was with me while I was running errands. We made a quick stop at a grocery store and loaded a shopping cart down with packs of soda cans. After grabbing a few more groceries, we struggled to push the heavy cart to the checkout lanes. As we got up our speed and rolled past the deli meats, one lady stared at me disapprovingly. I knew what she was thinking. Assuming she could plainly see why my daughter is overweight, she shook her head and said, “Ugh! I can’t...

I just can’t...” as she turned away from us. I wanted desperately to set her straight, but the cart was rolling with a lot of momentum now, and it wasn’t worth my effort to bring it to a stop just to tell this lady how wrong she was.

Tonight my house is quiet and my brain is active, so I thought I’d send out a public service announcement: if you see a child with weight issues in the grocery store with a mom whose cart is full of soda, please reserve judgment. You just might not know as much as you think you know.

The lady in the grocery store did not know my daughter has a rare genetic syndrome called Bardet-Biedl syndrome that causes obesity. She didn’t know my daughter’s hypothalamus does not correctly receive the satiety signal and that she lives every day of her life feeling hungry, even when she’s eaten enough.

She didn’t know my daughter’s hypothalamus believes she is starving and constantly tells her to seek and eat food with intensity, or that a starving hypothalamus will tell the body to decrease metabolism to conserve energy so my daughter only burns 75 percent of the calories a healthy child burns. This lady had no idea this genetic syndrome also causes fat cells to more rapidly store fat than in a healthy child.

The lady in the deli aisle didn’t know we’ve worked incredibly hard to control my daughter’s weight, including placing her on special diet, restricting her calories, and encouraging daily exercise and participation in sports. She didn’t realize my daughter’s endocrinologist had praised our efforts at our last appointment and declared my daughter was “the healthiest child with Bardet-Biedl syndrome” she’d ever heard of.

But you may be thinking, “surely drinking soda doesn’t help the problem.” And you would be correct. This is one reason my daughter hasn’t had a sip of soda in more than six years, and why we strictly limit fruit juice to 3 ounces per day — just enough to help her absorb her daily iron supplement.

So why did I have a cart loaded down with packs of soda cans? I’m a mobile home park manager. It’s my job to fill the soda machine.

Please be careful to not judge, even when it seems you know the situation. You just might not know as much as you think you know. +

“I knew what she was thinking.”

MONEY DOCTOR… from page 10 retirement analysis, social security strategies, real estate buying or selling, lump-sum pension options, and more.

The retirees and young accumulators we work with are able to focus on things they enjoy as they delegate most of the heavy lifting on the items above to us. We use a proactive approach where we quarterback and coordinate their financial plan with other trusted advisors. This helps our clients live an intentional life with purpose and direction which is truly amazing to watch and be part of through financial planning. +

by Clayton Quamme, a Certified Financial Planner (CFP®) with Preston & Cleveland Wealth Management, LLC (www.prestoncleveland.com). Preston & Cleveland is a fee-only financial planning and investment advisory firm with offices in Augusta, GA and Columbia, SC.

We live in a very very noisy world. And it isn’t all audible.

There is a constant din of background “noise” from texting, email, Facebook, Twitter, Instagram and dozens of other sources. In olden times, newspaper columnists had a voice; Paul Harvey had a voice; Austin Rhodes has a voice. Today, everyone does.

And then there’s literal noise. Television. Muzak.

Ipods and ear buds. Radio.

Author Susan Cain is not content with the noisy status quo. Her bestseller Quiet is the manifesto for a world drowning in its own cacophony of voices.

She explores the historic era a hundred years ago when the loud and brash person became the model for the ideal shaker and mover.

There’s just one problem.

Quiet is an absolute necessity. For everybody.

Including people like musicians who make their living from sound. Beethoven didn’t write his masterpieces with a radio or TV blaring in the background, right?

(Forgive the flawed analogy, but you get the point.)

We need quiet to innovate.

cards.

• If you’re an introvert, staying true to your temperament is the key to finding work you love and work that matters.

• Everyone shines, given the right lighting. For some, it’s a Broadway spotlight, for others, a lamplit desk.

• “Quiet leadership” is not an oxymoron.

We need to celebrate the quiet colleague, the quiet boss, the silent partner. There’s a word for people who are “in their heads” too much: thinkers.

That’s just one of many wise maxims this book brings to light: • Our culture rightly admires risk-takers, but we need our “heed-takers” more than ever.

• Solitude is a catalyst for innovation.

• Texting is popular because in an overly extroverted society, everyone craves asynchronyous, non-face-toface communication.

• Rule of thumb for networking events: one genuine new relationship is worth a fistful of business

Many of us have probably worked for someone whose management style was yelling. People who cannot make a major point without cursing or yelling are, unfortunately, not an endangered species.

