News from the Front Line on Covid

FLCCC Protocols - A Guide to the Management of COVID-19 - updated Feb 23, 2021 (covid19criticalcare.com)

An overview of the MATH+ and I-MASK+ Protocols A Guide to the Management of COVID-19

Developed and Updated by Paul Marik, MD, FCP (SA), FRCP (C), FCCP, FCCM for the COVID-19 Critical Care Alliance (FLCCC Alliance). This is our recommended approach to COVID-19 based on the best (and most recent) literature. This is a highly dynamic topic; therefore, we will be updating the guideline as new information emerges. Please check on the FLCCC Alliance website for updated versions of this protocol. www.flccc.net.

Database of all HCQ COVID-19 studies. 257 studies, 187 peer reviewed, 210 comparing treatment and control groups.

c19study.pdf

Covid19—when I realized we’d turned the corner

A week or so ago there was a sign covid19 was coming under control. What did I see? The task force noted it was time to start throwing more time and energy at racial disparities. So much of our medical research dollars have been spent the last 30-40 years looking at poverty, obesity, sexual promiscuity of gays, family dynamics, educational achievement, smoking, drugs, and now transgenderism, it's no wonder CDC and NIH don't get the viruses and bacteria under control.

Today I saw: "Columbus Mayor Andrew Ginther and Columbus Public Health Director Dr. Mysheika Roberts have opened the Center for Public Health Innovation to address racism as a public health issue. The new center seeks to reduce health inequities to increase life expectancy and improve quality of life. The center will also address racial disparities related to COVID-19 in Columbus and around the country." This is regurgitating epidemiology, social sciences and public health research that has been going on since the 1960s, and some earlier pieces are classics, still true. Behavior affects health, whether white, Asian, Hispanic or black. More money to advance careers and enhance resumes.

We don't prevent or cure AIDS by studying how gay men think about the size of their penises, yet that research has been on going for years. You don't solve diabetes by measuring the girth of Filipino Americans compared to Swedish Americans. You can't end nicotine addiction by more funding of support groups on-line paid for by Medicare. And concluding that LaTisha and LaToya had too many "daddies" in their home growing up, isn't going to make them want to exercise when they are 50 and overweight. Bridget and Bonnie are also overweight and their parents were married and faithful.

There are thousands, maybe millions of these articles stuck deep in data bases now--we don't need more to tell us behavior matters in keeping us healthy and happy. If anyone, of any race or culture, eats too much, smokes and drinks too much, sleeps around, and only exercises long enough to change the channel, he or she is not going to be healthy based on statistical studies and grandma's advice.

There. I could have saved the tax payers billions, although no one will take my advice because it's too lucrative for academics and politicians.

Optimism about Covid-19

Want some good (or at least better) news? If your liberal friends deny it, the author is probably on the right track.

"First, the rate of increase in deaths from COVID-19 is decreasing, in the United States and in most countries. That means there is a slowing of deaths, not just the calculated mortality rate, a different statistic that will keep decreasing as we unveil a larger number of people carrying the virus with mild or no symptoms. In the United States as well as in Italy, Spain and other countries most heavily impacted, there is a significant slowing in added deaths. This is evidence that isolation policies are working."

And second. . .

And third . . .

https://thehill.com/opinion/healthcare/490582-the-case-for-optimism?

More money for obesity research?

"For decades, experts at CDC, National Institutes of Health (NIH), U.S. Department of Agriculture (USDA), U.S. Department of Education, the Administration for Children and Families, and the Food and Drug Administration (FDA) have been researching and developing strategies to prevent and address obesity among children and adults nationwide." (The State of Obesity, 2018)

And apparently their strategies aren't working except to ask for more money to fund more research to pay more government workers. 1999-2000 30.5% adults obese; 2015-2016 39.6% obese. I don't find that impressive. Don't cut our budgets--we need that money to address obesity! To fail bigger!

Looking through the research, I see. . . racism is embedded.

• The differences between blacks and whites are called INEQUITIES.
• The differences between black males and black females (more likely to be obese) are called differences.
• The differences between Asian American men (more likely to be obese) and Asian American women are differences.
• The differences between Asians and whites (more likely to be obese) are called differences.
• The differences between rural (more likely to be obese) and urban are called differences.
• The differences between first generation and second generation (twice as likely to be obese) are called differences.
• The differences between Filipino Americans (more likely to be obese) and Chinese Americans are called differences.

