Tuesday, April 16, 2019

How To Choose Speakers Audio Amplifier Review

Whenever you set up any sort of sound framework you have to ensure that every one of your ducks are in succession. Regardless of whether it's a home theater framework or something custom for your auto, they all require the appropriate measure of capacity to go ahead. Typically huge speakers that have a great deal of wattage require a particular kind of enhancer to ensure they control on effectively. The entire procedure of knowing how to pick sound intensifier for speakers is extremely simple once you comprehend the procedure.
How To Choose Audio Amplifier For Speakers


1 How To Choose Audio Amplifier For Speakers

1.1 What Is An Audio Amplifier?

1.2 What Is The Role Of An Amplifier?

1.3 What About Speaker Impedance?

1.4 Is Sensitivity Important?

1.5 Should I Get An Amplifier With More Power?

1.6 Understanding The Modes

1.6.1 Stereo Mode

1.6.2 Parallel Mode

1.6.3 Bridged Mode

1.7 Which Audio Amplifiers Perform The Best?

2 Two Awesome Speaker/Amplifier Combinations You Can Buy Right Now

2.1 Pioneer SP-FS52 Speakers

2.2 Pioneer SP-BS22-LR Speakers

3 Final Thoughts

Instructions to Choose Audio Amplifier For Speakers

To pick a sound intensifier you essentially need to know the specs, voltage and different subtle elements encompassing them. Intensifiers can be procured in either powerful or low fueled renditions. You'll need to know what number of channels it has so you can arrange that according to the measure of speakers you need controlled. The other thing you have to consider is the sort of sound you need to deliver. There are possibilities for both single channel, stereo and even multi-directed yield. Regularly you'll discover 5 to 7 channel enhancers available for their adaptability and capacity to complete an assortment of things. It knows how they are composed and function too which we'll get into straightaway.

What Is An Audio Amplifier?

A sound speaker is a gadget who's primary capacity is to give the power expected to drive your amplifiers. They are little gadgets yet they have a lot of usefulness. Every one of them has a specific number of channels on them. The measure of channels alludes to what number of those speakers it can control at the same time. For instance in the event that you have a subwoofer and customary speaker then you'll need an intensifier that has something like two channels. All things considered we would think about this as a stereo intensifier which gives you a full stable and panning. Speakers come in all shapes and sizes which enables you to fit it to your coveted circumstance.

What Is The Role Of An Amplifier?

Intensifiers work by expanding the intensity of a flag. These little streams are transformed into bigger ones. The flag is basically the electrical rendition of a sound wave and the entire objective is to push that as far as possible and extend it. We measure those increments by a metric called "gain". Gain is basically the extent of the voltage and current to the information. It's essential to see however that speakers do have their cutoff points. When they hit those points of confinement we hear contortion. This commonly happens when there's insufficient power left to coordinate the affectability levels of the speakers (more on this later).

What Is The Role Of An Amplifier

Shouldn't something be said about Speaker Impedance?

The principal thing you need to do while picking a sound intensifier your speakers is understanding on the off chance that it resolve it viably or not. To make sense of that you'll need to investigate the impedance level of your speakers. As a rule you'll see this alluded to as "ohms" when taking a gander at the specs of speakers and earphones. Generally this is given as various either 4 or 8 ohms. The higher the impedance the more power you'll have to control that speaker. To improve of thought of what impedance is perused this article.

Fortunately most speakers are appraised to create for either 4 or 8 ohms so finding a perfect one isn't excessively troublesome. What you need to recollect while picking an intensifier for your speaker is that your amplifier can fit inside that range. For instance if your speaker falls underneath that scope of 4 to 8 ohms then you need to find an enhancer that is of a lower impedance rating. Speakers can wind up flimsy in case you're utilizing contradictory hardware.

Is Sensitivity Important?

Affectability is completely essential to the execution of your speakers. This is a metric that is straightforwardly identified with the volume yield of your speakers. Typically when you attempt to peruse this rating on the speaker framework it very well may be a bit of confounding. You'll see a mix of letters and numbers like this; 90dB @ 1W/1M. That number is fundamentally disclose to you 90 decibels at 1 watt more than 1 meter. In short it implies that with 1 watt of intensity sitting at 1 meter away you'll get a creation of 90 decibels of sound. This is your volume yield level.

The general purpose of this however is the lower that number is the more power your enhancer will need to draw out a higher volume level. In the event that the number is higher however at a similar watt and meter level then the enhancer would require less power. This is critical in light of the fact that the less power you have the more harm you can really do to your speaker framework after some time.

Would it be a good idea for me to Get An Amplifier With More Power?

The response to this is a staggering yes. Since music is such a dynamic stream of waves you need to represent those changes in tone. In case you're tuning in to a delicate tune and after that out of the blue it gets boisterous, you'll need to have the ability to achieve that dynamic. The power originates from your speaker.

Be that as it may if the enhancer isn't solid enough to create that tone in connection to the speakers affectability rating then it will battle to do as such. This puts more strain on the speaker framework to attempt and compensate for what the intensifier isn't improving the situation it. Generally you hear this frequently heard as cutting in the blend. It's a cruel sound which is flagging that the cutoff points have been come to. The more twisting you have after some time the more harm you can do.

Understanding The Modes

We said the channels and a portion of the diverse choices out there, and they all play into the different working methods of a sound enhancer. The modes you'll need to be worried about are stereo, parallel and crossed over mode. These working modes influence how the speakers will sound and their execution qualities. A large portion of this needs to do with flag yield and power appraisals. Every mode takes into account a particular kind of setup depending your necessities in those territories.

Stereo Mode

In the event that you are occupied with 2 channel speakers then stereo mode is the thing that they'll work in for the most part. Stereo intensifiers are ideal for controlling a couple of speakers rather than one or multi-channel frameworks. What's flawless is that every one of those channels has their own signs that work freely of each other. Consider it having two individual speakers working under their own mono settings. The cool thing is you can have every speaker play out their own individual errand without having any impact from another. One speaker could work for music while the other can be your screen speaker.
Parallel Mode

Parallel mode is somewhat unique in relation to stereo however enables you to send a solitary flag to two channels. On the off chance that you had three speakers or so this is an incredible element since you can pass that same flag to every one of your speakers.

Crossed over Mode

Scaffold mode remains consistent with it's name by consolidating channels. Those channels are sent to a solitary yield and in this manner copies the power. In case you're utilizing a subwoofer this is an ideal setup to utilize.

Which Audio Amplifiers Perform The Best?

There's a huge amount of brands out there for sound intensifiers. Numerous trustworthy brands like Sony, BOSS and Yamaha make incredible models as well. In the event that we needed to propose something then we would state attempt to guarantee your speakers coordinate by mark. This is dependably the best case for when you need extraordinary similarity when you remain inside the brand. On the off chance that you have Yamaha speakers, at that point get a Yamaha enhancer et cetera. Likewise make sure to coordinate your determinations by the ohms and affectability appraisals and you'll have everything that you require.

Two Awesome Speaker/Amplifier Combinations You Can Buy Right Now

Maybe you're in a position right now where you really don't claim an amp or speaker framework. Perhaps you don't know which mixes would work best for your own home theater or excitement needs. To help make things somewhat simpler for you we've assembled an amazing mix of speakers and amps that you can without much of a stretch get at the present time. These are extraordinary entertainers and above all they are perfect with one another. The other thing to note is that the speakers are not super costly and you can consolidate them with generally shoddy enhancers and still get wonderful execution.

Pioneer SP-FS52 Speakers

The Pioneer SP-FS52 are an astounding arrangement of floor standing boisterous speakers that deliver stunning sound. It's one of pioneers tallest speakers at 8.88 x 10.62 x 35.19 inches. They include bended cupboards and fantastic surface subwoofers for extraordinary sound. The bass reaction is smooth and there's likewise larger than average magnets worked in to help with that. There are three of those implicit and they measure in at 5 1/4 inches. To help tailor the high frequencies there's a 1 inch delicate vault tweeter worked in too. This helps make those abnormal states run over smooth and refined rather than cruel and tin sounding. It's likewise a high effectiveness tweeter that enables you to play your music louder yet without requiring as much capacity to do that.

Periodically with floor speakers you'll have erroneous mixes in the blend because of it's shape and plan. With the Pioneer SP-FS52 however there's a 8 component hybrid the mix of both the high and low ranges is precisely what audiophiles are searching for. The hybrids work by separating those frequencies into different ranges with the goal that you get everything from low to mid-go and past. These speakers are evaluated at 6 ohms, so they'll combine flawlessly with the Adopt Texas Instruments TDA7498E. It's a 2 channel amp that can draw out 160 watts and it has a lot of intensity supply. It's additionally generally modest, calm in activity and has a decent minimal edge that you can put anyplace.

Pioneer SP-BS22-LR Speakers

In case you're searching for a decent determination of bookshelf speakers then the Pioneer SP-BS22-LR speakers will be your decision. These rae more reduced speakers at 8.4 x 7.1 x 12.6 inches and weighing around 9 pounds. They direct out a noteworthy 80 watts and an impedance of 6 ohms. They additionally include the RF shaped bended cupboards. The subwoofer is 4 inches and furthermore includes larger than average magnets for a superior bass quality. As opposed to 8 complex hybrids this model just highlights 6 because of it's size.

