Does Lipozene work?

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I was watching TV the other day and happened to see a commercial for a weight loss supplement known as Lipozene.  It sounded amazing!  People lost 20, 50, or even 90 pounds without having to change their lifestyle.  They didn't have to exercise more or even modify their diets.  Sounds like a winner right?

Well, not so fast.  I looked closer at the fine print at the bottom of the screen.  You know, the one that requires a magnifying glass or a pause button.  The fine print, also found on their website, states that in an 8 week clinical study, the "Active Group lost 4.93 pounds more than the Placebo Group."  What that means is that those who took this supplement on average lost only about 5 pounds compared to those who didn't.  So what happened to all those that lost 50 pounds or more?

The truth is that Lipozene doesn't tell you what the average starting weight for study participants was.  If an individual weighs 300 pounds, then losing 50 pounds is not as difficult as when a person weighs 200 pounds.  If a person weighs 150 pounds and wants to lose some weight, losing those extra pounds is significantly more difficult.  Even if people did lose 20 or 50 pounds, the average weight loss is still only 5 pounds with this supplement.

The reviews on their website have a majority of people who changed their lifestyle and are working out  now to lose more weight.  I hate to break it to you but exercising without Lipozene also leads to weight loss.  Why take a supplement that makes you "feel fuller faster and longer"?  Why not just eat better and exercise more often without introducing a foreign substance into your body (which has no FDA guidelines by the way).

Lastly, what is really shocking is that Lipozene claims to have no caffeine or other ingredients, yet they send you a bottle of MetaboUP with every order.  When you look at the ingredients on this, it contains 120 mg of caffeine which is more than a cup of coffee.  Additionally, it contains an ingredient called "pharmaceutical glaze."  I don't even want to begin to guess what a pharmaceutical glaze is.  If Lipozene was so effective, why include a bottle of a stimulant that contradicts everything that your product is supposed to represent?

It's sad to see the obesity epidemic reach new heights in America, but it is even more disappointing to see companies such as Lipozene exploit victims of obesity.  The proof is in the pudding though.  Lipozene is not any more effective at weight loss than diet and exercise and does not offer any of the cardiovascular benefits either.  It's time to take that Lipozene money and spend it eating better and exercising.

Russell Wilson and his Recovery Water claim

Russell Wilson recently went on Twitter to say that a brand of water called "Recovery Water" prevented him from having a concussion.

I believe @Recovery_Water helped prevent me from getting a concussion based on a bad hit! 😇 #NanoBubbles

— Russell Wilson (@DangeRussWilson) August 26, 2015

It just so happens that Russell Wilson is a spokesperson for Recovery Water.  The claim he made is unfortunately unproven and not well thought out. Recovery water is "electrokinetically modified water" which means it has some added electrolytes.  The company also claims it has something called "nanobubbles" which isn't even a medical term and nobody understands what these bubbles do.  Essentially, the water has some minerals that are supposed to help with muscle recovery.

The difference in the company's claim and Russell Wilson's claim is that the company only mentions muscle recovery from muscle fatigue.  Their claims are based on studies done on 40 people.  Think about that for a second, 40 people.  That is about as small a sample size as you can get.  That study basically holds no merit, but at least the company isn't coming out and saying they have hard data.  Russell Wilson, however, takes it to another level and thinks it prevented a concussion.  So far we know of basically one thing that prevents concussions: not getting hit in the head.  There are various helmets and products that are trying to prevent concussions, but they aren't quite there yet either.  Simply put, Russell Wilson's claim is invalid and a poor job at marketing. I just hope this doesn't lead to uninformed young adults running out to buy Recovery Water.

Too old to exercise?

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When we think of the benefits of exercise, we somehow always picture it benefitting a young adult who will continue to exercise regularly.  We rarely think of the benefits of exercise in older individuals.  It turns out we don't think about it enough.

A new study in the British Journal of Sports Medicine monitored 6,000 Norwegian men for 12 years and found that 51% of the men who died in their 70s were sedentary, whereas only approximately 25% of the men who died exercised moderately to vigorously.  This shows a clear correlation that men who exercise moderately or vigorously are likely to live longer.  They also found that 30 minutes of moderate exercise six days a week was associated with a 40% lower risk of death.

