Sunday, August 31, 2008
Exactly three years ago today we were glued to our TV sets watching the horror unfold in that unique American city, New Orleans. The unthinkable was happening...an entire city was under water and tens of thousands of people were stuck on rooftops, abandoned on freeways and inside the superdome in stifling heat with no provisions. It was such a shock. Within 24 hours I heeded an email call for help and found myself on a red-eye to Baton Rouge, where all flights were landing. President Bush's Air Force 1 was on the tarmac and he was doing a "good job, Brownie" photo op. The governor and Mayor were belatedly begging for help and the national guard was deploying much needed security and manpower.
Registering at the large relief command center and getting a waiver to practice medicine in Louisiana was the last organized function I witnessed. Hundreds of volunteers were streaming in, and help was needed, but there was no way to dispatch them to the needed areas. No-one ever seemed to be in charge and there was no coordinated communication.
Fema contracted with American Medical Response Ambulance company and there were dozens of EMTs ready and poised for action. But we didn't have GPS or maps and we were lost on the streets of New Orleans. A local sheriff in the 9th Ward became our map and guide and we, in turn, took a side trip to his parents home where we recovered 3 bodies...his mom, dad and a neighbor. The devastation in that area was surreal and it looked like an abandoned ghost town. The only life was an occasional snake slithering in the mud or a sad, sick animal looking for its owner.
My work varied according to need. First I helped set up the medical area in the evacuation center and began taking care of 5000 victims of the flood. They had only the clothes on their back and we spent time trying to piece their medical issues together and distribute much needed medication for diabetes, hypertension, pregnancy and mental illness.
The evacuation center in Baton Rouge was run by the Red Cross and they effectively fed 5000 people and provided cots and security and air conditioning. I was impressed with the Red Cross because this was a massive task. The temperature was 100 º with humidity as high. The people and churches of Baton Rouge opened their hearts and doors to rescue volunteers and fed us in the wee hours of the morning when we ended our work. It was an example of people helping people and everyone was at their best. When I needed a small refrigerator to hold medication at the medical tent, the local family who housed me delivered one within 24 hours. I witnessed nothing but generosity under terrible conditions.
Other need took me into New Orleans with medical support for the EMTs doing search and rescue and then, search and recovery. Even the volunteers were having medical issues...one local man suffered a heart attack on the deserted streets but there were no local hospitals open for business. We stabilized him and transported him back to an outlying town. Don't be fooled by these stories...it was really chaotic with inadequate communication in the field.
Now Mayor Nagin is effectively evacuating some of these same people in preparation for Hurricane Gustav. Buses are rolling and they are taking no chances. 15,000 residents have already evacuated and they are focused on St. Bernard's Parrish, which was totally wiped out by Katrina and the storm surge.
Senator McCain plans a visit with his new cute running mate and President Bush won't make the same mistake twice of ignoring a major American city. This is great because if we don't learn from the tragic mistakes of Katrina we truly deserve to be called a third world country and not a "superpower". Third world countries have no safety net. They have armies and military but few social programs. I believe the USA can do better.
Posted by Toni Brayer, MD at 9:14 AM
Friday, August 29, 2008
Thursday, August 28, 2008
Hospital acquired infections are a serious problem that the quality improvement movement is shining a light on. Each year 2 million Americans acquire an infection while hospitalized. We used to accept these rates as just unfortunate events.
From methacillin resistant staph (MRSA) to Clostridium difficile (C. diff), we now know that these infections can be prevented through rigorous precautions and awareness. Here are 12 steps you can take to reduce your risk of hospital infections.
1. Ask hospital staff and visitors (very important!) to wash their hands before treating you.
Alcohol based hand cleaners should be at every bedside. Make sure it is used.
2. Make sure the Doctor or nurse wipes the stethoscope with alcohol before examining you.
3. Ask your surgeon about his/her infection rate. He should know the answer for the
procedure being performed.
4. Beginning 3-5 days before surgery, shower or bathe daily with chlorhexidine soap. You can
buy it over the counter.
5. Ask your surgeon to have you tested for MRSA one week before your surgery. It is a
simple test with a nasal swab.