Life expectancy dropping since 2014

Our behavior is showing up in our health statistics as well as our homes.

"Between 1959 and 2016, US life expectancy increased from 69.9 years to 78.9 years but declined for 3 consecutive years after 2014. The recent decrease in US life expectancy culminated a period of increasing cause-specific mortality among adults aged 25 to 64 years that began in the 1990s, ultimately producing an increase in all-cause mortality that began in 2010. During 2010-2017, midlife all-cause mortality rates increased from 328.5 deaths/100 000 to 348.2 deaths/100 000. By 2014, midlife mortality was increasing across all racial groups, caused by drug overdoses, alcohol abuse, suicides, and a diverse list of organ system diseases. The largest relative increases in midlife mortality rates occurred in New England (New Hampshire, 23.3%; Maine, 20.7%; Vermont, 19.9%) and the Ohio Valley (West Virginia, 23.0%; Ohio, 21.6%; Indiana, 14.8%; Kentucky, 14.7%). The increase in midlife mortality during 2010-2017 was associated with an estimated 33 307 excess US deaths, 32.8% of which occurred in 4 Ohio Valley states."  https://jamanetwork.com/journals/jama/article-abstract/2756187?

Americans can't smoke, over eat, have multiple sex partners, sooth the soul with alcohol and become a zombie with drugs and not have it show up in a study down the road. Although the numbers ticked up 2010-2017, the behavior began much before that--the 1980's-1990s.

And that Ohio Valley information in the study--straight up from Mexico—black tar heroin.  Read “Dreamland; the true tale of America's Opioid Epidemic” by Sam Quinones. He was a speaker at Lakeside, I think in 2018.  The stories of young men in Mexico, independent of the drug cartels, in search of their own American Dream via the fast and enormous profits of trafficking cheap black-tar heroin to America’s rural and suburban addicts combined with Big Pharma.  https://nihrecord.nih.gov/2018/05/18/author-recounts-how-opioids-took-hold-america

Older people and protein needs

Today I attended a program on protein at the wellness center at Lakeside and wasn’t satisfied with what I heard.  Most of her references were 15-20 years old. Her citations for RDA were for the “universe” of adults, rather than the elderly, and most attending were over 70.   Here’s my recommendation when googling health information.  Add the letters NCBI to your search.  Here is “elderly protein ncbi”.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924200/

https://www.ncbi.nlm.nih.gov/pubmed/30036990

https://www.ncbi.nlm.nih.gov/pubmed/24814383

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4882708/

https://www.ncbi.nlm.nih.gov/pubmed/30037048

Lakeside 2019, Week 4

The daytime lectures this week feature Kelly Dillion of Wittenburg University speaking on “Kids, Guns & the Media,” and “Media Literacy for  all Ages” on Monday and Tuesday.  On Wednesday Mark Dawidziak speaks on “The Twilight Zone,” and on Thursday, “Rod Serling & Mark Twain: moralists in disguise.”

Tuesday evening at Hoover Auditorium will be author, Michael Roizen, MD, Cleveland Clinic, speaking on the 6 + 2 normals.  Here’s a YouTube of one of his lectures. https://www.youtube.com/watch?v=SzSaI73NKaw 

At another lecture, https://www.healthandwealthresearch.com/free-research/how-to-become-a-1-percenter  given this year, he said,

“Consider that 84% of all healthcare costs are due to chronic disease, and 75% of chronic diseases are driven by just six measurable factors:

• Blood pressure

• Body mass index (BMI)

• Fasting blood sugar (or hemoglobin A1C)

• LDL cholesterol

• Smoking (measured by blood cotinine levels)

• Unmanaged stress

These six predictors of chronic disease are controllable in up to 95% of people.”  (+2) See your primary care provider and stay up to date on your immunizations.  So for being 80 and 81, we’re in pretty good shape (but I need to lower my cholesterol).

Today, Sunday afternoon, a woman is speaking for the Heritage Society about how she came back to Marblehead Peninsula to start a business.  On Monday in Chautauqua Hall we’ll have another evening of Porch Stores—this little feature now in the 3rd year has been so popular (and it is nationwide) that it is held in Chautauqua Hall in the Fountain Inn rather than on a porch.  Tuesday at the Women’s Club I plan to attend a program about Mrs. Warren Harding.