These numbers are impressive when you consider the fact that most medications cannot produce the same results.  Add to the fact that most medications usually have some type of side effect, exercise is quite simply the safest bet in preventing disease.  Best of all, exercise comes in various forms and you can decide what works best for you.

So if you've ever wondered if it's too late to exercise, think again.  Exercise can not only be started at any age, but this study shows that it is never too late.  For more information on exercise, visit Exercise is Medicine.

Most common causes of Sore Throat

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While we are deeply entrenched in cold and flu season, patients often think that they have strep throat.  Many will have children who had strep throat or friends of their children who had it and want to be checked out to see if they have picked it up.  The fact is, strep throat is less common than you think, and that's a good thing.  There are several other reasons for a sore throat that are far more likely than strep throat.  So what exactly is strep throat?

Strep throat is a term that is commonly used to describe an infection of the throat by a bacteria called Group A Streptococcus.  This accounts for 15 to 30 percent of sore throats in children but only 5 to 20 percent of sore throats in adults.  The most common features of a strep throat are high fever, white patches on the throat or tonsils, swollen glands, and lack of a cough.  This is very different than the common cold which presents with sore throat, cough, congestion, low-grade fever, and bodyaches.

So what are the most common causes of a sore throat?

Viral infection- this is by far the most common.  Since colds are caused by viruses they will almost always lead to a sore throat in the beginning.

Allergies and Post-nasal drip- environmental allergens can irritate the throat directly or lead to fluid draining into the back of the throat.

Acid reflux- when there is acid build-up in the stomach, it flows back up into the throat and creates irritation and may even lead to a hoarse voice.

There are many other conditions that can lead to sore throats, but those are the most common.  Viral infections and allergies/post-nasal drip are by far at the top of the list and should be considered first in the absence of the symptoms mentioned for strep throat.  So the next time you have a sore throat, take a closer look at your symptoms, your temperature, and your previous medical history for a possible answer.  It may be easier than you think!

The Dr. Oz Show and "The Doctors" may not be as accurate as you think

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It seems that most doctors these days cannot go a day without having patients mention Dr. Oz or The Doctors TV show.  Patients will often tell their doctors that they read about a specific test or treatment on one of these shows and would now like to try them.  This can sometimes lead to frustration for the patient and the doctor.  The question is, are these shows correct in their medical recommendations?

The British Medical Journal just released a study that looked at claims made by The Dr. Oz Show and The Doctors.  They randomly selected 40 episodes of each show and evaluated all of the recommendations made in these episodes.  They found that there was evidence for only 54% of the 160 total recommendations in medical literature.  On The Dr. Oz Show, there was no evidence for 39% of claims and 15% of the claims were actually the OPPOSITE of true medical recommendations.  On The Doctors, 63% of the recommendations were supported by medical literature and 14% of the recommendations were again opposite of medical standards.

If those numbers aren't shocking enough, there is one more important number.  The study found that "Disclosure of potential conflicts of interest accompanied 0.4% of recommendations."  This number indicates the honesty of these shows in promoting products that they are affiliated with.  For instance, if Dr. Oz is promoting a new type of herbal tea for weight loss and he is the spokesperson for that tea, he should be disclosing this information.  However, only in 0.4% of the cases was this ever disclosed.  In fact, Dr. Oz was summoned by Congress for his promotion of the green coffee bean diet for these very reasons.

Health is a very sensitive topic because it can be a roller coaster of emotions.  Patients go to their doctors and ask for advice under the assumption that their advice is based on at least some type of evidence.  Often times a doctor may make a recommendation and may tell the patient that there is not enough evidence for this yet but that isolated cases have shown positive results.  This is perfectly acceptable because not every recommendation has a large number of studies to back it up.  However, making claims on national television that are not supported or are at times completely incorrect is unethical.  Be an advocate for your health and form a trustworthy relationship with your doctor.  They would be happy to answer your questions and work with you.  The doctor-patient relationship is a sacred one, not one that can be had with a television set.  So the next time you watch one of these shows, do your own research or ask a doctor with an unbiased opinion.  It may save you a few bucks, and your life!

Think young, live longer

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At a certain point in life, many people feel they are younger than their actual age.  It turns out this may actually have a relationship with how long they may live down the line.  A recent study in the UK by Dr. Steptoe and Dr. Rippon tracked 6489 patients with an average age of 52.  These individuals were asked how old they felt and the results were classified into 3 groups:  1) those that felt close to their actual age (1 year older to 2 years younger), 2) those who felt more than 1 year older than their actual age, and 3) those that felt 3 or more years younger than their actual age.  This seems rather silly at first, but the results that followed were pretty astonishing.