That doesn’t mean that quiet and introverted people cannot be good leaders — or simply good and valued employees. Cain extols the virtues of the introvert, and it’s a message many of us need to hear.

As Gandhi expressed it, ”In a gentle way, you can shake the world.” + Quiet: The Power of Introverts in a World That Can’t Stop Talking by Susan Cain, 368 pages, published in January 2013 by Broadway Books

Research News Ask your dentist Even though you’re — ahem — still flossing (See page 1), you may nevertheless have the occasional cavity. If so, ask your dentist about silver diamine flouride, or S.D.F. Although approved for use in other countries for decades, it has been available in the US for only the past year or so.

Its main application is as a tooth desensitizer, but a socalled “off-label” use is that it stops tooth decay painlessly, without drilling. In fact, it’s applied by simply painting it on.

It takes all of 30 seconds and dentists say it’s “better, faster and cheaper” than drilling.

It’s inexpensive too. It has just one drawback: it blackens decay, which is already brownish pre-treatment. That no doubt precludes use of S.D.F. on readily visible teeth, but may not be objectionable on molars that are hard to see and hard to reach. It also wouldn’t present a problem on baby teeth that will fall out soon enough anyway.

This is weird According to a study released this week from the University of Cambridge, our body clock affects our ability to ward off disease. In other words, we can be more susceptible to infection at certain times of day.

Granted, the study was carried out on mice, but it clearly showed that circadian rhythms in control of many body functions are not as alert to intercept intruders. When viruses were injected into mice just as they were about to go into their daily resting phase, replication was ten times greater than in mice injected at the beginning of their active phase.

The research may help explain why shift workers, whose body clocks are routinely disrupted, are prone to more health problems, and it may help find a solution to the problem.

Sitting: the new smoking As more and more studies prove the perils of our sedentary lifestyles, a new study from the

University of Missouri-Columbia is good news for sitters.

Some of them, anyway.

You know that person who can’t sit still, who fidgets constantly, shaking their foot back and forth or tapping their toes incessantly?

It turns out that all that fidgeting can protect the arteries in the legs, promote circulation, prevent arterial disease, and negate some of the ill effects of long-term sitting.

Researchers made the point clear that fidgeting is no substitute for walking and exercise, which are vastly superior to mere fidgeting. But any movement is better than no movement at all.

Better brushing the selfie way Participants in a tooth brushing study at Case Western Reserve University improved their oral hygiene skills by taking a video while they brushed. Researchers saw “an 8 percent improvement” in brushing effectiveness. +

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AUGUST 19, 2016

AUGUSTA MEDiCAL EXAMINER

THE EXAMiNERS

THE MYSTERY WORD

+

When did that I don’t know. I think light fixture start we should have flickering? someone look at it.

by Dan Pearson

I don’t think that’s very safe. We need to call an electrician.

I’ll get a ladder and check it out.

Nonsense. Well if you get electrocuted, I’ll be fine. don’t be shocked.

The Mystery Word for this issue: TER BLEATT

THE MYS

© 2016 Daniel Pearson All rights reserved.

EXAMINER CROSSWORD

PUZZLE

1

2

3

4

5

6

7

8

9

10

14

15

16

17

18

19

11

12

All Mystery Word finders will be eligible to win by random drawing.

We’ll announce the winner in our next issue!

VISIT WWW.AUGUSTARX.COM

13

Click on “READER CONTESTS”

QUOTATION PUZZLE

20 21 22 23 24 ACROSS 1. CT and MRI, for example 25 26 27 6. Former Russian ruler 28 29 30 31 10. Pineapple seller 32 33 34 14. It sometimes precedes larceny 35 36 37 38 39 15. South American Indian 40 41 42 16. Level 43 44 45 46 47 48 17. Sun-dried brick 18. Heating fuel 49 50 51 19. Curve 52 53 54 20. Battering word 21. Charge per unit 55 56 57 58 59 23. Unusual word for trouble 60 61 62 25. Like Neapolitan ice cream 63 64 65 27. Skating figure 28. Assign

by Daniel R. Pearson © 2016 All rights reserved. Built in part with software from www.crauswords.com 29. Sign on 50% of certain doors 62. Slang 29. Augusta park 30. To come down with 63. Linkletter and Garfunkel 31. Young boy something 64. Bleary tail 33. Andre’s nickname?

32. Dentist’s org.

65. Impede 34. Anticipation singer 33. “From ___ to Beersheba” 35. Prostate test abbrev.

34. Capital of Fiji DOWN 36. Needle-shaped (said of 35. Home of a noted tower 1. Hancock County seat crystals) 38. Lopsided, as a grin 2. [blank] of Sinai 37. Warning of great danger 39. Put away papers 3. Super-accurate clock type 38. Tue-Thu bridge 40. Palmetto util.