6. Stop smoking well in advance of surgery. Smokers are 3X as likely to develop surgical site infections.
7. Remind your doctor that you may need an antibiotic one hour before the first incision. (this depends upon the type of surgery but is a critical time period)
8. Do not shave the surgical site. Razors can cause small nicks in the skin and allow infection.
9. Avoid putting food or utensils on furniture or hospital bed sheets.
10. Ask your doctor about monitoring your glucose levels continuously during and after
surgery, especially cardiac surgery. Tight glucose control helps patients resist infection.
11. If possible avoid a urinary tract catheter. (This is not always possible but be aware)
12. Make sure your IV is inserted under clean conditions and changed every 3-4 days.
Infection control is every one's responsibility. I know it is hard to question a caregiver when you are the patient, but these infections are absolutely preventable and we can't afford to make excuses for not doing the right thing. The evidence is clear. Now we need to make sure everyone adheres to them.
Posted by Toni Brayer, MD at 10:31 PM
Wednesday, August 27, 2008
The answer is #5. Squamous-cell carcinoma (above is another image that shows squamous cell and basal cell. A biopsy is needed to confirm diagnosis).
The squamous cell lesion is exophytic and hyperkeratotic with central ulceration, features that are most typical of a squamous-cell carcinoma. Basal-cell carcinomas typically present as a papule with a pearly border. Granuloma fissuratum refers to a mass of granulation tissue. Melanomas are often flat and hyperpigmented. Seborrheic keratosis typically originates on the back of the ear.
Remember, any new skin change should be shown to your physician.
Posted by Toni Brayer, MD at 1:05 PM
Tuesday, August 26, 2008
One of the benefits of a bad economy and weakened dollar is that the "Ugly American" can't travel as much anymore so we can leave the bad behaviour to the British. The New York Times has a surprising (to me) article about some Brits being too unruly and not being welcome at European resorts.
Getting drunk, having orgies, crowding the emergency rooms with injuries from fighting and carousing seem to bring the term "tourist" to a new level. “When things do go wrong, they go wrong in quite a big way,” said Alison Beckett, the director of consular services.
“What we’re trying to do here is reduce some of these avoidable accidents where they have so much to drink that they fall off balconies and are either killed or need huge operations.”
It appears that alcohol is the nidus of most of the problems. Local officials say the blame lies not just with the tourists themselves, but also with the operators of package tours promising drinking-and-partying vacations, and clubs offering industrial-strength alcohol at rock-bottom prices. For about $50 in Malia, tourists can go on unlimited-drinking pub crawls.
The Malia Loft bar, offers a special deal: four drinks and two shots for $8. What a bargain!
I'm glad I am having a staycation this year. If I want to see drunks and STDs, I'll go work in my local Emergency Department and avoid the travel hassle.
Posted by Toni Brayer, MD at 7:59 AM
Monday, August 25, 2008
Here is this weeks Medical Challenge from the New England Journal of Medicine.
If you look at ears (especially on men) you will often see something like this. What is the diagnosis? (click on image for a better view)
1. Basal-cell carcinoma
2. Granuloma fissuratum
4. Seborrheic keratosis
5. Squamous Cell Carcinoma
Make your guess and the answer will be posted tomorrow!
Posted by Toni Brayer, MD at 5:07 PM
Sunday, August 24, 2008
Certain medications should not be taken within hours of drinking grapefruit juice...and it appears even orange juice and apple juice may have interactions that affect the drug levels of certain medications.
The juices block absorption by latching onto an enzyme in the intestines called CYP3A4. It can cause abnormally high levels of the medication or block absorption of the medication in other instances. We have know this about grapefruit juice, but scientists now find orange juice and apple juice may have similar effects.
Here are a few of the drugs affected with grapefruit juice:
- statins -(Lipitor, lovastatin (Mevacor), simvastatin (Zorcor)
- calcium channel blockers- diltiazem (Cardiazem, others) felodipine (Plendil), nicardipine (Cardene) nifedipine (Procardia, Adalat) nisoldipine(Sular), verapamil (Covera, Verelan)
- other heart drugs- (amiodarone (Cordarone, Pacerone), cilostazol (Pletal, generics) losartin (Cozaar,Hyzaar)
- immunosuppressant drugs
- sedatives -diazepam (Valium), midazolam (Versed), triazolam (Halcion)
- other neurological medications- buspirone(BuSpar), carbamezepine(Tegretol), sertraline(Zoloft)
- impotence drugs- (Viagra, Cialis, Levitra)
You are probably safe if you drink grapefruit juice or eat grapefruit in the morning and take your meds at night. Remember, don't take your meds with a "greyhound cocktail".