These three groups were then followed for 99 months.  It turns out that the crude mortality (death) rate was 14.3% in those who felt younger, 18.5% in those who felt about close to their actual age, and 24.6% in those that felt older than their age.  This indicates that those who felt younger had a lower rate of death than those who felt older.  So is this a simple case of mind over matter?  Yes and no.

I think it is important to take a look at why people feel the way they do.  Those that felt younger than their actual age likely had reasons to feel that way.  They may have exercised, had less stress, enjoyed life more, and had a better outlook.  On the other hand, those that felt older may have led a sedentary lifestyle, gotten less sleep, had more stress, etc.  Having said that, the perception that you are younger than your actual age definitely has benefits.  It likely causes you to be more active, eat better, and want better for yourself.  While this sounds logical, it had never before been demonstrated in such a large study.  So the bottom line is: live forever young and it may help you live longer.

Flu vaccine may be less effective this year

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The Centers of Disease Control (CDC) put out a health advisory to physicians last week in regards to this year's influenza (flu) vaccine.  The advisory stated that the vaccine this year may be less effective than usual because of antigenetically different or "drifter" strains that have surfaced.  What does this mean?  A quick run down on the influenza virus and vaccines in general will make this clear.

The influenza virus has many strains.  These strains are structurally different just slightly, but enough to have their own identity.  It's almost like hair color.  It's still hair, but it can be black, red, brown, or even blue in some teenagers.  In the same way, the influenza virus has differences.  Every year, the flu vaccine is developed in order to provide immunity against the most common strain for that year.  However, this is somewhat of a guessing game.  The flu vaccine is actually developed earlier in the year with only a very small sample size of influenza strains that have been captured.  For that reason, a flu vaccine does not cover every single strain of the flu, only the one(s) that we predict will be the most common this year.

That takes us back to this year's flu vaccine.  This year it was predicted that a specific type of H3N2 strain of the flu would be the most common.  So they developed the vaccine that was appropriate.  Now they have discovered that as many as 50% of the strains in the population may be different than the strain that the flu vaccine covers.  The strain is still H3N2, but it's like instead of having brown hair, you've thrown in red highlights.  This subtle change is enough that the body will not be able to form antibodies to it and it can still lead to an infection.

The flu vaccine is never perfect because there are so many different strains and it is almost impossible to protect all of them.  Even if the flu vaccine covers 100% of the most common strain for the year, you can still get the flu from uncommon strains.  So the question is, do we vaccinate?  The recommendation from the CDC is still to receive the flu vaccine because protecting against 50% of the strains is better than not protecting against any.  What we will see though is that the flu season this year may be pretty bad in most parts of the country and more people will need anti-viral medications at the first onset of the flu.  So remember to get your flu shot this year, just be aware that a brunette with red highlights may still spoil the party.

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CDC says circumcision may be beneficial

Circumcision is an age old practice throughout the world and has become common practice in the  United States as well.  It is a procedure in which excessive foreskin from a newborn is surgically removed at birth.  The thought is that removing the skin prevents germs from causing infections as a child and as an adult.

How is it done?  Within a couple days of birth, a newborn is given sugar water to suck on and remain distracted.  Then a small needle is used to inject numbing medicine at the base of the penis to make the entire penis numb.  This works very well if done correctly.  A special tool is then used to protect the penis and cut off the excess skin.  The entire procedure takes 10 to 20 minutes to complete.

Anti-circumcision groups have said that this practice is inhumane and painful to a newborn.  In reality, how much more painful is this compared to blood draws and vaccines?  The most painful part is the injection for numbing, but this is again no different than shots and needles used to draw blood.  The other question was, is it effective in preventing infections?

Today the CDC released guidelines that show circumcision can:

• Cut a man's risk of getting HIV from an infected female by 50 to 60 percent
• Reduce the risk of herpes and HPV by 30 percent or more
• Lower the odds of urinary tract infections in infancy and penile cancer in adulthood

These are pretty significant points that the CDC is making.  However, opposition groups will surely make a lot of noise to refute this.  Personally, I have seen many patients that wish they were circumcised.  Some patients get fungal infections frequently due to moisture, some with those infections mentioned by the CDC.  In the end, every parent has a choice to make and nobody can fault them for their decision in either direction.  With these new facts, it will also be interesting to see if insurance companies will have to cover the procedure as a standard of care.  If this happens, expect more individuals to make the choice to circumcise.