For the associations you'll discover restricting posts. There's openings for banana plugs or exposed wire. Generally speaking the sound is magnificent, particularly in the higher registers. It's not very splendid and you can get some respectable volume from it even at bring down levels. A decent amp for this unit would most likely be the Pyle Home 2×120 Watt Audio Speaker Power Amplifier. It's a quite modest unit with a lot of controls and it's anything but difficult to utilize. There's additionally EQ controls worked in alongside RCA inputs.

Last Thoughts

Since you discover somewhat more about how speakers function it's an ideal opportunity to go get the best one for you. We've demonstrated to all of you the essential elements you have to know. The main thing you have to search for is the impedance of your speakers and in addition comprehend what the affectability levels are. Those will be the two most critical components for you since that will practically figure out which intensifier you get.

Once you have that settled make a point to get an enhancer that coordinates with those specs. Keep in mind that on the off chance that you get something that is under the power level you require that you may keep running into a few issues. It's in every case great practice to simply purchase something with more power than you require so you have that headroom to work with. Additionally get an enhancer that has some movable settings on it on the off chance that you can. Something like the Pyle Home 2×120 Watt Audio Speaker Power Amplifier is an amazing precedent with it's volume handles and EQ settings. On the off chance that you need to truly take things up an indent there are magnificent home theater recipients that can do the majority of this and more in one area.

Eventually you needn't bother with anything super extravagant to begin. By and large floor speakers utilize more wattage because of their size and structure contrasted with bookshelf speakers. Remember that as you search for your framework. Good fortunes!
Read More »

Ways to Choose Outdoor Speakers

Appreciating great music outside is something a large portion of us get a kick out of the chance to do. Beyond any doubt we can simply sit inside or be limited to our earphones, yet a decent arrangement of outside speakers can make things fun. Regardless of whether you're relaxing by the pool or soaking up the sunshine at the shoreline; having music with you is constantly fun. Open air speakers can come in all shapes and sizes as well. Here and there they're little and compact like the JBL Charge 3 and different occasions they are significantly bigger like the Sony GTK Xb90. There's even a few circumstances where you can interface Bluetooth speakers to extremely spread the a good time for a gathering. Making sense of how to pick open air speakers isn't excessively extreme on the off chance that you comprehend the vital specs and your listening purposes.
Image result for How To Choose Outdoor Speakers


1 How To Choose Outdoor Speakers – 5 Things To Consider

1.1 Size and Portability

1.2 Bluetooth Speakers Work The Best

1.3 How Much Sound Do You Need?

1.4 Durability and Weather Proof Speakers

1.5 Mountable Speakers Work Well

1.6 Final Thoughts

Step by step instructions to Choose Outdoor Speakers – 5 Things To Consider

Beneath we've assembled an accommodating aide on the most proficient method to pick open air speakers for your home, next excursion and gathering. There's two or three particular choices we'll interface you to that we think function admirably. We'll get into a few points about how to pick speakers in light of their size, compactness and even on in the event that you can mount them up on a divider or not. Ideally these tips give you some amazing knowledge on the diverse kinds of open air speakers and how you'll need to utilize them advancing.

Measure and Portability

The greatest thing you have to consider while picking open air speakers is the size. A great many people think remote speakers must be these minor little gadgets to grasp. Think about the Beats or Bose small scale speakers to get a thought of what we mean. Anyway there are a few expansive yet in addition minimal choices you can pick as well. It sort of comes down to where you're going and the capacity you're utilizing these speakers for.

In the event that you intend to go to an open area like the shoreline then chances are you don't need something huge that you need to carry around. The bigger the speaker the more work you need to experience to haul it out there. Something like the Beats Pill is perfect here on the grounds that you can rapidly hurl it in a sack and take it out.

Likewise consider utilizing a speaker that doesn't require any sorts of wires to work. In the event that it's battery controlled then that opens up where you can set the speaker up. Commonly you need to stay with something that can keep going for 4 hours or more off of a solitary charge. Numerous speakers additionally can pass on battery juice to your spilling gadgets too. For instance if your cell phone is getting low you can share a portion of that vitality by connecting it to with a USB link to your speaker. No outlets are required for this and it's totally versatile.

Bluetooth Speakers Work The Best

Regardless of what sort of speakers you put resources into you have to ensure that they are Bluetooth. Bluetooth truly changes the manner in which you can cooperate and play your music; however above all else it's the most helpful. A considerable lot of the prevalent speakers available presently are furnished with Bluetooth 4.0 so the stream characteristics are constantly choice. There's once in a while any sort of faltering or incessant skips which is vital for you pleasure needs. A large number of these speakers are likewise stacked with codecs to help channel the most noteworthy quality playback conceivable. You can even upscale mp3 documents and more to CD quality playback rather than that old, fluffy sound.

A considerable lot of the brands are currently including applications that you can download to your cell phones and tablets. For instance Sony and Bose have applications where you can control different speakers on the double, spare music documents, control the volume and more from any area. In case you're facilitating a gathering it's significantly simpler to control the sound while you blend as opposed to having to always stroll back to the speaker to modify things. That is simply irritating right? Over that a considerable lot of these open air speakers take into account different gadgets to interface with them all in the meantime so you can partake in on the good times.

The amount Sound Do You Need?

Playing music outside is somewhat not quite the same as doing as such inside. Dislike when you have a couple of earphones and that sound is piping straight into your ears. Rather you must manage the majority of the outside components. This incorporates wind, autos and even only the sheer measure of room you need to fill sound with. It's critical to pick speakers that can accommodate your coveted need. Time and again individuals buy these extensive speakers and acknowledge they have considerably more than they require. It occurs in the invert too with them getting littler speakers trusting they'll draw out the quality they require. It's critical to have a devoted speaker for particular capacities rather than a one size fits all.

In case you're having a family assembling or grill out back on the porch then you presumably need an OK measured speaker. A little Bose speaker essentially won't take care of business. Something with substantial tweeters, a lot of sub frequencies and high power will do best in this circumstances. We can suggest something like the Yamaha NS-AW150 speakers which you can discover on Amazon. Speakers like that one can draw out exceptional power like 120 watts of sound to oblige their drivers. Numerous open air speakers likewise have devoted woofers worked in so you don't need to purchase a bundle of partitioned parts to pull everything together. Something like the Yamaha would be incredible in case you're endeavoring to engage a considerable measure of visitors, appreciate a family motion picture on the open air projector and that's only the tip of the iceberg.

In case you're in to a greater degree a private space like perusing a book on the shoreline or something of that nature you won't require something that ground-breaking. The Doss Soundtouch for instance is to a great degree minimal, has great sound and has long playback times as well. With little speakers like this you're continually searching for double execution drivers so you can get that stereo impact. Typically 12 watt drivers will do fine and dandy making it sufficiently uproarious for you however not to the point it would bother others.

Strength and Weather Proof Speakers

Whenever you're managing the outside you need to factor in how the components can influence your hardware. You can't simply put any sort of speakers outside where it's breezy, stormy and even tempests can play a factor. Simply envision the water getting into the packaging, fouling up the circuits and destroying your speakers. That is for the most part the dread individuals have when they take customary open air speakers outside.

Rather you ought to put resources into a decent arrangement of waterproof speakers. With climate confirmation speakers you have materials that can deal with being drenched and they are for the most part constructed harder. The external packaging for instance is extremely firm and doesn't simply permit water into it effectively. Climate evidence speakers are additionally incredible for extraordinary high temperatures, visit introduction to the sun and even extremely cool conditions. You ought to have the capacity to make the most of your music at whatever point you need so it's imperative you get speakers that can toward the end in all seasons. Likewise these sort of speakers can without much of a stretch withstand soil, shoreline sand, mud and minor drops. You need to ensure your speakers are not all that delicate that they'll quit chipping away at you rapidly.

Mountable Speakers Work Well

Some of the time individuals need speakers that can be set up once and not disturbed once more. In the event that that sounds like you then mountable speakers are ideal. These are the kind that you can set up on shafts or hang up in a divider. Numerous speakers like the PDWR62BTBK will have mounting sections on them with the goal that you can edge them at any rate you might want to.

We suggest ensuring that the sections enable you to effortlessly turn the speakers easily so you're not adhered getting off it keeping in mind the end goal to change that. To oblige this in case you're getting mountable speakers then you have to consider how they connect together. On the off chance that they're not Bluetooth then you'll need to utilize a few links to daisy chain them together. For an incredible rundown of Bluetooth speakers that can be connected snap here.

Last Thoughts

At last purchasing speakers for the outside is an extremely close to home thing. It comes down to what you need to hear, the amount of it you need to hear and where you need to hear it. We sincerely recommend that you put resources into two distinct sizes of speakers so you can deal with various circumstances. It's alright to have a substantial speaker for engaging a few people and after that something little and compact only for yourself.

Most versatile small scale speakers are generally cheap except if you move with something from an exceptional brand like the JBL Flip. Typically you can get something little and economical however and think that its charming however. Likewise consider getting a brand of speakers that you can connect together however. That way you can truly have a ton of fun immersive experience.
Read More »

Friday, April 12, 2019

Sleep apnea may raise your risk

In the 1890s, a Shakespearean actor named Frederick Matthias Alexander set out to discover why he often lost his voice when he performed. (Imagine yourself as a Shakespearean actor, completely dependent on your voice to pay your bills, finding yourself without a voice just when you needed to perform!) Needless to say, Alexander had to figure out why this was happening.

He began by observing himself in multiple mirrors while he prepared to perform. Indeed, he did discover that something changed prior to his speaking: He was contracting the muscles in his upper body, especially his neck, so strongly that his entire posture changed. He theorized that his voice loss could be a result of his disrupted posture.