Last night a huge crowd showed up to enjoy the Spinners, a black do-wop group, but although we stuck our heads in the door, it was so hot we went over to the Barris’ and chatted with Dan.  Friday’s Cooking with Chef Stacy lecture  in the morning featured how to purchase, chop, treat and store knives, and she did a demo for corn chowder, made with 2 quarters of cream!  We asked, but she said, no, it should be cream—just eat less of it if concerned about calories. I’m not a member of the CLSC discussion group, but Thursday they are doing “A Gentleman in Moscow” by Amor Townes, and our book club did that one, so I may see what that’s about.  On Friday July 12, we’ll have another Organizing 101 on dealing with “stuff.”  The first one was very good.

What about NAD+

Highlights:  “NAD+ and sirtuins in aging and disease,” Shin-ichiro Imai and Leonard Guarente, Trends in Cell Biology, 2014, Aug. 24(8): 464-471. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4112140/  71 references

• NAD ⁺ plays a key role in regulating metabolism and circadian rhythm through sirtuins.
  
• NAD ⁺ becomes limiting during aging, affecting sirtuins’ activities.
  
• NAD ⁺ decline is likely to be due to a NAD ⁺ biosynthesis defect and increased depletion.
  
• Supplementing key NAD ⁺ intermediates can restore NAD ⁺ levels and ameliorate age-associated pathophysiologies.
  

Another article (print full text, free) to read at the fitness center.
“NAD AND THE AGING PROCESS: ROLE IN LIFE, DEATH AND EVERYTHING IN BETWEEN” Mol Cell Endocrinol. 2017 Nov 5; 455: 62–74.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5419884/

“NAD was discovered over a hundred years ago (Harden and Young, 1906), and now that it has achieved its status as a super-centenarian molecule, its role in the biological process of aging is being recognized (Braidy et al., 2011; Gomes et al., 2013; Lin et al., 2000; Massudi et al., 2012; Scheibye-Knudsen et al., 2014; Zhu et al., 2015). It has been shown that NAD levels decline during chronological aging, and that this decline is both a consequence of the aging process and also a contributor to the development of age-related cellular dysfunction (Braidy et al., 2011; Gomes et al., 2013; Massudi et al., 2012; Scheibye-Knudsen et al., 2014; Verdin, 2015; Zhu et al., 2015). It is possible that a vicious cycle exists in which molecular mechanisms involved in the aging process, such as oxidative stress, DNA damage, senescence, and inflammation, lead to tissue NAD decline which subsequently exacerbates the processes that caused its decline in the first place (Figure 1). To potentially intervene in this vicious cycle it is crucial that we understand the mechanisms that lead to cellular NAD decrease during aging and, in particular, whether the decrease is mediated primarily by changes in its degradation, synthesis, or both. Furthermore, it is critical to understand how oxidative stress, DNA damage, inflammation, and senescence impact cellular NAD metabolism during the aging process. In the current review we will present a critical analysis of this subject, and will provide new mechanistic hypotheses to explain the age-related NAD decline.”

Are tattoos telling us something?

I kept seeing things float past about tattoos, sex, sleep and mental illness, so I decided to try to track down the research, since none of the summaries gave a definitive source—just something about University of Miami.  Finally found it in the International Journal of Dermatology, “Are tattoos associated with negative health‐related outcomes and risky behaviors?” Jan. 24, 2019  Two of the authors are at the University of Miami.

Abstract (the article is not available on-line)

Background

Tattoos have reached broadening mainstream acceptance. Medical professional societies have noted that tattoos may co‐occur with high risk behaviors.

Methods

Using a variety of statistical models applied to a sample of 2,008 adults residing in the United States via Amazon's Mechanical Turk, we estimate the associations between tattoo characteristics, three health‐related outcomes (overall health status, ever diagnosed with a mental health issue, sleep problems), and three risky behaviors (current smoking, ever spent time in jail or prison, and number of sex partners).

Results

We find that the presence, number, and specific features of tattoos are positively correlated with two of the health‐related outcomes (ever diagnosed with a mental health issue and trouble sleeping) and all three of the risky behaviors (P < .05). Magnitudes are larger for those with multiple, visible, and offensive tattoos.