We are still learning about other juices. To be on the safe side, take your medications with water, not citrus juice.
Other drugs may also be affected. New research shows the allergy drug, fexofenadine (brand name Allegra) was only 1/2 absorbed into the bloodstream when taken with grapefruit juice compared with water.
Take home message: Water to wash down pills.
Posted by Toni Brayer, MD at 5:15 PM
Saturday, August 23, 2008
Ed McMahon, I have one thing to say to you:
"You don't have much talent, yet you've had a great career as Johnny Carson's sidekick, host of Star Search and pitch man for magazines. I am sorry you blew through all of your millions in Beverly Hills. It is sad to be in your senior years and realize you didn't manage your money well.
But filing malpractice lawsuits is not the way to recoup your losses. "
Ed McMahon filed a lawsuit today against Cedars- Sinai hospital (read deep pockets) and the treating physicians, not only for what he says was mistreatment, but also for "elder abuse". Why elder abuse? Because those two words get him out of the capped amount that California has placed under tort reform. His damages would be unlimited and he can rake in as much as a sympathetic jury would give him. His attorneys stand to cash in also.
He fell at a friend's home (the friend is being sued too) and he alleges the hospital failed to diagnose a broken neck after the fall and he has suffered months of discomfort and pain and emotional distress, not to mention fraud, battery and elder abuse.
More advice from EverythingHealth to Ed MacMahon:
"Look, Ed, millions of Americans, like you, have been caught up in the housing squeeze. Your 6.25 million dollar home in a gated community might be sold and you and your young wife may need to downsize the spending in your life. At your age, you don't need such a large mansion anyway, do you?
Be happy the surgery was available to you under your Medicare. I am sure your out- of -pocket amount was zero because you have SAG performers insurance also and that covers the Medicare co-pay. You are still able to go on Larry King Show and you still live in glamorous Beverly Hills. Call off this frivolous lawsuit and live out your years with dignity."
Posted by Toni Brayer, MD at 7:29 AM
Thursday, August 21, 2008
I saw a husband and wife yesterday who have duel citizenship...the USA and France. They travel to Paris and the French countryside several times a year (and he has that beautiful French accent!) My mouth was hanging open when I heard about health care in France. Here's what made me perk up:
- His sister, who is age 70 but quite healthy, has the usual hypertension and difficulty seeing. Since being hospitalized with pneumonia, she gets a home visit TWICE A DAY from a visiting nurse to take blood pressure and load her pills into the container and make sure she is OK. Apparently the nurse and she chat, drink coffee and read the paper together!
- My patient went to the pharmacy with a rash. The pharmacist said "Oh that is shingles...go to this doctor" (located next door). Doctor agreed and gave RX for treatment. No appointment needed. Cost $18 Eu.
- No appointment needed to see your doctor. Just walk in. Very little wait and cost is $18Eu or $15Eu if you have an appointment. This is the cost for a visitor. It might be free for a local resident.
- Can't make it to the doctor? He/she will make a home visit for about $30Eu.
This is not meant as an economic analysis...just another way of looking at how health care is delivered in a patient-centric way. Oh, by the way...their outcomes are also better than ours.
Posted by Toni Brayer, MD at 7:25 AM
Wednesday, August 20, 2008
Pharmaceutical companies often perform drug trials to prove the effectiveness of their drug by paying physicians to participate in a clinical trial and use the drug on their patients, using the trial protocols. The Annals of Internal Medicine wisely asks the question this month:
"Why would pharmaceutical companies go to the expense and bother of conducting numerous trials with private physicians and a few of their patients, rather than conduct large trials at medical centers to accomplish the same scientific results with greater efficiency?"
Dr. Harold Sox (editor and brilliant thinker) answers it: "The true purpose is to get physicians in the habit of prescribing a new drug." A secondary purpose is to get physicians to be "opinion leaders" and advocate with their colleagues about the new drug. They get paid to do so and become de facto marketers for the drug, without really being aware of it.
These drug studies are called "seeding trials" and they are exceedingly common. But those days are coming to an end as greater awareness of how drug company sponsored trials, and the physicians who consult on them are made public.