Fortunately, his guess turned out to be correct. When he was able to release the tension in his muscles with a variety of movements, not only did his voice loss resolve, but he was able to change the habit he had developed of contracting his neck. As he continued to refine and improve his methods, Alexander realized they could help others improve their health and well-being. His discoveries, which have since been codified into the Alexander Technique (AT), are still in use today.
How is the Alexander Technique used today?

Today, AT is considered a mental discipline that teaches individuals how to let go of tension in the body and how to enable the body to move with ease and minimal effort. AT is used to treat a variety of conditions, from musculoskeletal pain and repetitive strain injuries to breathing problems, voice loss, and sleep disorders. Many artists, musicians, dancers, singers, and actors use AT to help enhance their performance. The purpose of AT, ultimately, is to enable individuals to methodically unlearn maladaptive (negative) habits — which can show up in the way we stand, sit, eat, walk, or talk — and instead learn how to return the body to a relaxed, balanced state of alignment and poise.
Is AT for you?

But you don’t have to be a musician or dancer to benefit from AT. Here’s just one example: You, like most of us living in today’s world, spend much of your time on a computer or checking your smartphone for emails and texts. This means you spend much of your time looking down, rather than straight ahead, the way your vertebrae were designed to support your head. Keeping your head bent down for long periods puts continual strain on the large neck muscles, which are meant to normally be lax. In contrast, the small neck muscles (which are meant to hold up your neck vertebrae) are not being used and are therefore lax. The result is that your vertebrae lose their support, so that you end up not only with neck stiffness or pain, but possibly some degeneration in your cervical spine, too.

AT can address this habitual contraction of the neck and teach you how hold your phone, how to position your head, and ultimately, how to re-establish better posture and ease in your body.
Is there science to support AT?

A recent randomized controlled study published in the Annals of Internal Medicine found that Alexander Technique lessons led to significant reductions in neck pain over 12 months, compared with usual care. (Interestingly, the study also found that acupuncture reduced pain as well, compared with usual care.)

Another interesting study published in the medical journal BMJ in 2008 tested a variety of treatments for back pain. A total of 579 patients with chronic or recurrent low back pain were randomly divided into four groups. The first group were given “normal care” (that is, they were the control group). The second group received massages. The third took six Alexander Technique lessons. The fourth group took 24 Alexander Technique lessons. Half of each group also received a prescription for exercise (primarily walking) from a doctor, plus behavioral counseling from a nurse. The results showed that the patients who had AT lessons along with an exercise plan improved the most. In addition, this combined intervention was also the most cost-effective (in particular, taking six lessons combined with an exercise plan).
What does this mean for you?

Proponents of the Alexander Technique would tell you to start paying attention. Pay attention to your posture — the way you walk, talk, sit, stand, or generally do anything, even lifting a forkful of food to your mouth. If you are like most people, your body is likely stuck in tense muscle patterns that may be causing you myriad problems, from back pain to headaches to possibly even anxiety. It may behoove you to unlearn these stuck patterns so you can move through your life with more ease — and much, much less pain. Leftover Halloween candy. Marathon Thanksgiving meals. Up-for-grabs office chocolates. One holiday party followed by another…and another.

Whether you want to avoid overeating and gaining those extra pounds, you need to control your blood sugar (for example, if you have diabetes), or you simply wish to consume only what your body requires, the holiday season can make that goal challenging.

But mindful eating might help you reach it.

Mindfulness refers to the practice of being aware and in the moment. All too often, our thoughts wander somewhere other than where we are in the moment. Perhaps we are preoccupied with what happened an hour ago, worried about what might happen tomorrow, or stressed over what we need to do next week. Mindfulness encourages us to notice these preoccupations, and then to gently bring ourselves back to the now.

Mindfulness can help you fully enjoy a meal and the experience of eating — with moderation and restraint. Some studies suggest that mindfulness-based practices help improve eating habits. For those who binge-eat or eat for comfort or out of stress, mindful eating may even aid with weight loss.

Here are 10 tips for more mindful eating. Not all of these tips may feel right for you — try a few and see how they work.
1.  Reflect.

Before you begin eating, take a moment to reflect upon how you feel. Are you rushed? Stressed? Sad? Bored? Hungry? What are your wants, and what are your needs? Differentiate between the two. After you have taken this moment to reflect, then you can choose if you want to eat, what you want to eat, and how you want to eat.
2. Sit down.

Don’t eat on the go. Have a seat. You’re less likely to appreciate your food when you are multi-tasking. It’s also difficult to keep track of how much you are eating when you snack on the go.
3. Turn off the TV (and everything else with a screen).

Have you ever glanced down from your phone or tablet or computer, only to wonder where all the food went? These distractions make us less aware of what and how much we are eating.
4. Serve out your portions.

Resist eating straight from the bag or the box. Not only is it easier to overeat when you can’t see how much you’ve had, but it is also harder to fully appreciate your food when it is hidden from view.
5. Pick the smaller plate.

You might crave less if you see less. Smaller plates will help you with your portion control — an especially good strategy for those all-you-can-eat buffets.
6. Give gratitude.

Before you start to eat, pause and take a moment to acknowledge the labor that went into providing your meal — be it thanks to the farmers, the factory workers, the animals, mother Earth, the chefs, or even your companions at the table.
7. Chew 30 times.

Try to get 30 chews out of each bite. (30 is a rough guide, as it might be difficult to get even 10 chews out of a mouthful of oatmeal!) Take time to enjoy the flavors and textures in your mouth before you swallow. This may also help prevent overeating by giving your gut time to send messages to the brain to say you’re full.
8. Put down your utensil.

Often, we are already preparing the next morsel with our fork and knife while we are still on our previous bite. Try putting down your utensils after each bite, and don’t pick them back up until you have enjoyed and swallowed what you already have in your mouth.
9. Resign from the Clean Plate Club.

Many of us were brought up to finish everything on our plate and were not allowed to leave the table until we did. It’s okay to cancel your membership to the Clean Plate Club. Consider packing the leftovers to go, or just leaving the last few bites. Even though nobody likes to waste food, overstuffing yourself won’t help those in need. (This is also where Tip #5 comes in handy.)
10. Silence.

Try eating your meals in silence once in a while. When it’s quiet, it is natural for the mind to wander; acknowledge these thoughts, and then see if you can gently return to your experience of eating. Be conscious of the food’s consistency, flavor, tastes, and smells, and fully appreciate the moment. Of course, mealtime can be an important time for sharing the day when the whole household gathers, so having an entire meal in silence might be impractical or just feel awkward. But even spending the first five to 10 minutes in silence can be refreshing and set a grateful tone for the rest of the meal.

Mindfulness offers many benefits throughout the year, but can be especially helpful during the holidays, even beyond healthful eating. Purposefully focusing your attention on the present can help you embrace companionship, connectivity, and overall contentment and help make the season more meaningful for you. If you have arthritis, you may have noticed that the weather affects your symptoms. I hear it from my patients all the time.

If it’s true that the weather can worsen arthritis pain, how does that work? Is there any scientific evidence to explain it? People have been asking these questions for many years without finding good answers. But that’s not keeping researchers from trying to understand it better.
What we (think we) know

Past studies examining the effect of rain, humidity, and other weather-related factors on symptoms of arthritis have been inconclusive, and in some cases, contradictory. Some suggest that the key variable is rising barometric pressure. Other studies found just the opposite — that falling pressure could provoke joint pain or stiffness. There have even been attempts to artificially vary environmental conditions to mimic weather changes, such as placing arthritis sufferers in barometric chambers and varying the pressure up and down.

Despite this, we still don’t know whether it is one particular feature of the weather or a combination of features that matters. There are many potential factors — humidity, temperature, precipitation, and barometric pressure among them. Even if we could precisely identify what about weather affects arthritis pain and stiffness, we’re still not sure why — biologically speaking — weather should have any impact on joint symptoms.

Having reviewed the studies, I find myself not knowing how to answer my patients who ask me why their symptoms reliably worsen when the weather is damp or rain is coming, or when some other weather event happens. I usually tell them that, first, I believe there is a connection between weather and joint symptoms, and second, researchers have been unable to figure out just what matters most about the weather and arthritis symptoms or why there should be a connection.
The newest studies

In just the past year or so, two new studies have weighed in on the question of whether weather has an impact on arthritis symptoms. And both found that yes, indeed, weather matters!

In the first study, Dutch researchers enrolled 222 people with osteoarthritis of the hip — the most common, “wear-and-tear” type of arthritis — and compared their reported symptoms with a variety of weather variables. They found that over a two-year period, pain and stiffness were slightly worse with rising barometric pressure and humidity, although the overall average impact was small. The second study included more than 800 adults living in one of six European countries and who had osteoarthritis of the hip, knee, or hands. Although changes in weather did not seem to affect symptoms, higher humidity was linked with increasing pain and stiffness, especially in colder weather. So, while these studies varied in the specifics, we now have a bit more evidence linking weather to joint symptoms.
So what?

It’s a fair question. After all, even if we could prove a clear and powerful impact of weather on symptoms of arthritis, how is that helpful to know? It’s not as if doctors are likely to suggest that a patient move to a more arthritis-friendly climate. It’s even less likely that patients would follow such a recommendation. Until we can control the weather or our internal environments with precision, these new studies probably have little impact for the individual arthritis sufferer.