Conclusions

Our results suggest that individuals with tattoos are more likely to engage in risky behaviors relative to their non‐tattooed counterparts, which may lead to health consequences. Dermatologists, healthcare providers, and public health advocates should recognize that having a tattoo(s) is a potential marker for mental health issues and risky behaviors.

Do you know the sex/gender terminology?

Grant #2011-JF-FX-0001  Urban Institute  “Access to Safety, Health Outcomes, Substance Use and Abuse, and Service Provision for LGBTQ Youth, YMSM, and YWSW Who Engage in Survival Sex “https://www.urban.org/research/publication/access-safety-health-outcomes-substance-use-and-abuse-and-service-provision-lgbtq-youth-ymsm-and-ywsw-who-engage-survival-sex   

This report provides a list of definitions for LGBTQ youth at risk for health problems. It was sort of wordy, so I condensed a bit.  In a discussion group we were noting the changing terminology.

Cisgender: Individuals whose experiences of their gender match the sex they were assigned at birth.

Gender expression: The aspects of behavior and outward presentation that may (intentionally or unintentionally) communicate gender to others in a given culture or society.

Gender nonconforming: People who have or are perceived to have gender characteristics or behaviors that do not conform to traditional or societal expectations. Gender-nonconforming people may or may not identify as transgender.

Sexual orientation: Whom a person is physically and emotionally attracted to. Sexual orientation is distinct from gender identity; transgender people may identify as heterosexual, bisexual, gay, lesbian, or any other sexual orientation.

Transgender: People whose gender identity (internal sense of being female, male, or another gender) is incongruent with their sex assigned at birth (physical body).

Young men who have sex with men (YMSM): Young men who may identify as heterosexual but have sex with members of the same sex, often in exchange for money and/or material goods.

Young women who have sex with women (YWSW): Young women who may identify as hetero-sexual but have sex with members of the same sex, often in exchange for money and/or material goods.

Exploiter: An individual who uses tactics involving force, fraud, and coercion to control a young person’s involvement in the commercial sex market.

Peer facilitator: A peer, who may or may not be engaged in survival sex, who provides nonexploitative support to someone engaging in survival sex, so the person engaging in survival sex does not have limited mobility; decides what they do and what they trade sex for; and is not subject to force, fraud, or coercion.

Youth engaged in survival sex: The phrases “youth engaged in survival sex” and “youth who exchange sex for money and/or material goods (e.g., shelter, food, and drugs)” are used here to reflect young people’s experiences of involvement in the commercial sex market in their own terms.

Gay family: An alternative familial network of LGBTQ people that may act as an alternative to the family of origin from which many LGBTQ people, particularly youth, have been excluded. The term may also be used to refer to drag houses in the ball scene.

Ball scene/house culture: A community consisting primarily of black and Latino and Latina LGBTQ people organized around anchoring family-like structures, called houses, and competitive balls. [I’d never heard of Ball Culture, but you can find a description in Wikipedia https://en.wikipedia.org/wiki/Ball_culture .  Apparently, Langston Hughes in the 1920s described it.)

Barrier and nonbarrier protection: Any contraceptive or other protective device or method used to prevent unwanted pregnancy or the transmission of human immunodeficiency virus (HIV) or other STDs.

 Interesting findings about the almost 300 youth in this study (this is the 3rd report):

99% of these LGBTQ at risk youth in this study were using contraceptives (barrier and nonbarrier). [A quick look shows that compares with about 50% of non LGBTQ teens)

93% were using the services of a helping agency, 99% accepted help from them and 94% said they would seek help from that agency again

only 5% in the study were white.

47% male, 36% female, 11% transwoman (i.e.biological male), 3% transman (biological female), 5% other, not specified, or wouldn’t say

These youth are at greater risk than heterosexual male and female youth for violence, abuse, sexual victimization, mental health risks,  sexually transmitted diseases, and homelessness

Other reports funded by this grant

https://www.urban.org/sites/default/files/publication/71446/2000424-Locked-In-Interactions-with-the-Criminal-Justice-and-Child-Welfare-Systems-for-LGBTQ-Youth-YMSM-and-YWSW-Who-Engage-in-Survival-Sex.pdf

The right to try

Democrats don't want to put dying people whose treatments have failed "in danger" so they didn't support the "right to try" bill. Big Whoop. Here are the big reasons.