As Sox says:
"Physicians have a fiduciary obligation to ask questions on behalf of their patients, as do institutional review boards and researchers, which have the skill set and personnel to judge whether a trial is asking an already-answered question. They could look for other clues, such as a study with an open-label design, no control group, a very large projected enrollment relative to the importance of the question, a short-term study of a chronic disease, a study of an already approved drug, and so forth. None of these clues is highly specific, but institutional review boards should start asking questions when a study has several of them. "
Private practice physicians have no "institutional review board" and will need to rely on their own ethical and professional barometer. As Dr. Sox says "Just Say No to Seeding Trials". This practice is marketing in the guise of science.
Tuesday, August 19, 2008
This is a real Quiz and I don't have the answer.
This is a photo I took in Honduras of a woman's foot. It is resting on a wheelchair as she previously underwent a BKA (below the knee) amputation for complications of diabetes. She now had this strange, slightly ulcerated, non tender lesion on her foot for several months. You can see a smaller, less ulcerated lesion on her heel area.
I could not make a diagnosis without a biopsy. It did not appear infected, but certainly it could have been atypical TB. I also thought of necrobiosis lipoidica diabeticorum but it did not have the shiny typical features.
In Roatan there is no dermatologist nor did I have the means to do a biopsy with pathology. My final diagnosis was a pyogenic granuloma. Any ideas from you diagnosticians out there?
Posted by Toni Brayer, MD at 5:11 PM
Monday, August 18, 2008
Just like the "My-Space" social networks, physicians have their own forums for sharing medical issues and networking. The latest item from Medscape Physician Connect:
Too Heavy for CT Scanner
"...patient who is 480lbs fell from standing position and landed on his back. We attempted to get plain films of his back. Our scanner has a weight limit of 350lbs, so we could not scan the patient. My partner tried for about 4 hours to find someone with a scanner that could hold a 500lb man. The patient was signed out pending our vet school calling us back to see if we could scan him by the vet radiologist."
The comments that followed were pretty fascinating. Most were quite respectful. My favorite was from this doctor:
"It's like saying that the beer mugs are too small for the alcoholic so we should be making bigger beer mugs. Super size the MRI scanners to meet America's super size bodies. In France there are elevators that allow for 10 Europeans or 6 Americans. We have a national obesity crisis and before we grow bigger equipment to match our weight, we need to fix our excessive lifestyle."
Posted by Toni Brayer, MD at 6:54 PM
Sunday, August 17, 2008
In the past year, I can't open a journal without seeing more and more evidence that we have been underestimating the benefit of Vitamin D on health and longevity.
Vitamin D is a fat-soluble vitamin that is naturally present in very few foods. It is also produced when ultraviolet rays from sunlight trigger synthesis in the body. Vitamin D obtained from sun exposure, food and supplements must then undergo two hydroxylations in the body to become active so it is a complicated process. A number of drugs interfere with Vitamin D synthesis also.
Vitamin D (along with Calcium) is essential for promoting bone health. But is also is important in neuromuscular and immune function and reduction of inflammation. It affects genes that encode proteins and other cells have Vitamin D receptors.
A new study from Archives of Internal Medicine reports low levels of Vitamin D are associated with cardiovascular disease, cancer and overall shortened longevity. Not only is this a big WOW but this applies to levels that are at the "lower" end of normal. So having Vit D levels in the lower quartile was an independent predictor of mortality in both men and women.
I am starting to check Vitamin D levels in all patients and I'm finding a high percentage of people who have levels that are too low. Sunlight, fortified milk, cereal, yogurt, eggs, salmon, tuna and mackerel are good sources of Vitamin D but may not be enough. Supplementing with 1000 mg of Vitamin D a day is often needed in addition.
Posted by Toni Brayer, MD at 11:47 PM
The answer is #1 osteoarthritis. The patient's right hand reveals the typical changes with both Heberden's and Bouchard's nodes and irregular deformities at the joints.
Osteoarthritis is a degenerative syndrome where low-grade inflammation results in pain in the joints. The cause is unknown and there is an abnormal wearing of the cartilage that covers and acts as a cushion inside joints. OA affects nearly 21 million people in the U.S. and it affects the hands, spine and large weight-bearing joints such as hips and knees.