However, identifying a link between a particular type of weather and joint symptoms might help us understand the causes and mechanisms of arthritis symptoms. And that might lead to better treatments or even preventive strategies. In addition, figuring out why some people seem to feel worse in certain circumstances while others notice no change (or even feel better) in those same environments could help us understand subtle differences between types of arthritis or the ways individuals respond to them.
“Everyone keeps talking about the weather…

…but no one is doing anything about it.” That’s an old line but, of course, there’s truth to it. But even if weather does affect the symptoms of arthritis and there’s nothing that can be done about the weather, that doesn’t mean there’s nothing to be done about the arthritis! There are more treatment options than ever before, with and without the use of medications. If you have significant and persistent joint pain, stiffness, or swelling, see your doctor — rain or shine. If you’ve never heard of the Nordic diet, you might imagine a plate of those Swedish meatballs sold at Ikea. But in fact, this eating style focuses on healthier fare, including plenty of plant-based foods that nutritionists always encourage us to eat. And while the data are limited so far, several studies suggest following a Nordic eating pattern may foster weight loss and lower blood pressure.

As the name suggests, the Nordic diet features foods that are locally sourced or traditionally eaten in Denmark, Finland, Iceland, Norway, and Sweden. Developed in collaboration with the acclaimed Copenhagen gourmet restaurant NOMA, the diet emphasizes the use of seasonal, healthy, regional foods. (It doesn’t necessarily represent how most Scandinavians eat on a daily basis, however.)
What the diet delivers

Nordic diet staples include whole-grain cereals such as rye, barley, and oats; berries and other fruits; vegetables (especially cabbage and root vegetables like potatoes and carrots); fatty fish such as salmon, mackerel, and herring; and legumes (beans and peas).

“The Nordic diet is a healthy dietary pattern that shares many elements with the Mediterranean diet,” says Dr. Frank Hu, professor of nutrition at the Harvard T.H. Chan School of Public Health. The Mediterranean diet — widely considered the best eating pattern for preventing heart disease — also emphasizes plant-based foods. Both diets include moderate amounts of fish, eggs, and small amounts of dairy, but limit processed foods, sweets, and red meat.

While the Mediterranean diet includes olive oil, the Nordic diet favors rapeseed oil (also known as canola oil). Like olive oil, canola oil is high in healthy monounsatured fat. But it also contains some alpha-linolenic acid, a plant-based omega-3 fatty acid similar to the omega-3 fatty acids found in fish. Of course, fatty fish — the richest dietary source of omega-3s — play a role in both Nordic and Mediterranean diets (try for two to three servings a week).

The Nordic diet also emphasizes high-quality carbohydrates: cereals, crackers, and breads made with whole-grain barley, oats, and rye. Americans may be familiar with Swedish Wasa crispbreads, most of which are made with whole grains. In Denmark, a dense, dark sourdough bread called Rugbrød is popular. These whole-grain foods provide a wealth of heart-protecting nutrients, including fiber, vitamins, minerals, and antioxidants.

Eating lots of berries is another unique aspect of the Nordic diet that may account for some of its health benefits. Research by Harvard scientists has linked eating plentiful amounts of berries (such as blueberries and strawberries) to less weight gain and a lower risk of having a heart attack. Berries are excellent sources of plant chemicals known as anthocyanins, which seem to lower blood pressure and make blood vessels more flexible.
Bonus: It’s easy on the environment, too

The Nordic diet offers an added bonus: it’s environmentally friendly. For one thing, plant-based diets use fewer natural resources (such as water and fossil fuels) and create less pollution than meat-heavy diets. In addition, eating locally-produced foods also reduces energy consumption and food waste, says Dr. Hu. And while the Nordic diet makes sense for those living in Northern Europe, people everywhere can apply those same principles to their diet no matter where they live.

While the Nordic diet isn’t proven to prevent heart disease to the same extent as the Mediterranean diet, it’s clearly a step above the average American diet, which has too much processed food and meat to be considered good for the heart. “People who really like berries, rye bread, and canola oil should go ahead and enjoy a Nordic-style diet rather than waiting 10 years to get more evidence,” says Dr. Hu. Stress-related health problems are responsible for up to 80% of visits to the doctor and account for the third highest health care expenditures, behind only heart disease and cancer. But as few as 3% of doctors actually talk to patients about how to reduce stress.

Mind-body practices like yoga and meditation have been shown to reduce your body’s stress response by strengthening your relaxation response and lowering stress hormones like cortisol. Yoga has been shown to have many health benefits, including improving heart health and helping relieve depression and anxiety.

But the cost-effectiveness of these therapies has been less well demonstrated — until now.
The study

Dr. James E. Stahl and his team of Harvard researchers studied a mind-body relaxation program offered through the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital. The 8-week program taught participants several different mind-body approaches, including meditation, yoga, mindfulness, cognitive behavioral skills, and positive psychology. The study volunteers participated in weekly sessions and practiced at home as well.

The researchers found that people in the relaxation program used 43% fewer medical services than they did the previous year, saving on average $2,360 per person in emergency room visits alone. This means that such yoga and meditation programs could translate into health care savings of anywhere from $640 to as much as $25,500 per patient each year.

“There are many ways to get to the well state — many gates to wellness, but not every gate is open to every person. One of the strengths of the program is that it draws upon many different tools that reinforce each other and allow many gates to be opened to a wide array of people,” says principal investigator Dr. Stahl, who is now section chief of general internal medicine at Dartmouth-Hitchcock Medical Center.
Yoga and meditation are soaring in popularity — but will insurance pay?

Yoga and meditation programs are gaining wide appeal. Nearly one in 10 Americans practices yoga, and 45% of adults who don’t practice yoga say they are interested in trying it. Americans are also using other forms of complementary health therapies, such as meditation (8%) and deep breathing (11%).

Many health care plans do not cover yoga or meditation, although some provide discounts for fitness programs including yoga or tai chi. States like Washington require private health insurers to cover licensed complementary health care providers, but the majority of states do not. However, that may soon change.

A recent article in the Harvard Business Review recommends that health insurers cover wellness and prevention-oriented therapies that are both low-cost and evidence-based, as both yoga and meditation are. The article discusses a study of Aetna employees who participated in the company’s mindfulness program and enjoyed a 28% reduction in stress, 20% better sleep, and 19% less pain, as well as an increase in worker productivity worth an estimated $3,000 per employee per year. The company offers free yoga and meditation programs to its employees.

“There are a lot of great studies on the biologic side, just not enough on the economics,” notes Dr. Stahl, who is looking to change that with his ongoing research. As the evidence for the health benefits and cost-effectiveness of yoga and meditation programs continues to grow, we can expect to see more interest from health care insurers
Read More »

Wednesday, April 10, 2019

Benefits men with locally advanced prostate cancer

When I talk to parents who are hesitant about vaccines, what they most want to talk to me about are possible side effects of the vaccine. They worry about everything from fevers and soreness to additives to possible links to autism. They rarely worry about the diseases that vaccines prevent—and that’s what worries me most of all.

It is the inconvenient truth of vaccine refusal: when you don’t get vaccinated against an illness, you are more likely to catch it.

A study just released in the Journal of the American Medical Association (JAMA) makes this very clear. Researchers looked at information about recent measles and pertussis outbreaks. They found that unvaccinated people made up the majority of those who caught measles and a large proportion of those who caught pertussis (waning immunity from the pertussis vaccine plays a role in those outbreaks). Some weren’t old enough to be vaccinated—but of those who were old enough, most came from families who had chosen not to vaccinate.

We developed vaccines for a reason: to stop children from getting sick and dying. This was not a money-making stunt by drug companies, as some claim. Here in the United States, vaccines have done such a great job that we have literally forgotten about the ravages of measles, polio, pertussis, diphtheria, and the many other illnesses that we can now prevent.

They truly were ravages. Who even remembers diphtheria? Between 1936 and 1945, there were about 21,000 cases and 1,800 deaths a year of diphtheria. In those same years, paralytic polio affected 16,000 and killed 1,900 each year. And for measles and pertussis, the numbers are even higher. Every year 530,000 people caught measles and 440 people died from it; 200,000 caught pertussis and 4,000 died from it.

Four thousand died every year from pertussis. In 2014, that number was 13. We simply cannot ignore that vaccines are incredibly effective, and save thousands and thousands of lives.

It’s the scarcity of the illnesses that has made some parents comfortable with the decision not to vaccinate. If you are unlikely to run into anyone with measles or chickenpox, why take any chances with side effects?

There are two problems with that argument. First, as more people have chosen not to vaccinate, there have been more outbreaks. And when those who choose not to vaccinate live in the same communities, as a study out of Kaiser Permanente showed was the case in California, it can create the perfect environment for a vaccine-preventable germ to spread.

Second, we live in a global community. Travel is relatively easy, and lots of people do it. And while we may have done a great job eradicating vaccine-preventable diseases here in the U.S., they certainly haven’t been eradicated from the world. Diphtheria is still alive and well, affecting 50,000 people a year and killing half of them. There are 344,000 cases of measles—and 145,000 deaths from it. For pertussis, the numbers are even higher: 30-50 million cases, and 300,000 deaths.

People are often contagious before they even know they are sick. Someone could bring measles to a community without knowing it—and 90% of the unvaccinated people who are exposed to the measles virus will get sick (the virus can even hang out in a room for two hours after the person with measles leaves). Half of the babies who catch pertussis end up hospitalized—and of those who are hospitalized, three out of five have trouble breathing, and one in 100 die despite the best possible care.

We just can’t say that it’s safe to be unvaccinated. It’s not safe for the child whose parents choose not to vaccinate—and it’s really not safe for the infants or people with immune problems who cannot be vaccinated, who need vaccinated people around them to keep them well.