• They didn't support it because it is a "right to life" issue (which includes fighting euthanasia),
• they didn't support it because it's a win for Trump,
• they didn't support it because some of their biggest donors in the medical and pharmaceutical field don't like it, and
• they didn't support it because it puts more control of health in the hands of the consumer. 

Rich Democrat celebrities can always fly to Asia or Mexico for experimental drugs; no use letting the hoi polloi do that and cheapen the glamor.

Protections for special groups, but not the majority?

Obama  is offering special protections for the .3% of Americans that are supposedly confused about their gender and he's demanding the rest of us pay for their fantasies of body mutilation.  One has actually sued her employers because they use a pronoun s/he objects to.  Where are the special accommodations for other groups who are bullied, ridiculed, or can't find suitable clothing or furniture? Especially women. 

82% of black women, 77.2% of Hispanic women, and 63.2% of white women have been declared overweight or obese by researchers funded by the government. They endure a lot, including bathroom stalls designed for size 6 women, and airline seats for people no bigger than a size 10. Ridiculous portion sizes. They've been taunted by everyone from classmates to doctors to academics to wait staff, and all the government does is publish more papers on how they need to change their eating habits and life style. I'm not suggesting that you not be allowed to comment on Hillary's weight and pants suits, or Chris Christie's girth, but where is their protection from the size bigots and butt bullies? Where's your compassion, Mr. President?

http://www.hopkinsmedicine.org/gim/research/content/obesity.html

 http://www.womenshealth.gov/publications/our-publications/fact-sheet/overweight-weight-loss.html

 https://report.nih.gov/categorical_spending.aspx

https://phpartners.org/obesity.html

 http://www.mrctv.org/blog/taxpayers-continue-spend-millions-find-out-why-lesbians-are-fat

Health Benefits of Reading

That's a lot of veggies!

The following is from the Harvard Medical School HealthBeat, May 28, 2015

"Several studies have shown that in countries where men eat a typical "Western" diet containing a large amount of meat, the incidence of prostate cancer, especially aggressive prostate cancer, is higher than in countries where plant-based foods are a primary part of the diet. Unfortunately, these studies weren't designed to prove cause and effect. So for now, definitive answers about prostate cancer and diet aren't yet in — although researchers are actively studying this topic.

Investigators have launched a federally funded national study to see whether a diet that's higher in plant-based foods and lower in animal-based foods than the typical Western diet will help control tumor growth in men with early-stage prostate cancer.

Participants in the Men's Eating and Living (MEAL) study will try to eat nine servings of fruits and vegetables daily — significantly more than the three to four servings consumed each day by the typical American man — as well as two servings of whole grains and one serving of beans or other legumes.

This clinical trial will include men 50-80 years old who have small, low-grade tumors and who have opted to have their condition followed closely (active surveillance) rather than undergoing immediate treatment. Researchers will randomly assign participants to telephone counseling about how to achieve the dietary MEAL goals or to a control group that receives standard dietary advice for Americans.

During the two-year study, the investigators will collect blood samples to assess levels of antioxidants and nutrients, and then monitor the men with PSA tests and prostate biopsies to determine whether the cancer is progressing. A pilot study showed the approach is workable, and that with enough telephone prompting, men can increase their intake of vegetables and other healthy foods. To learn more about the larger phase III MEAL study, or to enroll, visit www.clinicaltrials.gov and search for Trial NCT 01238172."

Coffee research

Free image from Pixabay.com

Do you need some more reasons to enjoy that cup of coffee in the morning? I switched to decaf because of a-fib, but it still has the good stuff. A really good summary of current research. http://samadimd.com/latesthealth/coffee-and-your-health

I watch Dr. Samadi on week-ends on Fox, and find him a good balance between sound research and alternative concepts.

I've tried several brands of decaf (never brewed coffee until about 2 years ago) and have settled on Folger's. I like it with some half n half, or if mixing it with dark chocolate, about half a cup of 2% milk. I use a little Mr. Coffee machine, and have no problem with reheating in the microwave, which brings nightmares to purists.

Are these men really missing?