4. Penpoint 39. More than quadruple 41. Victory sign 5. Body builders’ favorite way 41. Capital beginning 42. A 2¢ word for caliginous to cheat?

42. Challenge 43. Help 6. _____ around: carefully 44. Bind 44. Talk of a certain kind avoid 45. Derailed 45. Privileged 7. Contemptuous smile 46. Blvd in medical district 49. Mamie’s _______ 8. Obamacare acronym 47. Materialize 51. John or Mary, for instance 9. Coarse woolen fabric of old 48. Borrower 52. ______ train 10. Fix program problems 50. Endow with 53. “As gladly” (Archaic) 11. Renovate and renew 51. Distress signal at sea 54. Belle of the ball (in brief) 12. Mild laxative 52. Ali’s last name 55. On sheltered side 13. Conclusions 57. 2004 Foxx film 56. Russian range 22. Honest CEO 59. Contend 58. Blatant 24. Transgression 60. Obstructs 26. Former Augusta DA Solution p. 14 61. Uncommon

BY

O D H O W T T F L Y C U E Y M U I D E A H T T S R O Y R U D T O R ’ A O I D S C O E O F N T U — Author unknown

by Daniel R. Pearson © 2016 All rights reserved

DIRECTIONS: Recreate a timeless nugget of wisdom by using the letters in each vertical column to fill the boxes above them. Once any letter is used, cross it out in the lower half of the puzzle. Letters may be used only once.

Black squares indicate spaces between words, and words may extend onto a second line.

Solution on page 14.

E

7

4

3 9

X A M I N E R

6 4

8 6 2

S

1 8 5

3

7

3

2 9 5

7 8

6 4

2 5

6

3

by Daniel R. Pearson © 2016 All rights reserved. Built with software from www.crauswords.com

U D O K U

DIRECTIONS: Every line, vertical and horizontal, and all nine 9-square boxes must each contain the numbers 1 though 9. Solution on page 14.

Use the letters provided at bottom to create words to solve the puzzle above. All the listed letters following #1 are the first letters of the various words; the letters following #2 are the second letters of each word, and so on. Try solving words with letter clues or numbers with minimal choices listed. A sample is shown. Solution on page 14.

1

N 1 2 3 4 5 6

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by Daniel R. Pearson © 2016 All rights reserved

WORDS NUMBER

YW

RD ISthen Simply unscramble theOletters, exploring ON begin V A C A TIOword our ads. When you find the correctly spelled N hidden in one of our ads — enter at AugustaRx.com

AUGUST 19, 2016

13 +

AUGUSTA MEDiCAL EXAMINER

THE BEST MEDICINE ha... ha...

Moe: What do you call a penguin in the desert?

Joe: Lost.

Moe: What do penguins like to eat on Cinco de Mayo?

Joe: Brrrrrritos.

A

n arsonist immediately regretted his crime and doused the fire he had just started, slightly burning his hands in the process.

He went straight to confession afterward and told the priest, “Bless me father for I have singed.”

If Trump replaces Obama as president, orange will be the new black.

Moe: We went to the zoo yesterday.

Joe: Did you see an elephant?

Moe: Oh no, we saw a whole pachyderm.

Moe: What do you call an American basketball player who leads his team to third place in the Summer Olympics?

Joe: LeBronze James?

Moe: What is Trump’s favorite dog breed?

Joe: Probably a Border Collie.

Moe: Did you hear about the guy who got so frustrated with his computer that he punched it and broke his hand?

Joe: I bet he needed tech knuckle support.

Moe: Did you know that I was addicted to soap the last two years?

Joe: No! Moe: I’m clean now.

Moe: Why did the blonde crash her car during her driver’s test?

Joe: The examiner told her to keep her hands on the wheel at 10 and 2, but the test was at noon.

Moe: You misspelled Armageddon.

Joe: Big deal. It’s not the end of the world.

Moe: Thanks for explaining the word “many” to me.

Joe: No problem.

Moe: It means a lot Moe: I have a step-ladder.

Joe: So? Moe: So I’ve never known my biological ladder.

Moe: What would you do if you won a million dollars in the lottery?

Joe: I’d donate a quarter of it to charity.

Moe: That’s very generous of you.

Joe: I know. And I would still have $999,999.75. +

Why subscribe to the Medical Examiner?

Because no one should have to make a trip to the doctor or the hospital just to read Augusta’s Most Salubrious Newspaper.

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SUBSCRIBE TO THE MEDICAL EXAMINER By popular demand we’re making at-cost subscriptions available for the convenience of our readers.