Vaccines are a medical treatment, and like any medical treatment, they can have risks and side effects. So much has been done, and is still being done, to make vaccines as safe as possible. It’s always important to ask questions and be careful in making decisions.

But when making those decisions, it’s crucial to think not just about the vaccine—but about the disease it can protect you from. A new study has shed light on one of the long-term effects of proton pump inhibitors (PPIs). These drugs are commonly used to treat gastroesophageal reflux disease (GERD), heartburn, and peptic ulcers. PPIs (omeprazole, lansoprazole, esomeprazole, pantoprazole, and others) help reduce the amount of stomach acid made by glands in the lining of the stomach.

Research published online on February 15 in JAMA Neurology showed that there may be an association between chronic use of PPIs and an increased risk of dementia. Experts compared prescription PPI intake and diagnosis of dementia among approximately 74,000 adults ages 75 and older. In the study, chronic PPI use was defined as at least one prescription every three months in an 18-month window. The most common PPIs in use were omeprazole (Prilosec), pantoprazole (Protonix), and esomeprazole (Nexium). All participants were free of dementia at the study’s beginning. Yet, after the eight-year follow-up, chronic PPI users had a 44% increased risk of dementia compared with those who did not take any medication. Men were at a slightly higher risk than women. Occasional users of PPIs had a much lower risk.
Putting the results in perspective

The researchers were quick to stress that this study only provided a statistical association between PPI use and risk of dementia, and that taking PPIs does not automatically mean you will get dementia. However, the study continues the ongoing discussion about the impact of long-term medication use, according to Dr. Houman Javedan, clinical director of inpatient geriatrics at Harvard-affiliated Brigham and Women’s Hospital. “Older adults take more medications as they age, and often continue them long after they are still necessary,” he says. “They either get used to taking it, and do not think to ask their doctor if they should stop, or they are afraid of what might happen if they do.”

Many older adults also take multiple drugs at one time, a situation known as polypharmacy. In fact, an estimated 44% of men and 57% of women older than age 65 take five or more medications; 12% of both men and women in this age group take 10 or more. “How different drugs interact with each other, and what the consequences of long-term use are, continues to be explored by scientists, as the researchers tried to do in this case with PPIs,” says Dr. Javedan.

It is not clear how PPIs might make a person more vulnerable to dementia. Evidence suggests parts of the drug may cross the blood–brain barrier, which becomes more porous as a person ages, and interact with brain enzymes. In initial animal studies, PPIs were shown to increase levels of beta amyloid in the brains of mice, and higher amounts of this protein have been linked to dementia and Alzheimer’s disease. Other research has shown a possible connection between chronic PPI use and vitamin B12 deficiencies, as well as an increased risk of osteoporosis. “There still may be other mechanisms at work that are unknown,” says Dr. Javedan. “But this study raises the question whether chronic PPI usage is safe, especially among the older population.”
What you should do if you take PPIs

If you currently take PPIs every day, or have for more than 18 months, you should consult with your doctor about whether to continue at your current dosage, Dr. Javedan suggests. “You only may need it when you have symptoms and not endlessly.” I take care of adults in primary care and I treat addictions. So when I was sent a journal article titled “Daily Physical Activity and Alcohol Use Across the Adult Lifespan,” it piqued my interest. This paper describes the drinking and exercise habits of 150 largely white, low-risk, community-dwelling adults (meaning it didn’t include people who were in the hospital or a nursing home) in central Pennsylvania. In this study, volunteers used a smartphone to record their daily drinking and exercise habits in 3-week blocks. This smartphone technique made it possible to get good information and to analyze daily variations for each individual. What is clear from the analysis is that people tend to drink more alcohol on days when they exercise more. This is true whether they’re young, old, male, or female.

This is not a study of problem drinkers or risky drinkers, nor of people with alcohol use disorders (what we used to call alcohol abuse or alcohol dependence). This is also not a study of the effect of an intervention to change lifestyle behavior. That is to say, this study does not tell me what happens if I advise a patient to exercise more or to drink less. The study also does not suggest that if you decide to exercise more, it’s likely you will drink more. It is solely an observational study, not a study of change over time.

These are healthy people in general. The mode and median number of drinks per day was zero. That is to say, among this group, there was no drinking at all on half or more of the days recorded. So the results may have been different in a different population (for instance, a more economically challenged or urban population). The results of a similar study, I expect, would be different were it conducted among a high-risk group; for example, people working to drink less or exercise more might engage in a “virtuous cycle” whereby the enjoyment of a sense of more energy, less fatigue, or better physical strength would provide the power to make further healthy choices. Increased exercise might be linked to decreased drinking in this kind of population.
The challenge of making — and keeping — healthy lifestyle changes

What I’ve observed in my practice is that significant changes in health-related behaviors travel in packs: people who adopt healthier drinking habits (for instance, reducing their intake to one drink per day if female or two per day if male, on average) also get off the couch, walk more, lose a pound or two, and generally pay more attention to their health. The challenge for them — and me — is to sustain these healthy changes.

There is a lot of seriously unhealthy sedentariness among adults in this country. Many people do not move around this planet under their own steam other than to go to the car, fridge, or couch. No joke. Hours are spent every day sitting in front of a lit screen. We come home from work, having been typing and mousing, straining our neck and back and keyboarding muscles, only to collapse on the couch to click around on the remote. Maybe we’re tense, so we have a drink. When it’s time to go to bed, we’re not physically tired, so we’ll have a few more drinks. So we won’t sleep efficiently (because alcohol disrupts healthy sleep cycles). And then we’ll do it all again the next day.

Making even a small sustainable dent in this cycle can be challenging. The positive effects may not be evident quickly. Only patience and commitment are rewarded. But the rewards, accumulating bit by bit, can be great.
A few ways an “exercise prescription” can make a difference

Although this study wasn’t intended to look at addiction, I’d like to mention the role of exercise in the treatment of mood disorders and addiction. There is evidence that aerobic and muscle-building exercise have positive effects on depression; research is ongoing on their effects on addiction. The attractive aspects of a sensible “exercise prescription” include its relative “safety profile” (meaning lack of negative side effects), its known positive effects on brain health, and the ability to customize it to whatever a person’s favorite activity might be. Of course, pacing oneself is paramount so as not to over-train or sustain injury. Some of the changes in the central nervous system due to exercise — for instance, increases in some dopamine activity (similar to the effects of intoxicants) enhanced blood flow, and glial cell proliferation — may also be related to improvements in mood and cognitive function.

People who have substance use disorders often suffer from a lack of joy (other than the chemical high) and from isolation. Isolation both permits the use of drugs or alcohol without bothering others, and may drive the use of them as a salve for loneliness. So combatting isolation is part of addressing addiction. Exercise (in groups) is a pro-social activity: the sense of community, and the positive emotional impact of interpersonal contact (that is, the simple joy of being with others), may be essential ingredients of getting — or staying — on the road to recovery. It’s hard to maintain the lifestyle changes you want to make. It doesn’t matter whether your goal is weight loss, exercise, normal blood sugar, or decreasing stress — research has shown that simply learning about the value of lifestyle changes is insufficient on its own to help people maintain their goals.

Of course, few people are actually ignorant about the number of calories in a chocolate truffle, the benefits of exercise, or the incredible danger, discomfort, and inconvenience of diabetes and stress. Still, despite this awareness, maintaining these changes is an uphill battle. And that’s largely because habits are hard to kick.

The rewards of the changes themselves have their limits. On a cold, snowy day in February, going to the gym is far less appealing than staying in bed for one more hour. And when you return home tired from a day of work, the calories in that extra glass of wine may in fact suddenly turn invisible. So how can you get that extra motivation?
The two types of rewards — and what they can do for you

Despite a growing body of evidence on the value of reward-based systems in promoting health behaviors, they are notoriously ineffective. But these studies generally focus on one kind of reward. Having an understanding of the other category of rewards may provide additional motivation to maintain the changes that you want.

There are two kinds of rewards: hedonia and eudaimonia. Hedonia (H-rewards) includes superficial pleasures such as weight loss, looking good, and acceptance by others. These rewards are more concrete and often short-lived. Eudaimonia (E-rewards), on the other hand, refers to a sense of meaning and purpose that contributes to overall well-being. Connecting your lifestyle goals to E-rewards may help motivate you even more.

The greater the size of a self-processing region in your brain called the insula, the higher your E-rewards. Specifically, if you have a large insula, your senses of personal growth, positive relations with others, and personal purpose are high. It’s not hard to imagine how feeling this way can help motivate you in many different ways, let alone when it comes to making specific lifestyle changes.

E-rewards also motivate you by activating the brain’s reward region, the ventral striatum. You feel less depressed when this part of the brain is activated. In contrast, when you satisfy only your H-rewards (e.g., looking good and getting a massage), this can actually make you more depressed and less motivated in the longer term.

See the video below where I explain in more depths about the different types of rewards.
What are your E-rewards?

To stay motivated, ask yourself how you will enhance your sense of meaning and purpose. They can be strong motivators for achieving your goals. The following are all examples of people with strong E-rewards motivating their decisions:

    A college sophomore obsessed with pizza and beer starts to eat and drink healthily when she realizes that her career in broadcast journalism will probably require her to be on camera day in and day out, so she needs to look (and feel) her best.
    A grandfather won’t let anything stop him from going to the gym so that he can have the longest possible time alive to be with his grandchildren.
    A doting husband ignores most of the buffet table at a cocktail party (except for the veggies and dip) because he knows that he wants to be there for his wife and kids.
    A young woman decides to start skipping dessert when she recognizes that her work on eliminating poverty is too important for her to undermine her own well-being in any way.