Mumps in the Anaheim Ducks locker room

Two Anaheim Ducks players, Corey Perry and Francois Beauchemin, have just been diagnosed with Mumps.  This is a condition that is caused by a virus and presents with fever, headache, muscle ache, fatigue, and swelling of salivary glands.  The most textbook presentation is a large swelling of the neck.  Once a person is diagnosed with Mumps, the treatment is just supportive fluids, anti-inflammatory medications, and rest.  Patients should be isolated for 5 days after they notice the symptoms to prevent its spread.  Rarely, Mumps can lead to an inflammation of the testicles, ovaries, breasts, and in severe cases even infection of the brain or spinal fluid.  Luckily, those are very rare cases and most patients will recover without any problems.

So why do we care about Mumps?  Most people have never heard of it and most doctors will never see it in their careers so it should be relegated to textbooks right?  The reason we rarely see Mumps in this country now is because of vaccination.  Whether you remember it or not, almost all of us in the United States received the MMR vaccine which immunizes us against Measles, Mumps, and Rubella.  Great, so if we are all vaccinated, why are we still talking about this?  The reason is that there is a growing movement against childhood vaccines.  For this reason, we are starting to see diseases such as Mumps and Measles again.  The debate behind vaccination is something I will leave for another day, but I will say this.  We are seeing diseases in the United States that were practically eradicated due to vaccines, and that is not a good path to head down.  The Anaheim hockey team players will be just fine, but lets make sure to keep our ducks in a row when it comes to vaccination!

How many hours of sleep do you need every night?

For as long as I can remember, I was told that you need 8 hours of sleep a night.  This was a common belief from mothers to doctors.  But over the past several years, many studies have emerged that are changing that recommendation.

It turns out that 7 hours of sleep is the new magic number.  Studies have shown that cognitive performance peaks at 7 hours of sleep and may deteriorate after.  Additionally, some studies show that those that get 7 hours of sleep have lower mortality rates.  These various studies provide strong support for the notion that "Seven is the new Eight."

I think these studies provide us with some solid guidelines on the number of hours we sleep, but are we getting seven solid hours of sleep?  The answer to that question is much more important than the number of hours we sleep.  Many people will feel that even though they sleep 7 hours a night, they still feel tired the next day.  Unfortunately, sleeping 8 hours sometimes doesn't seem to be any better.  The reason for this is obvious: sleep hygiene.  Getting good sleep is better than getting more sleep.  Here are some tips on getting better sleep.

Cell phone hibernation: You hate to leave your phone for a second, we all do.  Putting your phone on silent and leaving it away from your bed is important to avoid its sounds and lights.

Water unloading:  You're going to bed, not to a desert in Africa.  No need to gulp a whole bottle of water before you try to catch some z's.  Use the bathroom before bed and you'll avoid waking up in the middle of the night.

Early dinner:  Eating dinner at least 2 hours before bed will prevent a heavy stomach and heartburn.  Having a snack such as fruit is acceptable, but a bag of Cheetos probably isn't.

Treat weekends like weekdays: Long gone should be the days of summer in high school where sleeping in until noon or 2 pm was okay.  If you sleep longer on weekends to make up for the previous week or the previous night, it may throw your sleep schedule off.  Instead, go back to bed earlier that night and get your 7 hours.

Don't sleep in a sauna:  Sleeping in a cooler room will provide better sleep than sleeping in a room that is warm.  You can always pile on bedding if it's too cold, but colder temps will help you sleep much better.

I know all of these things are much easier said than done, but those should become eventual goals.  Sleeping well will undoubtedly lead to more productivity the next day and likely reduce stress as well.  Not only will you feel better, but you'll look better when you aren't caught sleeping in a meeting or in class.  Sleep tight!