If you live beyond the Aiken-Augusta area or miss issues between doctor’s appointments — don’t you hate it when that happens? — we’ll command your mail carrier to bring every issue to your house!

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STATE

ON THE ROAD TO BETTER HEALTH A PATIENT’S PERSPECTIVE Editor’s note: Augusta writer Marcia Ribble wrote a long-time column in this paper entitled The Patient’s Perspective reincarnated in this new format. Feel free to contact her at marciaribble@hotmail.com “Night and Day.” Sigh. Big sigh. I recall looking forward to when the children would be grown and I would finally get some solid nights of sleep. But I hadn’t counted on reaching a point when sleep some nights would elude me. I don’t get restless leg syndrome. I wish. Instead, I am on occasion plagued with restless body issues. I lie down. I snuggle under my covers. And then I squirm. I wiggle. I twitch. I get up. I walk around. I go back to bed. Still no sleep.

I don’t have things to worry about. I am not in pain. I just am having a major case of the fidgets. I am awake in the same way toddlers who have gotten their days and nights mixed up can be awake at all the wrong hours. It doesn’t happen all the time, but often enough that I know I can turn on ABC and get the early national news by 3 am. On weekdays I know that my paper arrives by 4 am. I also know that after listening to world news for a while, bringing my paper in, and reading a few pages, I will fall sound asleep without even being aware of the fact that I am falling asleep. I only become aware after the fact, when I wake up and find the section of paper I was reading on the floor.

Fortunately, because I am retired, I can sleep when I fall asleep during the day, so I almost always get enough sleep. I laugh at myself, remembering all the nights in grad school, pulling all-nighters to study for exams, or to grade papers, or to try to catch up on my reading. Elizabeth Gilbert, in her book Eat Pray Love, suggests that we are always living within a process of becoming who we are. That process doesn’t end when we become seniors, but continues bit by surprising bit throughout life. So my occasional upside down sleeping habits are simply a part of that discovery process.

I am no longer that always-tired mother of five children falling asleep the second I am lucky enough to climb into bed.

I am no longer that adult college student, struggling with the demands of parenting, studying, and teaching. It helps me to realize that I am not just a victim of insomnia, but someone who is exploring the possibilities of a life expanding into the additional time that is available, time no longer ruled by the demands of a hungry baby at 2 am, a job that requires me to be up at 6 am, or any of the other requirements of pre-retirement life. I can freely test the late night hours after years of feeling guilty if I start reading a wonderful novel that I just cannot put down at “bedtime.” I can happily read all night long, as I did with all of the Harry Potter books.

I can do the same thing with eating. I can eat when I’m hungry without regard to the clock. Some seniors maintain their same schedules from pre-retirement. They eat breakfast at 7 am, lunch at noon, and dinner at 5 pm. Not me. For me eating is a moveable feast like the rest of my life. There is a lot of happy anticipation attached to a life that is a moveable feast.

If someone calls and asks me to go on a trip I can be ready in a few moments, lock the door behind me, take KC (my dog) to stay with my grandson, and dash off into the adventure. +

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AUGUST 19, 2016

AUGUSTA MEDiCAL EXAMINER

THE MYSTERY SOLVED TION A C A V N O issue was: The Mystery WordOin IS last Dour R W Y TER TABLET THE MYS

The Short White Coat THE PATIENT’S VITAL ROLE

by Jasmine Rivas

T

...very cleverly hidden (in the bricks) in the p. 16 ad for AUBEN REALTY APARTMENTS

However, we had no winner!

Want to find your name here next issue? The new Mystery Word is on page 12. Start looking!

The Celebrated MYSTERY WORD CONTEST ...wherein we hide (with fiendish cleverness) a simple word. All you have to do is unscramble the word (found on page 12), then find it concealed within one of our ads. Click in to the contest link at www.AugustaRx.com and enter. If we pick you in our random drawing of correct entries, you’ll score our goodie package!

SEVEN SIMPLE RULES: 1. Unscramble and find the designated word hidden within one of the ads in this issue. 2. Visit the Reader Contests page at www.AugustaRx.com. 3. Tell us what you found and where you found it. 4. If you’re right and you’re the one we pick at random, you win. (Winners within the past six months are ineligible.) 5. Prizes awarded to winners may vary from issue to issue. 6. A photo ID may be required to claim some prizes. 7. Other entrants may win a lesser prize at the sole discretion of the publisher.

The new scrambled Mystery Word is found on page 12

SENDING US A CLASSIFIED? USE THE FORM BELOW AND MAIL IT IN, OR GO TO WWW.AUGUSTARX.COM AND PLACE & PAY CONVENIENTLY AND SAFELY ONLINE. THANKS!

he fi rst patient of the day was ready to be seen.