It’s not just the service or job that inspires E-rewards either. The story is a little more complex.

The concept of E-rewards can be traced back to Aristotle, who believed that the highest level of human good was not about satisfying one’s appetites, but about striving to express the best that is within us. This could only really be achieved by self-realization, a continuous process that looks different for each person, depending on his or her unique talents and dispositions.

As Aristotle points out, the first and foremost ultimate goal of all living humans is this feeling of well-being, which must be the primary focus if we are to achieve any of our health-related goals. Contrary to other theorists on the subject, Aristotle points out that H-rewards — good friends, wealth, and power — help as well. Yet, there is more to it than that. To truly feel E-rewards, you need to feel like you are flourishing in your life. In this inspired state, you are more likely to be motivated to achieve your goals.

To start this process, ask yourself how much of your day you spend in activities that nurture this sense of self. According to Carol Ryff, there are six areas of your life that you can reshape to enhance these E-rewards: greater self-acceptance, higher-quality relationships, being in charge of your life, owning your own opinions even when others oppose them, personal growth, and having a strong intrinsic sense of purpose. If you work on these factors, you will likely feel more intrinsic reward, and therefore enhance your motivation to accomplish your lifestyle changes as well.

We tend to focus on H-rewards to motivate ourselves to achieve our goals. But E-rewards may offer an additional focus to maintain your motivation for the lifestyle changes you desire. Hormonal therapy, also known as androgen-deprivation therapy, can be a powerful weapon in the fight against prostate cancer because it deprives malignant cells of the fuel they need to grow. Androgens — meaning the family of male sex hormones that includes testosterone — contribute to physical characteristics such as a deeper voice, thick facial hair, and increased muscle strength and bone mass. But when prostate cancer develops, testosterone also contributes to tumor growth and progression. Depending on the specific treatment used, hormonal therapy can either stop the body from making testosterone or prevent it from interacting with cancer cells.

Though it was once reserved solely for treating prostate cancer that has spread, doctors now also combine hormonal therapy with radiation to treat locally advanced tumors that have not yet spread to more distant locations, such as the bones. Hormonal therapy reduces the chance that a tumor will progress or return, and it makes radiotherapy more effective at controlling prostate cancer. But it also causes side effects such as weight gain and bone loss, and the optimal duration of treatment remains an open question.
The latest study results are promising

Studies have consistently shown that the longer a man receives hormonal therapy, the better his chances for extended survival. Now, results from a phase 3 clinical trial suggest that men with locally advanced prostate cancer should get at least 2 years of additional hormonal therapy after finishing their initial combined treatment. “Our question was simply: is a short course or a long course of treatment better for the patient?” said Dr. Colleen Lawton, clinical director of radiation oncology at Milwaukee’s Medical College of Wisconsin, who led the research. “And we found that the survival benefits of long-term hormonal therapy outweigh the risks.”

The study, known as RTOG 9202, was launched in 1992. It enrolled approximately 1,500 men with cancer confined to both lobes of the prostate, or cancer that had spread into nearby tissues, such as the bladder. All the patients had prostate-specific antigen (PSA) levels lower than 150 nanograms per milliliter, and their Gleason scores — which describe the aggressiveness of a prostate tumor — ranged from 6 (not aggressive) to between 8 and 10 (highly aggressive). The participants’ ages ranged from 43 to 88, with a median of 70 years, and the vast majority of participants were white.

During the study, half the men got only four months of hormonal therapy, starting 2 months before radiation treatment and continuing for two months during radiation treatment. The other half got that treatment plus 2 years of additional hormonal therapy.

Lawton presented the results (which have not yet been published) last November at the annual meeting of the American Society for Radiation Oncology. The data show that after a median follow-up of 20 years, men who got the long-term treatment had a 40% lower risk of the cancer spreading and a 33% lower risk of dying from prostate cancer than the men who were given hormonal therapy for just 4 months. And in a subset analysis of men with the highest-risk prostate cancer, long-term hormonal therapy dropped the odds of metastasis and death from prostate cancer even further: by 48% and 45%, respectively.

According to Lawton, the side effects of the hormonal treatment were manageable with diet, weight-bearing exercise, and drugs that boost bone density. But she emphasized that researchers are still grappling with how to define long-term hormonal therapy. As an example, she mentioned that a different study of men with locally advanced prostate cancer presented at a medical meeting in 2013 had found that disease-specific survival rates were nearly identical whether hormonal therapy lasted 18 or 36 months.

“The duration of treatment for localized prostate cancer is complicated and controversial, especially with the known cardiovascular side effects of some types of hormonal therapy,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of “Few would argue with the view that for patients with high-risk features, such as high PSA and Gleason scores, longer is better. But we still need more clarity on the lower-risk patient populations.”
Read More »

The inconvenient truth of vaccine refusal of Health

There’s been a lot of back-and-forth recently about how much sleep we really need, with recent studies suggesting that some long-held notions about this may be outdated. For example, a recently published study challenged the widely held belief that adults need an average of eight hours of sleep a night to function well. The researchers found that members of pre-industrial societies, free of the technological distractions that often keep us up at night, tend to get an average of 5.7 to 7.1 hours of sleep per night (more on that in a bit).

However, while the actual amount of sleep required to function optimally may vary from person to person, it is still very clear that not getting enough sleep — whatever that “magic number” is for any specific individual — can have serious consequences. This is especially true in children and adolescents, whose developing brains are very sensitive to insufficient sleep.
Studying the effects of sleep deprivation in teens

This was borne out in a new study published in this month’s issue of Sleep. Researchers from Singapore compared two groups of high school students before, during, and after a week in which half were allotted nine hours sleep per night and the other half only five hours per night. Not only did the sleep-deprived kids exhibit impaired cognitive function, alertness, and mood during their week of five-hour nights as compared with their peers, but it took them more than two nights of “recovery sleep” to catch back up again.

One way of looking at this is that not only do you suffer the day after not getting enough sleep, but that the idea of skimping on sleep during the week with the plan to somehow “catch up” on the weekend isn’t a good one: it simply doesn’t work. Even after getting lots of sleep on the weekend, you’ll still be far away from where you could — and probably should — be as far as sharpness and mood go.
Setting up a great night’s sleep for your child

One way of helping kids get the sleep they need is by eliminating some of those things that tempt them into staying awake. There is a lot of evidence that kids with televisions in their bedrooms, for example, not only sleep less but also have poorer-quality sleep. (Increased screen time is also associated with higher rates of obesity and with less time spent reading, but that’s a topic for another post.) The same is probably true for computers, tablets, and smartphones as well. Removing electronic media devices from the bedroom will make it more likely that your child will fall asleep sooner — and sleep better — than she will with the world at her fingertips.

Another way of helping kids fall asleep sooner and with greater ease is by removing stressors from their bedroom and encouraging them to relax before bedtime. This means, for example, not doing homework in the bedroom (and never in bed!), but at the dining room table instead. This creates a distinct boundary between the pressures of the day and the comforting space of the bedroom, which is so important for falling asleep. It may also have the added benefit of keeping them focused on the task at hand instead of the distractions of YouTube, Snapchat, and texting that can turn one hour of homework into a three-hour ordeal. Likewise, ending the day with 20-30 minutes of mindfulness practice, yoga, or quiet reading can help your teen redirect himself to a different plane as he gets ready to sleep.

Finally, keeping to a regular sleep schedule, seven days a week, with fixed wake-up and bed times will help keep your teen’s internal clock synchronized with the external one, preventing the development of a circadian phase delay between the two that may interfere with his or her being able to fall asleep at their appointed bed time on week nights. Do you know your BMI? Increasingly, people know theirs, just as they know their cholesterol.

If you don’t know your BMI, you can use a BMI calculator available online, including this one at Harvard Health Publishing. All you need is your height and weight. Or, you can calculate it yourself, using this formula:

BMI = (Weight in Pounds x 703) / (Height in inches x Height in inches).

So, now that you know your BMI, is it worth knowing? What are you going to do with it?
What your BMI means

To understand what your BMI means, it’s useful to take a step back and understand what it’s measuring and why it’s measured.

BMI is a calculation of your size that takes into account your height and weight. A number of years ago, I remember using charts that asked you to find your height along the left side and then slide your finger to the right to see your “ideal weight” from choices listed under small, medium, or large “frame” sizes.

These charts came from “actuarial” statistics, calculations that life insurance companies use to determine your likelihood of reaching an advanced age based on data from thousands of people. These charts were cumbersome to use, and it was never clear how one was to decide a person’s “frame size.”

BMI does something similar — it expresses the relationship between your height and weight as a single number that is not dependent on “frame size.” Although the origin of the BMI is over 200 years old, it is fairly new as a measure of health.
What’s a normal BMI?

A normal BMI is between18.5 and 25; a person with a BMI between 25 and 30 is considered overweight; and a person with a BMI over 30 is considered obese. A person is considered underweight if the BMI is less than 18.5.

As with most measures of health, BMI is not a perfect test. For example, results can be thrown off by pregnancy or high muscle mass, and it may not be a good measure of health for children or the elderly.
So then, why does BMI matter?

In general, the higher your BMI, the higher the risk of developing a range of conditions linked with excess weight, including:

    liver disease
    several types of cancer (such as those of the breast, colon, and prostate)
    high blood pressure (hypertension)
    high cholesterol
    sleep apnea.