Doctor being tested for Ebola

A doctor who participates in Doctors Without Borders is being tested for Ebola in New York City today.  Craig Spencer, from Harlem, is awaiting results of his Ebola testing after he recently worked in an Ebola-affected country.  He returned to the US within 21 days and has now developed a fever.  The 21 day period is very important because this is the incubation period for Ebola and represents the time in which a person would present with symptoms.  The fact that the patient has a fever does not alone mean he has Ebola since he could have a fever from a cold, stomach flu, etc.

Of note is that we still have not had a single person in the United States with Ebola that was infected outside of a hospital setting.  The two nurses that are currently infected were both caring for a very sick Ebola patient and this patient was in close contact with Ebola patients in West Africa.  This should come as somewhat of a reassurance that the general public is not contracting Ebola.  While this is something that could change, Ebola seems to be pretty well contained in the United States.

The media has been hyping Ebola on an hourly basis, but I can't say that the public fear is entirely unrealistic.  This is a deadly virus and it is now in the United States.  It is, however, very important to remember that we only have 3 diagnosed cases and possibly one new one.  Unless you travel to West Africa, this is still a contained disease and officials are cautiously optimistic that an outbreak is unlikely.

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Domestic violence resurfaces in the NFL

This week's most popular news story has been the video tape of Ray Rice, an NFL football player, physically hitting his wife in an elevator.  There has been a lot of discussion about the NFL's role in correctly punishing Ray Rice in a timely manner.  The general population is rightfully furious about the gentle punishment Ray Rice initially received for knocking his wife out into unconsciousness.  This type of violence cannot be tolerated in our society, and especially against women.

The National Coalition Against Domestic Violence estimates 42.4 million cases of domestic violence in the United States and 1 in 3 women will experience physical violence by an intimate partner.  These are staggering numbers which need to be recognized by everyone in the community, but particularly by the NFL.  Why should the NFL be recognizing this more than most other organizations or sports leagues?  Because there may be some connection between on the field and off the field violence.

I did some thinking about how our minds work, and it seems very unlikely that our minds simply "shut off" once we leave the workplace.  As a physician, I am around patients all day long and have the responsibility of figuring out what is wrong with them.  This is a constant thought process with no breaks, even during lunch.  When I'm not at work though, I watch sports religiously.  I always find myself trying to diagnose an injury a player just had on the field, even when I'm not doing it intentionally.  "Did he tear his ACL?  I doubt it, he walked off the field, it's probably a bone bruise or he tore his meniscus."  We as physicians do this all day long, whether it is physical health or mental health.  Our minds never shut off.  So the question is, does a football player have a switch that he immediately turns off when he leaves the field?

  Football today is much faster and harder hitting than it has ever been.  This can be seen in college football and also in the NFL.  The game has changed so much since it started that we have gone from leather "helmets" to helmets that now try to detect physical force by computerized sensors.  Clearly, the level of physicality has increased dramatically.  So it makes me wonder, if these players are constantly hitting in practice, physically imposing their will in games, how do they shut off that switch of violence?  This is where the NFL has a real problem.  They want their players to be more physical, yet they have not done much to help them control this physicality off the field.  Of course in the case of Ray Rice, it is not the NFL's fault that he brutally abused his wife.  But was this a case of Ray Rice not being able to shut off the switch?  What can the NFL do about this?

I think this goes back to the lack of attention paid to mental health in our country.  Diseases such as depression and anxiety are somewhat taboo, and most people don't like talking about their feelings.  We have no problem talking about how we fractured our arm or how our knee swells up, but talking about mental health seems to be such a touchy subject.  If we, as ordinary people in society, feel so hesitant to talk about it, how does a massive NFL player talk about it?  I think the NFL and college football really need to start addressing the mental health needs of their players.  We can't expect them to tackle and sack players on the field and then expect them to just walk away and leave their aggression at the stadium.  It's easy to say that most NFL players don't have a history of violence outside of the home, but that's not the point here.  Most people also do not have cancer or pneumonia, but isn't that what we are also trying to catch before it worsens?  It's about time the football organizations in this country spend time with their players and medical professionals to address violence and mental health. If they do that, we can all just sit back and enjoy the great game of football.

Torn ACL vs. Torn Meniscus

Knee injuries in sports are incredibly common because the knees are weight-bearing joints.  Most sports require running and pivoting of the foot in order to change directions quickly.  This can unfortunately lead to various types of knee injuries.  I am always asked by patients and athletes the symptoms of knee injuries.  Two very common injuries that athletes are curious about are a torn ACL and a torn meniscus.  Both of these structures are very different and when injured, each have a unique presentation.