Posted by Toni Brayer, MD at 1:22 AM
Saturday, August 16, 2008
There is always lots of debate about pediatric vaccinations. The latest study from Pediatrics tells us that the needle length that has been recommended by the Centers for Disease Control (CDC) is wrong and in many cases IS TOO LONG.
The CDC has recommended needles up to 1-1/4 length, which would result in over penetration in a high percentage of babies and children, especially for injections in the shoulder. By looking at MRIs and evaluating the depth of the subcutaneous fat and muscle layers, these authors recommend much smaller needles and basing the size on the child's weight and age rather than using a universal needle length.
Isn't it amazing that this has not been studied before by the CDC? As the top regulatory agency, it is just assumed that their recommendations are based on science. Assume nothing!
I'm always gratified when actual scientific studies confirm what any mother could have told you just by common sense and sight. Don't be afraid to look at that needle length for your baby or toddler and make sure it fits the new recommendations.
Posted by Toni Brayer, MD at 9:51 AM
Friday, August 15, 2008
You too can be in peak physical shape with this diet:
— three fried egg sandwiches with cheese, lettuce, tomatoes, fried onions, and mayo
— one five-egg omelets
— a bowl of grits
— three slices of French toast with powdered sugar
— three chocolate chip pancakes
— two cups of coffee
All you need to do is follow it with the same exercise regimen as this guy!
Hat tip to Cynthia C.
Posted by Toni Brayer, MD at 11:00 PM
This week's New England Journal of Medicine challenge is good. What is the diagnosis for this lady's hand. Hint: it is common. (click on image for a better view)
1. Psoriatic arthropathy
2. Reflex sympathetic dystrophy
5. Rheumatoid arthritis
The answer will be posted tomorrow. If you don't know...you might learn something.
Hey, It's a full moon tonight!!
Posted by Toni Brayer, MD at 10:43 PM
Thursday, August 14, 2008
A comment on my post about volunteering in Honduras caught my eye. (Actually I obsessively read all comments so keep them coming!)
The comment was:
Make a conscious effort to do one unexpected act or favor a week for someone else. Leave a bigger tip than usual for a minimum wage worker. (And please always always tip the maid at a hotel. They are invisible and work harder than anyone.) Help a mom struggling with kids to put her groceries in the car...Let the impatient, hassled person cut ahead of you at the grocery store...Volunteer at the homeless food pantry in your community...log on to Women for Women International and adopt a sister in war ravaged Congo.
I am not trying to sound preachy but opportunities are all around us if we look. And one of the best things you can do for a 3rd world country is travel there and spend your money as a tourist. You also return with an appreciation of how good we really have it.
Posted by Toni Brayer, MD at 7:51 PM
Wednesday, August 13, 2008
I came across some words of wisdom from a guy named Omar Periu that intrigued me and so I'm sharing it here on EverythingHealth.
Most people live lives that aren't completely fulfilling because they’ve never learned to manage their minds and emotions. These are 10 rules for living a motivated life.
- Condition your mind. Train yourself to think positive thoughts.
- Condition your body. It takes physical energy to take action.
- Avoid negative people. Don’t take anything that they say seriously.
- Always remain flexible. No plan should be cast in concrete.
- Act with a higher purpose. If it doesn’t serve your goal, it’s wasted effort.
- Take responsibility for your own results. Don’t credit luck, good or bad.
- Stretch past your limits on a daily basis. That’s how you grow and evolve.
- Don’t wait for perfection; do it now! Perfection’s the enemy of good enough.
- Be careful of what you eat. It takes physical energy to succeed.
- Hang around motivated people. The positive energy will rub off on you.
Posted by Toni Brayer, MD at 9:56 PM
Los Angeles has taken a bold move in the battle against unhealthy eating by banning new fast food restaurants from opening in some of the city's poorest neighborhoods. The city council has issued a moratorium on new fast food for a year in South Los Angeles.
Sure there is criticism..government stepping into a free market...government treating people like children that can't make good decisions for themselves...government targeting poor neighborhoods, etc etc.
But more than 45% of the 900 restaurants are fast food chains in the affected 32-square-mile zone. There is do doubt that fast food chains (McDonalds, Wendys, KFC, Burger King) squeeze out competition. Most poor neighborhoods don't have large supermarkets with organic food or appealing vegi displays. The choices for people in poor urban neighborhoods are limited so let's face it...unchecked market forces are leading this country toward obesity, diabetes and heart disease.