The doctor gave us a brief introduction to the patient: name, age, and reason for visit. A four month old infant with respiratory issues. The patient was brought in by her father, a young man maybe in his early 20’s. His interaction with his child was memorable.

The customary questions were asked by the pediatrician. Dad knew every answer in detail. He knew which signs of respiratory problems she was exhibiting, when they began, when they worsened, what would alleviate them. He made the visit an easy one. Later that week there was a patient whose parent was unsure of how to answer the physician’s questions, and this made the assessment far more challenging.

Despite the advances in medicine, a knowledgeable patient or caregiver, always benefits both the physician and the patient. This is all the more so in pediatrics. When the patient is too young to

communicate their symptoms, it is up to the caregiver to observe the signs of illness and report them to the physician.

As medical students, we are in the perfect position to see what makes a patient visit better. More and more often I notice that physicians feel they leave a visit with a patient feeling unsatisfied, wishing they could have done more. I cannot speak for all physicians and I am still in medical school, but I can empathize with that idea.

Physicians are people who choose to dedicate over a decade of their life to medicine with the hope that their knowledge and skill will one day benefit people in a special way. However, sometimes there are barriers to patient care. Barriers can be presented by the patient, the physician, and sometimes even by insurance companies.

With all of the medical advancements and progress it is easy to forget that limitations still exist.

Sometime patients and/ or caregivers provide the

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Your ad should reach us no later than 7 days prior to our publication date.

HOMES, APARTMENTS, ROOMMATES, LAND, ETC. MEDICAL OFFICE Large brick twophysician office for sale or lease. Newly renovated, convenient, very busy location in charming Aiken, South Carolina, just 15 miles from Augusta. Call Kay at (803) 270-1740 FOR SALE 3 bedroom/2 bath, single garage Townhouse in Martinez. Master/ bath down, 2 upstairs bedrooms share bath, large loft for office, playroom, den; wood-burning fireplace, covered back porch. Freshly painted with new flooring, lighting and ceiling fans. Easy access to Riverwatch Parkway, Washington Rd, I-20, Augusta. 1987 sq.ft. $147,900.

706-836-7001.

ROOM FOR RENT 1 room, private bathroom, 2bdrm MH on private lot. Clean quiet neighborhood. Non-smoker. $600 monthly. Must be stable, verifiable references and income. Cable and Internet included. Warrenville, 5 min from Aiken, 20 min to Augusta. (803) 270-2658 POND VIEW! Evans all-brick 2-story with solar panels. Avg. electric bill $170 in Northwood, 3,400 sqft. Call 1-800401-0257, ext. 0043 24/7 for price and details.

AUGUSTAGAHOMESEARCH.COM Foreclosures • MLS • Builders • Rentals (706) 564-5885

MISCELLANEOUS SUNSET MEMORIAL GARDENS Opening and closing at Sunset Mem. Gardens in Graniteville. Sale: $760 (Value: $1520+) Call 706-736-0596

ANTIQUE maple dinette set with buffet corner cabinet table with pull-out leaves.

Four chairs with two captain’s chairs.

Excellent condition. $300. Double bed early 1930s with mattress spring coverlet shams $150. Call (706) 860-2170 WANT TO BE HEALTHY? (Energy, weight loss, mental clarity) Go to gethealthyat.le-vel.com See video and Facebook. Sign free as customer.

BEING PAID WHAT YOU ARE WORTH? Then make more money! Watch movie all out interview: ExtraMoneyInterview.net CEMETERY SPACES (2) Sunset Memorial Gardens, Graniteville SC adjacent to lighted military flagstaff, includes granite bench with urn space, installation and inscription. All $4700 ($8600 value).

Spaces only: $2700. Call (803) 2953033 FISHING CLUB wants more grey-haired members. Meet 2nd Thurs of month at Harbor Inn Restaurant, 12 noon.

“Adventure Before Dementia” Info: (706) 736-8753

SERVICES HOUSE CLEANING Your house, apartment, rental move-outs. Thorough, dependable. Weekly, or whatever schedule you prefer. References. 706-267-9947 BIBLE BY PHONE - Free daily Bible readings; for Spiritual Encouragement and Growth. Call 706-855-WORD (9673) F. E. GILLIARD, MD FAMILY MEDICINE Acute & Chronic Illnesses Occupational Medicine PROMPT APPOINTMENTS (706) 760-7607

A med student’s notebook necessary information, other times they don’t. Medicine is being practiced differently with each passing year, but patients still can make or break the system.