The ACL (Anterior Cruciate Ligament) is one of 4 important ligaments in the knee along with the PCL (Posterior Cruciate Ligament), MCL (Medial Collateral Ligament), and LCL (Lateral Collateral Ligament).  It is responsible for holding the knee in place while also providing flexibility.  The meniscus is cartilage that functions to cushion the inside of the knee.  Here is a picture for some clarity (Photo credit fpnotebook.com):

The classic presentation of an ACL tear is a buckling and hyperextension (bending back) of the knee with a pop.  The pop in the knee can either be heard or felt by the athlete.  Since the ACL has a very rich blood supply, it will bleed quickly and will lead to immediate swelling of the knee.  The athlete is generally not able to keep playing that day once the ACL tears.

The meniscus, on the other hand, tears due to a twisting type injury where the two bones rub against the meniscus and cause a tearing.  There is usually no pop in the knee.  The meniscus has a poor blood supply and so it will bleed much more slowly and athletes will usually report swelling later that evening, 4 to 5 hours later.  Many times an athlete is able to keep playing through the injury and it is only diagnosed a few days later.  

Over the next few days, the symptoms are also very different.  Those with an ACL may report that the knee feels unstable or feels like it will give out.  The swelling may resolve and they may actually even be able to play again since the knee feels better.  This may, of course, lead to further injury since the athlete is unaware of the underlying injury.  An individual with a meniscus tear will have symptoms of pain, locking, or catching of the knee. They may also feel pain with activity as the torn meniscus continues to grind in the knee joint.   

These are the basic signs and symptoms of an ACL tear vs. meniscus tear.  These injuries can also get very complicated based on location of tear, degree of tear, and multiple injuries at the same time.  As always, have your doctor evaluate your injury to avoid further damage!  

What is ALS?

Recently, the ALS Ice Bucket Challenge has taken the nation by storm due to social media.  It begins by an individual or a group pouring a bucket of ice on their head and then calling out 3 others to do the same.  They then hashtag it with #alsicebucketchallenge or #icebucketchallenge.  With this raised awareness, the ALS Association has received over 22 million dollars in donations.  The challenge is fun to watch as your favorite celebrities and athletes take part, along with your neighbor next door.  Everyone knows about the ice bucket challenge, but very few know about the disease itself.  Here is a brief rundown:

What is ALS?

ALS stands for Amyotrophic Lateral Sclerosis.  It is a disease that affects the motor neurons in our body.  Motor neurons control muscle function, whereas sensory neurons allow you to feel things.  In ALS, motor neurons slowly begin to die and patients begin to have muscle weakness and eventually loss of muscle function.

What are the symptoms of ALS?

The symptoms of ALS are not simple like the symptoms of a cold or flu.  Each person can have very different symptoms.  Some may have severe symptoms, other will start with very minor changes.  These can include, weakness in one limb, trouble swallowing or breathing, slurred speech, or twitching or cramping of muscles.  As the disease progresses, patients will have significant trouble breathing, chewing, swallowing, or speaking.  These symptoms are very broad and can be caused by various other diseases, making the diagnosis of ALS a very tough one early on.

Who gets ALS?

• Higher incidence in men by about 20%
• Most commonly found in ages 40 to 50
• Only about 5% report a family history.  Most cases are random.
• 5,600 people diagnosed annually with ALS in the United States
• Unclear who will get ALS and why.  Research studies are ongoing.

Is there a cure for ALS?

There is no cure for ALS.  There is a medication called riluzole which can help slow down the progression of ALS, but it is eventually a fatal disease.

How can you help?

Spreading the word is important, but donating to the cause at the same time is invaluable.  You can donate to the ALS Association at http://www.alsa.org/.  Your contributions will contribute to ALS research and hope to one day treat this debilitating disease.

In the end, I wanted to post a very funny Charlie Sheen #alsicebucketchallenge and also one by the Ohio State Buckeyes football team.  Both are unique and entertaining.

Now it's your turn to take the challenge and make a donation!

Sunscreen and sun damage

This is a great video of how sun damage looks on the human skin and how sunscreen can help protect you.  If you need help figuring out what type of sunscreen to buy, check out my earlier post at How to buy sunscreen.  Feel free to ask any questions or comment below!