Ask any mom (poor or rich) if she wants fast food restaurants on every block and the answer will be "no". How about a convenient supermarket with appealing fresh food or deli? You won't easily find that in South LA.
Families are eating out more often and advertising that targets kids, coupled with low prices and supersize high fructose corn syrup soft drinks is killing America.
I don't think this is heavy handed government. Prudent urban planning is the responsibility of government and LA got it right.
Posted by Toni Brayer, MD at 7:05 AM
Tuesday, August 12, 2008
Monday, August 11, 2008
Garifuna or Black Caribs are communities living on the Caribbean coast of Central America. In 1635 two Spanish ships carrying slaves to the West Indies were ship-wrecked near St. Vincent. The escaped slaves were welcomed and protected by the indigenous Carib Indians. Their intermarriage formed the Garifuna of today. In 1797 the British relocated all the Garifuna along with some black slaves to the island of Roatan in Honduras. From there they have spread to Belize and Guatemala. Their language and religion remain similar to those found among their ancestral peoples of the Amazon and their dances and heritage show a strong African Influence.
Many of these Afro-Caribbeans live in Punta Gorda, where the Siempre Unidos HIV clinic is located. They performed their cultural drumming and dancing for us at a fiesta the last day we worked at the clinic. Wearing traditional costumes, the men in masks leaped and danced while the women sang. It was a wonderful display of culture and history.
Posted by Toni Brayer, MD at 8:36 PM
Sunday, August 10, 2008
I am just back from Roatan, where I volunteered for a week at an HIV clinic run by Siempre Unidos. This is the "seldom seen" part of the island where the locals live and a good wage is $5.00/day. Honduras is the poorest of the Central American countries and has the highest prevalence of AIDS of any Spanish speaking country. Siempre Unidos California was established as a non-profit in 2005 and provides medical screening, treatment and employment to HIV patients in three clinics. Two are on the mainland and one in central Roatan island.
Along with a group of 20 volunteers, we visited the clinic in Roatan to provide medical care, bring needed supplies and work on several building projects. We also started a small jewelry making micro-industry. It offers fair wage employment to women who are discriminated against because of AIDS and have been fired from jobs. The jewelry and sewing workshops are already established on the mainland but it was a first for the Roatan clinic.
Two gynecologists performed pap smears and gyn consults for the patients and I was the first visiting doctor to provide general medical care.
The pap smears will be processed at California Pacific Medical Center in San Francisco for free. For many women who have several children, this is the first time they have had a pap smear.
Alta Bates Summit Medical Center in Berkeley/Oakland and Sutter Marin also contributed needed supplies and $$ for our visit. Each volunteer lugged two 50# suitcases filled with supplies and medicine. (It was easier to return with the empty cases!)
Despite the heat and humidity, we worked with the local nurse and doctor to accommodate all the patients. The local public hospital sent referrals to us also once they found out we were there. There was little I could do for the young man with thrombocytopenia (low platelet count) or the 34 year old mother with liver enlargement and ascites. It could be cancer and she could get a CT scan on the mainland but she didn't have the money to travel there. Since she is a regular HIV patient at the clinic, they will continue to work with her to get her the care she needs.
One young pregnant mother with diabetes had already had a stillbirth at 7 months. They will work closely with her, even doing home visits in the village, to make sure her blood glucose is controlled for this pregnancy.
Diabetes, (very high) hypertension, gastritis, arthritis, itchy skin, headaches are all common problems I deal with every day in the U.S. Limited pharmaceuticals made treatment in Honduras difficult. Now that I have the experience of seeing the limited pharmacy at the clinic, I can advocate for a better supply of needed medication. The patients are grateful for anything and are extremely compliant with meds. High doses of Lasix worry me when there is no way to check potassium or sodium levels. I adjusted medications for many patients who were taking too many medicines that could have adverse effects when taken together.
I'll post more photos of the trip later after I get some laundry done.
Posted by Toni Brayer, MD at 11:43 AM
Friday, August 1, 2008
I'll be taking a blog break for a week as I'm off to Honduras with Siempre Unidos, a wonderful non-profit that provides HIV education, prevention, treatment and employment for Hodurans. Check back next week for a recap of the trip and more EverythingHealth. For great medical blog reading this week...check out my favorite links on the right side. Adios