Physicians try their best to fi ll in the gaps and provide an accurate assessment and plan. As a medical student, one attempts to learn from their preceptors and acquire the skills needed to provide the best level of care for each patient, despite the obstacles one is faced with. +

by Jasmine Rivas, a third year medical student at University of Medicine and Health Sciences. Feel free to contact her with questions or feedback: jrivas@umhs-sk.net

THE PUZZLE SOLVED S P A R T A

C E D A R S

A T O M I C

P A R S C E A I D C A B U L A L E B A R A R T

N S I T B E R C O R I A D I S G T B I L E E S S

T I P A T L O B E A W V E E D N T U R R A E Y

S A R D N C A E E A T B E T S U R E I G M E N D A N S R Y F I E D I M F A V O F O R E N L I E F A L O V R E L I E D D E

O V E R H A U L

L E N I T I V E

E N D S

R A D E N T

E M E R G E

D E B T O R

L A D

SEE PAGE 12

QUOTATION QUOTATION PUZZLE SOLUTION: “If at fi rst you don’t succeed do what your mother told you.”

— Author unknown

The Sudoku Solution 7 2 9 8 5 3 1 6 4

5 1 8 6 4 7 9 3 2

4 3 6 2 9 1 8 5 7

2 9 5 4 3 6 7 8 1

3 7 1 9 2 8 6 4 5

8 6 4 1 7 5 3 2 9

9 5 3 7 8 2 4 1 6

6 4 2 3 1 9 5 7 8

1 8 7 5 6 4 2 9 3

WORDS

BY NUMBER “ A doubtful friend is worse that a certain enemy.”

— Aesop

AUGUST 19, 2016

15 +

AUGUSTA MEDiCAL EXAMINER

MILK… from page 9 or ice cream or even top your favorite sandwich with a slice of cheddar, Colby, Monterrey Jack, or Swiss cheese – these are low in lactose.

Soy Milk This plant-based substitute provides adequate protein when compared to dairy milk and is enriched with plenty of calcium. Soy milk is the liquid obtained after crushing cooked soybeans and soaking them in water.

The resulting fluid is usually enriched with nutrients such as calcium, vitamin A, vitamin D, riboflavin (B2), and vitamin B12. Nutritionally, unsweetened soy milk contains 80 calories per 8 ounce cup, 3-4 grams of fat, 4-5 grams of carbohydrates, 7 grams of protein, and 45% daily value of added calcium. Sweetened varieties have added calories and carbohydrates for flavor. Because soy milk is plant based, it is often a favorable substitute for individuals following a vegetarian diet.

Almond Milk Almond milk is also plant derived and is defined as a mixture of sugar, water, and the liquid obtained from ground, blanched almonds. Almond milk is a lower calorie alternative to most milk beverages and, like soy milk, it contains plenty of added calcium. On the other hand, it contains far less protein than its competitors and should not be considered an adequate source of protein per serving. Unsweetened almond milk contains 50 calories per cup, 3.5 grams of fat, 3 grams of carbohydrates, 1-2 grams of protein, and 45% daily value of added calcium. Potassium, vitamin A, vitamin D, and D-alpha-tocopherol (vitamin E) are also commonly added to almond milk for additional nutrition.

Almond milk is another substitute popular with vegetarian diets and can be a lower calorie addition to smoothies, cereals, oatmeal, etc.

Coconut Milk The coconut craze is a topic popular

to recent media, but what exactly is coconut milk? Coconut milk is the liquid extracted from the “meat” of a mature coconut - the white flaky product often used in baking once processed.

Nutritionally it contains 70 calories per 8 ounce cup, 4.5 grams of total fat, 8 grams of carbohydrates, 0 grams of protein, and 10% daily value of added calcium. When compared to fat free milk, coconut milk has no protein and has a higher saturated fat content. It is also enriched with vitamin A, vitamin D, calcium, and vitamin B12 and additionally contains zinc and folic acid.

Change up your daily coffee routine and swap dairy cream with coconut milk for a lower fat option!

allergies. It contains almost double the carbohydrates of dairy milk and very little protein per serving. Rice milk provides 113 calories, 2.5 grams of fat, 22 grams of carbohydrates, 1 gram of protein, and 30% daily value of added calcium. Like other milk substitutes, vitamin A, vitamin D, and vitamin B12 are also added for enrichment.

Rice Milk Rice milk is made from extracting the liquid, usually from brown rice, and adding sugar and water. Rice milk is the least allergenic when compared to other milks making it a friendly choice for individuals with milk, nut, or soy

Sources: • “NDL/FNIC Food Composition Database Home Page.” USDA Food Composition Database. United States Department of Agriculture, 17 May 2016. Web. 27 July 2016.

• “Milk vs. Milk Substitutes.” EatSmart.

Washington State Dairy Council, n.d. Web. 27 July 2016.