The New York Times Upshot column claims: “In New York, almost 120,000 black men between the ages of 25 and 54 are missing from everyday life. In Chicago, 45,000 are, and more than 30,000 are missing in Philadelphia. Across the South — from North Charleston, S.C., through Georgia, Alabama and Mississippi and up into Ferguson, Mo. — hundreds of thousands more are missing.”

I'm not sure why they are called missing. Black women abort at a much higher rate than white, so let's assume over half of those babies are male (birth ratio statistics); the crime rate for black men is about 8 times that of white, and their victims are black, so unless you want the police and courts to ignore the victims so the perps won't be in jail, what is the solution? More males than females are born, except among blacks; all boys are less healthy than girls, and by age 13 there is quite a discrepancy; visit the prisons and talk to the men of any race who grew up without fathers married to their mothers and in the home. CDC estimates that blacks account for almost half of all new infections of HIV in the U.S.each year, and although that's not the death sentence it used to be, it's also not the road to health, employment and marriage--and in a number of cities about 1/3 of the gay/bisexual black men are infected. When black men marry, about 24% marry outside their race, decreasing the opportunity for marriage for black women (Pew Study) so they might as well be missing. There is no plot.They aren't missing. But there is some negative behavior that can be changed.

Also, the author doesn’t seem to grasp the connection that the higher prison rate has resulted in lower crime rates for black communities.

Since the 1990s, death rates for young black men have dropped more than rates for other groups, notes Robert N. Anderson, the chief of mortality statistics at the Centers for Disease Control and Prevention. Both homicides and H.I.V.-related deaths, which disproportionately afflict black men, have dropped. Yet the prison population has soared since 1980. In many communities, rising numbers of black men spared an early death have been offset by rising numbers behind bars.

Confession and forgiveness

I play a YouTube while I'm exercising (Gold's Power Spin 210) because after 5 minutes all the news shows repeat. This morning I heard the phrase, "Going to confession is like getting free health care." That might mean more to Catholics because Confession is a sacrament for them, but it is also a basic principle. Whether you confess your sins to another person who prays with you and suggests changes or directly to our Lord, it is a tremendous relief to hand off that burden. How many health problems are stress related due to unforgiveness and grudges carried way too long?

Midlife Cardiorespiratory Fitness, Incident Cancer, and Survival After Cancer in Men

Good news.  Cardiovascular fitness in midlife may protect against cancer, not just heart disease.  Aren’t middle age?  Well, tell your sons, or grandsons.

Free article. http://oncology.jamanetwork.com/article.aspx?articleid=2203829

• High CRF was associated with reduced incident lung (HR, 0.45 [95% CI, 0.29-0.68]) and colorectal cancer (HR, 0.56 [95% CI, 0.36-0.87]) in white men.

• High CRF is associated with a one-third risk reduction in all cancer-related deaths among men who developed lung, colorectal, or prostate cancer at age 65 years or older compared with low CRF.

• High CRF is associated with a two-thirds reduction in cardiovascular death compared with low CRF among men who developed cancer at age 65 years or older.

http://generalfitness.tripod.com/id4.html

http://www.ucdenver.edu/academics/colleges/medicine/sportsmed/cusm_patient_resources/Documents/Training%20for%20Cardiovascular%20Fitness.pdf

Forget workplace nutrition and exercise classes. . .

“Workplace stress — such as long hours, job insecurity and lack of work-life balance — contributes to at least 120,000 deaths each year and accounts for up to $190 billion in health care costs, according to new research by two Stanford professors and a former Stanford doctoral student now at Harvard Business School.”

I would have guessed that irritation with supervisor or co-workers would have been the biggest cause of stress. I remember how stressful it was when my supervisor threw the phone through the window when she was mad at something (not me), then pulled it back in by the cord and threw it through a second window.  The windows were closed. Now that’s stressful. These days, the light weight phones couldn’t break a sweat, let alone a window.

http://www.gsb.stanford.edu/insights/why-your-workplace-might-be-killing-you

I’m still in Virginia!

How big is this state, anyway?  I’ve ridden my exercycle, Gold’s Gym Power 210 Spin, 380 miles since Christmas using an online program called “Tools to Keep you Active” into which you can log your biking, running or walking, and it will show you a photo of where you are.  And I’m still in Virginia!