Current estimates suggest that up to 365,000 excess deaths due to obesity occur each year in the U.S. In addition, independent of any particular disease, people with high BMIs often report feeling better, both physically and psychologically, once they lose excess weight.
And here’s why BMI may not matter

It’s important to recognize that BMI itself is not measuring “health” or a physiological state (such as resting blood pressure) that indicates the presence (or absence) of disease. It is simply a measure of your size. Plenty of people have a high or low BMI and are healthy and, conversely, plenty of folks with a normal BMI are unhealthy. In fact, a person with a normal BMI who smokes and has a strong family history of cardiovascular disease may have a higher riskof early cardiovascular death than someone who has a high BMI but is a physically fit non-smoker.

And then there is the “obesity paradox.” Some studies have found that despite the fact that the risk of certain diseases increases with rising BMI, people actually tend to live longer, on average, if their BMI is a bit on the higher side.
Should we stop giving so much “weight” to BMI?

That’s exactly what’s being asked in the discussion generated by a new study. For this study, researchers looked at how good the BMI was as a single measure of cardiovascular health and found that it wasn’t very good at all:

    Nearly half of those considered overweight by BMI had a healthy “cardiometabolic profile,” including a normal blood pressure, cholesterol, and blood sugar.
    About a third of people with normal BMI measures had an unhealthy cardiometabolic profile.

The authors bemoaned the “inaccuracy” of the BMI. They claim it translates into mislabeling millions of people as unhealthy and also overlooking millions of others who are actually unhealthy, but are considered “healthy” by BMI alone.

Actually, this should come as no surprise. BMI, as a single measure, would not be expected to identify cardiovascular health or illness; the same is true for cholesterol, blood sugar, or blood pressure as a single measure. And while cardiovascular health is important, it’s not the only measure of health! For example, this study did not consider conditions that might also be relevant to an individual with an elevated BMI, such as liver disease or arthritis.
Bottom line

As a single measure, BMI is clearly not a perfect measure of health. But it’s still a useful starting point for important conditions that become more likely when a person is overweight or obese. In my view, it’s a good idea to know your BMI. But it’s also important to recognize its limitations. In the United States, the national drinking age is 21. States can make it younger, but if they do they lose federal highway funding. The idea is that youth less than 21 are more likely to run into trouble if they drink, and that having them wait until they are older is better. You can argue about whether this actually works, but the idea is a good one.

And yet when it comes to tobacco, as far as the federal government is concerned, you just have to be 18. Which, for anyone who knows anything about what happens when youth smoke, makes no sense at all.

It was really Mothers Against Drunk Driving (MADD) that drove the national drinking age legislation. It’s true that smoking doesn’t cause immediate impairment in the way alcohol does; one can smoke a couple of cigarettes and drive. But the longer-term impacts of tobacco use are staggering. Cigarette smoking is the leading preventable cause of death in the United States, causing more deaths each year than HIV, illegal drug use, alcohol use, motor vehicle injuries, and firearm-related incidents combined. Even if it doesn’t kill you, smoking markedly increases your risk of heart disease, cancer, lung disease, rheumatoid arthritis, and diabetes, among other health problems. When pregnant women smoke, their babies are at higher risk of being born small, prematurely, or having birth defects. When parents smoke, it’s more likely that their baby will die of sudden infant death syndrome, or SIDS.

Here’s why it’s so crucial to stop youth from smoking: 90% of all smokers tried their first cigarette by 18, and 99% started by age 26. Three-quarters of teen smokers end up smoking into adulthood, even if they intend to quit. And here’s another important fact: most youth under the age of 18 get cigarettes from someone under 21.

If we make it so that nobody under 21 can buy tobacco, the impact could be enormous. And, according to an editorial just published in the New England Journal of Medicine, the time for Tobacco 21 laws may have come.

The editorial quotes a study from the Institute of Medicine that says that if we were to increase the national smoking age to 21, it would lead to, among other benefits:

    20-30% less smoking among 15 to 17-year-olds
    12% fewer smokers overall
    249,000 fewer premature deaths, with 4.2 million fewer lost life years
    286,000 fewer preterm births
    4000 fewer cases of SIDS

That’s pretty astounding. Many states have already made this change — and yet some, like New Jersey, have balked. Which is interesting, as according to the editorial most people support the idea — especially current and former smokers (66.5% and 73%, respectively). It is also indisputable that raising the smoking age to 21 would lead to huge health care savings. The biggest obstacle? Special interest groups. The tobacco industry has deep pockets and clearly doesn’t want to lose its future smokers, so it has lobbied hard.

It’s pretty difficult to come up with arguments against federal Tobacco 21 legislation. You could say that it infringes on personal rights. But unlike other rights, the right to an addiction that can kill you and those around you, well, that’s a bit hard to justify — especially among our youth. We have a responsibility to set them on the path to the healthiest life possible.

You could say — and those who fight this legislation do — that it will hurt businesses that sell tobacco products, especially small stores that rely on cigarette sales for income. That’s certainly true. But who are we as a country if we value the health of small businesses over the health of our people?

There is abundant evidence that cigarettes are bad for you — so much evidence that nobody disputes it. If we can’t come together to stop youth from smoking, and in doing so prevent so much disease and death, we should be ashamed. While it is obvious that your feelings can influence your movement, it is not as obvious that your movement can impact your feelings too. For example, when you feel tired and sad, you may move more slowly. When you feel anxious, you may either rush around or become completely paralyzed. But recent studies show that the connection between your brain and your body is a “two-way street” and that means movement can change your brain, too!
How exercise can improve mood disorders

Regular aerobic exercise can reduce anxiety by making your brain’s “fight or flight” system less reactive. When anxious people are exposed to physiological changes they fear, such as a rapid heartbeat, through regular aerobic exercise, they can develop a tolerance for such symptoms.

Regular exercise such as cycling or gym-based aerobic, resistance, flexibility, and balance exercises can also reduce depressive symptoms. Exercise can be as effective as medication and psychotherapies. Regular exercise may boost mood by increasing a brain protein called BDNF that helps nerve fibers grow.

For people with attention-deficit disorder (ADHD), another study showed that a single 20-minute bout of moderate-intensity cycling briefly improved their symptoms. It enhanced the participants’ motivation for tasks requiring focused thought, increased their energy, and reduced their feelings of confusion, fatigue, and depression. However, in this study, exercise had no effect on attention or hyperactivity per se.

Meditative movement has been shown to alleviate depressive symptoms. This is a type of movement in which you pay close attention to your bodily sensations, position in space, and gut feelings (such as subtle changes in heart rate or breathing) as you move. Qigong, tai chi, and some forms of yoga are all helpful for this. For example, frequent yoga practice can reduce the severity of symptoms in post-traumatic stress disorder to the point that some people no longer meet the criteria for this diagnosis. Changing your posture, breathing, and rhythm can all change your brain, thereby reducing stress, depression, and anxiety, and leading to a feeling of well-being.
The surprising benefits of synchronizing your movements

Both physical exercise and meditative movement are activities that you can do by yourself. On their own, they can improve the way you feel. But a recent study found that when you try to move in synchrony with someone else, it also improves your self-esteem.

In 2014, psychologist Joanne Lumsden and her colleagues conducted a study that required participants to interact with another person via a video link. The person performed a standard exercise — arm curls — while the participants watched, and then performed the same movement.

The “video link” was in fact a pre-recorded video of a 25-year-old female in a similar room, also performing arm curls. As part of the experiment, participants had to either coordinate their movement or deliberately not coordinate their movement with the other person’s arm curls. They filled out a mood report before and after each phase of synchronizing or falling out of synchrony. They also reported on how close they felt to the other person.

The results were interesting. When subjects intentionally synchronized their movement with the recording, they had higher self-esteem than when they did not. Prior studies had shown that synchronizing your movement with others makes you like them more. You also cooperate more with them and feel more charitable toward them. In fact, movement synchrony can make it easier to remember what people say and to recall what they look like. This was the first study to show that it makes you feel better about yourself, too. That’s probably why dance movement therapy can help depressed patients feel better.
Putting it all together

Your mind and body are intimately connected. And while your brain is the master control system for your body’s movement, the way you move can also affect the way you think and feel.

Movement therapies are often used as adjunctive treatments for depression and anxiety when mental effort, psychotherapy, or medication is not enough. When you are too exhausted to use thought control strategies such as focusing on the positive, or looking at the situation from another angle, movement can come to the rescue. By working out, going on a meditative walk by yourself, or going for a synchronized walk with someone, you may gain access to a “back door” to the mental changes that you desire without having to “psych yourself” into feeling better. Alzheimer’s disease often strikes fear in people’s hearts because it gradually erodes a person’s ability to remember, think, and learn. There is no cure, and available treatments alleviate symptoms only temporarily. An estimated 5.3 million Americans currently have Alzheimer’s disease, yet this brain disorder is far less common than heart disease. More than 85 million people in the United States are living with some form of cardiovascular disease or the after-effects of stroke, which also affects brain function.