So there you have it, not all milks are created equal. Aim for 3 servings of dairy each day by switching up your routine; add soy milk to your morning cereal or trying lactose free yogurt with lunch. Now it’s up to you to compare the facts and decide which milk or milk substitute is best for you. +

+

PROFESSIONAL DIRECTORY ALLERGY

Tesneem K. Chaudhary, MD Allergy & Asthma Center 3685 Wheeler Road, Suite 101 Augusta 30909 706-868-8555

CHIROPRACTIC Evans Chiropractic Health Center Dr. William M. Rice 108 SRP Drive, Suite A 706-860-4001 www.evanschiro.net

COUNSELING Resolution Counseling Professionals 3633 Wheeler Rd, Suite 365 Augusta 30909 706-432-6866 www.visitrcp.com

DENTISTRY

DERMATOLOGY

Georgia Dermatology & Skin Cancer Center 2283 Wrightsboro Rd. (at Johns Road) Augusta 30904 706-733-3373 www.GaDerm.com

DEVELOPMENTAL PEDIATRICS Karen L. Carter, MD 1303 D’Antignac St, Suite 2100 Augusta 30901 706-396-0600 www.augustadevelopmentalspecialists.com

DRUG REHAB Steppingstones to Recovery 2610 Commons Blvd.

Augusta 30909 706-733-1935

FAMILY MEDICINE

F. E. Gilliard MD, Family Medicine 4244 Washington Road Evans, GA 30809 706-760-7607 Industrial Medicine • Prompt appts.

Urgent MD Augusta: 706-922-6300 Grovetown: 706-434-3500 Thomson: 706-595-7825 Primary Care Rates

OPHTHALMOLOGY Roger M. Smith, M.D. 820 St. Sebastian Way Suite 5-A Augusta 30901 706-724-3339

PHARMACY

YOUR LISTING HERE

SENIOR LIVING

Augusta Gardens Senior Living Community 3725 Wheeler Road Augusta 30909 SENIOR LIVING COMMUNITY 706-868-6500 www.augustagardenscommunity.com

SLEEP MEDICINE Sleep Institute of Augusta Bashir Chaudhary, MD 3685 Wheeler Rd, Suite 101 Augusta 30909 706-868-8555

TRANSPORTATION Caring Man in a Van Wheelchair-Stretcher Transports • Serving Augusta Metro 855-342-1566 www.CaringManinaVan.com

VEIN CARE

Medical Center West Pharmacy 465 North Belair Road Evans 30809 Vein Specialists of Augusta Dr. Judson S. Hickey Your Practice 706-854-2424 Periodontist And up to four additional lines of your www.medicalcenterwestpharmacy.com G. Lionel Zumbro, Jr., MD, FACS, RVT, RPVI 501 Blackburn Dr, Martinez 30907 Floss ‘em 2315-B Central Ave choosing and, if desired, your logo. or lose ‘em! Keep your contact information in 706-854-8340 Augusta 30904 Parks Pharmacy www.VeinsAugusta.com 706-739-0071 this convenient place seen by tens of 437 Georgia Ave. thousands of patients every month. N. Augusta 29841 Jason H. Lee, DMD Literally! Call (706) 860-5455 for all 803-279-7450 116 Davis Road the details www.parkspharmacy.com Augusta 30907 Medical Weight & Wellness 706-860-4048 Specialists of Augusta THE AUGUSTA Maycie Elchoufi, MD MEDICAL EXAMINER Steven L. Wilson, DMD 108 SRP Drive, Suite B Psych Consultants Family Dentistry Evans 30809 • 706-829-9906 AUGUSTA’S 2820 Hillcreek Dr 4059 Columbia Road MOST SALUBRIOUS YourWeightLossDoctor.com Augusta 30909 Martinez 30907 NEWSPAPER (706) 410-1202 706-863-9445 www.psych-consultants.com

WEIGHT LOSS

I+

M.E.

PSYCHIATRY

+ 16 M E DI C I N E

I N

T H E

F I R S T

P E R S O N

It’s a marathon Editor’s note: A year ago, in our August 21, 2015, reader Ryan Heckendorn submitted his story of weight loss — “1/3 of me is gone!” — which began a year before. (Read his story by visiting issuu. com/medicalexaminer and scrolling down to the cover shown on page 1, or go directly to that issue at https://issuu.com/medicalexaminer/docs/aug21.15) We recently reached out to Ryan and asked for an update. This is his story at the start of Year 3 of his transformation.

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AUGUST 19, 2016

AUGUSTA MEDiCAL EXAMINER

nother year has passed but my change is still progressing. I’m about to pass the 2-year mark and I’ve learned as much if not more than I did the fi rst year.

You would think keeping up with being healthy would be easier. In a way it is, but at times it’s as hard if not harder than it was when I started.

What I mean by that is I’m in the habit of going to the gym or going for a run almost everyday. If I miss a workout I tend to get a little cranky.

It’s also hard to avoid monotony, so I change up my routine, nothing major

It’s not easy.

But it’s worth it. just changing the reps per set, warmup cardio workout, the miles that are being ran, the pace of the runs, or the route being ran. Changing the workout makes it easier since I’m keeping things fresh but it also makes the workout harder since I’m not used to it. A couple times a week I try to read articles on how to eat, different workouts, or things to try while running to increase my pace or mileage.

I have to admit I’m now about 5 pounds heavier than I was this time last year. It took me a long time to be ok with this, and was one of the harder things for me to learn. I still weigh myself every day, but now it’s not to compare with my previous day’s weight. Now it’s just part of my routine. I do it to calm my mind, but now I use pictures (see below) to remind myself of the changes I’ve made to my body and to really challenge myself to keep going and improving.

I’ve learned not every day will be an improvement, like

the year before. I just keep pushing, and instead of comparing one day to the next I compare with what I did the same time last year. There is still running, gym time, and eating healthy foods. I do cheat: my daily supplement is ice cream, but 80% of the time the food I eat is real and minimally processed. My “cheat day” is typically Saturday night or Sunday. When we do go out to eat I don’t worry about the calories much, but I don’t make that the norm.

In the coming months and year I have some pretty lofty goals.

I completed my fi rst half marathon this past April and had more fun than any person should while running 13.1 miles. This fall I plan on running at least one, hopefully two. Next spring I plan on running a half marathon in March, April, and May, keep challenging yourself. None of this means I’m working my way up to a marathon, I’m not even sure if that’s a goal anymore. I’m just doing what I can to challenge myself to make the harder parts a little easier to overcome and I’ve never been happier.

My workout schedule (which I worked up to gradually): Monday thru Friday during lunch I walk just over a mile.

Mondays and Wednesdays are gym days (after work).

Tuesdays and Thursdays are normal run days.

Fridays are either a short gym days, or a rest day if needed.

Saturdays are long run days.

Sundays are either rest days, recovery run days, or make up mileage if Saturday’s run is short.

This popped up on my Facebook feed this morning and it seems appropriate.” Progress is rarely a straight line. There are always bumps in the road...but you can make the choice to keep looking ahead.” — Kara Goucher + — Submitted by Ryan Heckendorn Columbia, South Carolina

WHY SO HARD?… from page 1

Ryan then

Ryan now

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WALK-INS WELCOME!

American diet is based on consuming 2,000 calories a day. So those unburned 800 calories are the equivalent of a 40 percent add-on to your daily diet without ever taking a single bite. Yikes.

But remember, we’re talking about Biggest Loser contestants, not you and me. That’s not something we necessarily have to contend with, but it does illustrate the difficulty of keeping lost weight lost.

“Human nature” was mentioned earlier. That’s a handy catch-all phrase for the inclination to return to the status quo, or to fight that inclination by dangling carrots in the direction of our goals.

The trouble is, they’re never carrots.

Someone may go to the track or the gym and spend an hour or two vigorously walking or exercising. To reward themselves for their good behavior, they’ll swing by Starbucks for a treat that will unwittingly, in five minutes, more than replace the calories they just spent hours burning.

We’ve all been there.

But don’t be discouraged.

If someone wants to lose weight — or their doctor has strongly advised them to do so — it’s definitely possible to succeed. No one said it would be easy. Take a look at Ryan Heckendorn’s weekly schedule (above) and you can see it takes work. But his story also

demonstrates that work works.

Is it drudgery? Not to him. “I’ve never been happier,” he says.

That brings up another key to success: changed thinking.

You may have noticed that political activist Al Sharpton, once upon a time a rotund character, has lost a lot of weight (167 pounds, to be exact), and has kept it off.

He stated in one interview that his friends were quite concerned about his weight loss. They thought he was sick.

His response: “They should have thought I was sick when I weighed 300 pounds; that’s when I was sick.”

The perception of what is normal and healthy weight, as Sharpton’s experience indicates, has grown right along with our collective waistlines.

A couple of the key takeaways from The Biggest Loser are that rapid weight loss can spell rapid weight gain.

Losing weight more slowly seems to give the body time to adjust and accept itself instead of trying to return to “normal.”

Additionally, a “diet” is almost by definition temporary.

They’re often weird and unsustainable over extended periods.

Instead of going on a diet, change your diet.

And remember: it’s not all about eating. It’s also how many calories are burned in regular, scheduled exercise.

You can succeed. +