Many people don’t realize that Alzheimer’s and heart disease share a genetic link: the apolipoprotein E gene, also known as ApoE. Genetic testing for ApoE — which is done mainly in research settings and isn’t yet widely available — cannot predict whether a person will develop Alzheimer’s disease, only whether they may be more likely than others to do so. The results of ApoE testing can be distressing for people who discover they carry a potentially a worrisome variant of the gene, but a recent Harvard study revealed a surprising silver lining.
Understanding the ApoE gene

The ApoE gene provides instructions for making a protein that transports cholesterol in the bloodstream. It comes in three different forms: e2, e3, and e4. Everyone inherits two variants, one from each parent. More than half of people in the general population have two copies of the most common variant, e3, which doesn’t appear to affect the risk of either heart disease or Alzheimer’s disease. The potentially problematic variant is e4. Having at least one copy of the e4 variant increases blood levels of both harmful LDL cholesterol and triglycerides by about 10 points. This translates to a slightly higher risk of cardiovascular disease.

“It’s a well-proven association. But the effect of the e4 variant on Alzheimer’s disease risk is stronger,” notes Dr. Kurt Christensen, instructor of medicine at Harvard Medical School. Exactly how the e4 variant is related to Alzheimer’s disease remains a mystery. But the variant seems to hamper the clearance of amyloid plaque, the clumps of protein found in the brains of people with Alzheimer’s. Amyloid plaque is thought to destroy brain cells, causing the disease’s devastating symptoms, says Dr. Christensen.

People who inherit one copy of e4 face a two-fold higher risk of developing Alzheimer’s than those without the e4 form. Those who inherit two copies of the e4 form have up to a four-fold higher risk. But it’s important to understand that these people won’t necessarily develop Alzheimer’s disease, and that people without the e4 variant can still get the disease. In fact, up to 60% of people with Alzheimer’s disease don’t have an e4 variant.
What the new study found

Dr. Christensen and colleagues recently published a study in the Annals of Internal Medicine that included 257 people who were interested in knowing their genetic risk of Alzheimer’s disease. Nearly 70% had a parent or sibling with the disease. All received information about their genetic risk of Alzheimer’s. But half were randomly assigned to get additional information about ApoE’s connection to heart disease, along with suggested strategies to lower their risk, including quitting smoking, eating a healthy diet, losing weight, treating high cholesterol, and exercising (with a doctor’s permission).

Among the people who had a higher risk based on their ApoE status, learning about the additional risk to their hearts actually reduced their distress, says Dr. Christensen. And over the following year, something even more unexpected happened: They made a number of healthy behavior changes, such as improving their diets, reducing their stress levels, and being more physically active. And while these habits haven’t been proven to help stave off Alzheimer’s disease, doctors generally agree that what’s good for the heart is good for the brain.

The findings offer reassurance that disclosing genetic information about possible health risks can be helpful — particularly when the knowledge comes with action-oriented suggestions about ways to lessen the impact of that risk. Parents of teenagers, here is another post that I hope will be helpful to you.

Moms and dads of teens — and the doctors who care for these children — know how difficult it can be to identify depression in adolescents. When is your teen simply feeling down or irritable, and when is it something more?

Doctors are receiving better and better training in diagnosing teenage depression, but perhaps the greatest challenge is finding time to make sure it happens. During a typical well-child visit, parents are usually busy trying to address the concerns they have about their child, while at the same time trying to understand what vaccines they need and making sure school forms are filled out. Pediatricians are busy trying to address physical and emotional concerns and anticipate problems that may come up for your child regarding friends, schoolwork, academic work, safe sex, and other risky behaviors.

Where does screening for depression fit in?

Several medical organizations that provide up-to-date, evidence-based guidelines to physicians recommend that we do screen our teens for depression. Among them is the United States Preventative Services Task Force (USPSTF), an agency charged with providing recommendations to the Primary Care community about preventing chronic or difficult-to-detect illnesses. To help us keep our teens as healthy as possible, the USPSTF recently published an updated guideline about screening for Major Depressive Disorder in adolescents.
What is screening?

Screening is the act of checking for a condition that is common in a community but not obvious to doctors unless some sort of testing is done. For example, doctors screen for high blood pressure by checking blood pressure measurements at most visits. Doctors can’t tell, just by looking at a patient, if his blood pressure is high. The same goes for depression. Sometimes it is very difficult to tell if a person is suffering from depression, until it is quite serious. The point of screening is to catch dangerous problems early, before they become severe problems. When doctors elect to screen patients for a condition, typically the following guidelines are met:

    The condition is common, but silent, in the community; lots of people have it.
    The condition is important to a person’s future health.
    Detecting the condition early improves outcomes.
    The condition is something we can treat!
    The testing required is good, easy to administer, and not overly painful or inconvenient.

Can we screen for depression in teens?

Yes, we can, and doctors have been doing so for years, although not necessarily in an organized or systematic way. The USPSTF recommendation is important because it emphasizes this need to test all teens — because depression is common in teenagers, and potentially dangerous.

A few facts about screening for teenage depression:

    Depression is prevalent, but often silent, in adolescents. We don’t have reliable numbers for children 11 or younger, but for children 12-18, rates of depression in the U.S. have been estimated to be around 8%. That means that about one out of every 12 teens will experience an episode of major depression in his or her teenage years!
    The condition is important! Depression in adolescence is associated with depression later in life. It can also lead to poor school performance, substance abuse, early pregnancy, and even suicide.
    Early detection may help prevent long-term, serious problems by allowing your teen to get good treatment in a more timely manner.
    Effective treatment is available. Readers of my last blog post may recall that I discussed how some antidepressant medications have been associated with higher risk of teen suicide. But this is not the case for all medications or all treatments. Psychotherapy, in particular, has been associated with much improved outcomes and little to no risk to a teen’s health.
    The screening test is painless and easy to do. Several simple, short questionnaires exist which have been vetted by experts and proven to be reliable, even when administered to teenagers.

What will screening look like for my teen?

When your adolescent comes to the pediatrician or family doctor’s office for a physical, he or she will be given a short questionnaire, such as the Beck Depression Inventory or the PHQ-A. These questionnaires typically have about nine questions and can be completed in 1-2 minutes. It is important to let your teen complete this questionnaire on his own. Your pediatrician may discuss the answers with your teen privately, but rest assured that if the concern of depression is raised, the pediatrician will never hide from you the fact that your teen is at risk.
A final word…

As parents, you spend much more time with your adolescents than we doctors can during brief office visits. If you notice that your teen has simply not been acting like himself, or if you are worried, please let your pediatrician know! He or she is always ready to help. My elderly dad is sporting a cool new mobile device these days, complete with a sleek design and an aluminum cover. It’s not a smartphone or a laptop or a tablet; it’s a medical alert system, a one-button gadget that can summon emergency help. “Many older people who live alone embrace the devices, because they worry how they would get help if they fell and couldn’t get to a phone. And it’s reassuring for their kids to know there’s a backup system in place,” says geriatrician Dr. Suzanne Salamon, assistant professor at Harvard Medical School.

The devices weren’t always so popular. Once the target of comedians (an issue that kept some seniors from using them), medical alert systems are now in big demand, perhaps due to an aging population, advances in technology, and the reality that one in three adults ages 65 and older might fall one day. Throw in a higher comfort level with mobile gadgets, and it’s not a big surprise that sales of the systems are rising steadily, expected to reach $21.6 billion by 2020, according to some marketing research estimates.
Lots of choices

The popularity of alert systems has resulted in a flood of choices. There are dozens of brands, and each company has several systems available.
Basic models

These typically consist of a pendant or wristband with a large electronic button, and a base unit (similar to a speaker phone) that you plug into your house phone jack. If you get into trouble, you simply press your button, which signals the base unit to call the alert system operators. The operators then talk to you through the speaker in the base unit, and send paramedics if you need help. Most gadgets are waterproof, and have built-in batteries that don’t need recharging; most batteries last for years, and will be replaced free of charge if they run out. Just like a wireless house phone, these buttons can signal the base unit only within a limited range, such as 400 feet. But the buttons don’t provide two-way communication with operators; only the base unit does that.

Typical price: $25-30/month.

This type of model usually come with a base unit and a wearable button, and they also upgrade the technology to include fall detection, an innovation that automatically contacts emergency operators if it detects a fall (handy if you’re unable to push your button).

Original versions of automatic fall detection weren’t the most reliable at discerning if you’d fallen or just leaned over. Newer versions claim to have worked out the kinks, promising much higher accuracy, as much as 95%.

Typical price: $30-40/month
Premium models

These products upgrade the button to top-of-the-line devices that use cellular technology to contact emergency help. The improved communication allows you to use the alert system wherever you go, whether it’s the grocery store or the great outdoors. Unlike the other options, this device has a built-in speaker, so you can talk to an operator through the button. It also features global positioning system technology (GPS), which gives alert system operators the ability to send help to your exact location. This button is thicker and larger than the type worn only at home, so you probably won’t be able to wear it comfortably on your wrist—you’ll have to put it in your pocket or wear it around your neck. Also, it must be charged every few days, just like a cell phone. If you’re not faithful about that, the button won’t work. Typical price: $40-50/month
The fine print

It’s not enough to find the latest and greatest alert system. Make sure that the company you choose has no long-term contracts, low activation fees, no cancellation fees, discounts for add-ons to your service, free replacement for equipment that’s not working, and most important: operators available 24 hours a day. Many alert system companies meet those standards, so it may help to get a recommendation from a friend, your doctor, or even a local hospital.

And remember: no matter what kind of device or deal you get, the alert system will be useless if you don’t wear it. “Not everyone remembers to wear the device, or they’re stubborn about them, or they take them off to take a shower, which is a place people often fall,” says Dr. Salamon.

In my dad’s case, the medical alert system is always around his neck. He has a premium model that looks a lot like a mini-cellphone. But believe me, the peace of mind the device brings to all of us is absolutely super-sized.
Read More »