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January 13, 2019
OnePlus resembles one monster, endless Kickstarter battle. It's an organization worked around a philosophy of network driven item improvement that makes each purchaser of an OnePlus telephone likewise feel a feeling of responsibility for brand's fortunes. Obviously, similarly as with Kickstarter, that is to a greater extent a promoting misleading statement than a reality, and the new OnePlus 6T demonstrates an organization willing to oppose and baffle its most enthusiastic fans.

A year back, OnePlus CEO Pete Lau composed that 80 percent of OnePlus clients still utilized the earphone jack. Today, Lau is propelling a telephone without an earphone jack. All the more as of late, organization prime supporter Carl Pei disclosed to me that the warning LED was so imperative to OnePlus clients that its incorporation even influenced the span of the OnePlus 6's score. Today, Pei and friends are discharging a telephone without a warning light.

The exchange offs that OnePlus has made are effectively seen: the 3.5mm jack accounts for a bigger battery, while the truant LED takes into consideration a littler score at the highest point of the showcase. The two choices align OnePlus closer with the mass market and further far from its causes as a restless pariah willing to make a telephone committed to the requirements and wants of a devotee crowd. With extended portable administrator bargains over the globe and deals in T-Mobile stores and support for Verizon in the US, OnePlus as an organization is flagging a more grounded plan to contend in the standard market.

To wow customers and telephone nerds alike, OnePlus has manufactured the unique mark peruser specifically into the showcase of the OnePlus 6T — which is as of now a commonplace element in China, yet not something that will have been knowledgeable about the US previously. Additionally atypical for the American market is OnePlus' evaluating, which begins at $549 for a sizable 128GB of capacity and 6GB of RAM, making the OnePlus 6T the most moderate lead you can get.




Well done

Flawless fit and completion

Great ergonomics for an extensive telephone

Rich smooth execution

Pretty presentation

Solid battery life

Terrible STUFF

Camera stays unremarkable

In-show unique mark peruser is conflicting

Needs remote charging

Still not completely waterproof

Calm amplifier

Purchase for $579.00 from T-Mobile Buy for $549.00 from OnePlus

With a greater presentation crossing 6.4 inches and a marginally thicker profile because of the bigger 3,700mAh battery, the OnePlus 6T is each piece the kind sized telephone that the OnePlus 6 was. To some degree illogically, I find that the more up to date 6T is less demanding to deal with due to its more noteworthy weight and thickness. It feels more normal to hold than the compliment, more board-like 6. That being stated, regardless you're managing a major telephone, right in accordance with the components of the Google Pixel 3 XL and iPhone XS Max. On the off chance that you don't extravagant those gadgets' ergonomics, loaded with dangerous (and delicate) glass on both front and back, well, OnePlus isn't giving you quite a bit of an option.

The fit and completion of the OnePlus 6T are just about flawless. Unloading this telephone and reviewing its physical frame, I am no less awed than when opening an iPhone box out of the blue. OnePlus even tosses in the additional piece of client administration of pre-applying a pleasant and unnoticeable screen defender to its telephone. OnePlus' plan refinement has developed close by the whole portable industry to the point where it's difficult to now discover lead telephones that don't look like bits of accuracy built electronic adornments. My solitary bandy is that the 6T's earpiece — sitting at the best edge of the telephone, pushed out of the ultra moderate indent — will in general assemble residue and garbage excessively effectively.

The whizzy new expansion to the OnePlus 6T over the past OnePlus 6 is an in-show unique mark sensor. OnePlus reveals to me it has tried the new biometric peruser to work for upwards of 300,000 opens without showing any disintegration in exactness or speed. It additionally works in wet climate and through screen defenders. The organization is certain this unique mark peruser won't lose precision after some time, yet I'm not awed with the exactness or consistency it has when it's pristine.

I enlisted my two thumbprints with the OnePlus 6T, and I got a maddeningly low achievement rate opening the telephone on the principal endeavor. Now and again, it would be a direct opening background, but a discernibly slower one than the past discrete unique finger impression scanner OnePlus had. All the more frequently, however, I'd need to reposition my finger on numerous occasions previously the telephone distinguished me. What's more, truly, I made a point to re-enlist my thumb examines more than once in the event that the first ID data wasn't adequate.

Likewise not exactly perfect is the brilliance of the unique finger impression ID realistic at the base of the screen. It doesn't cling to the brilliance setting of the general presentation (neither do surrounding screen warnings, however those are progressively pardonable in light of the fact that I really need to peruse them), thus it shows up jarringly splendid in dim conditions. OnePlus goes with the opening procedure with a tremendous vivified electrical circle around my finger. This is to a limited extent to spruce up the brilliant green light expected to enlighten my finger to get a reasonable perusing, yet I again think that its jostling. This would be a cool opening procedure for something I just access a few times each day — there's a sure feeling of event with this fastidiousness — yet it rapidly develops exhausting when you're opening your telephone upwards of a hundred times each day. In-show unique mark perusers are unquestionably cool, yet they must be actualized exceptionally well, and OnePlus simply hasn't done as such with its most recent lead.

The presentation of the 6T inspired me more the more I utilized it. At first, I saw the trademark OLED shading shift as I tilted the telephone to its side: whites would begin to display red and green tones. Be that as it may, as I got into the mood of utilizing the telephone (instead of investigating it to unreasonable detail), I truly got the chance to appreciate the hues, complexity, and freshness of this screen. It's an additional tall (19.5:9 perspective proportion) 1080p board, which doesn't coordinate the extraordinary pixel thickness of a Huawei Mate 20 Pro or Samsung Galaxy Note 9, however it doesn't have to. Both of those gadgets shrewdly downsize their goals more often than not, at any rate, to save battery life.

One thing I saw with both the OnePlus 6T, in its versatile mode, and the Mate 20 Pro in its Natural Tone mode, is that they appear to uncover shadows and dim territories that tad more than Google's Pixel 3 XL or Samsung's Note 9. Presently, I think the Pixel and Note are the more exact and steadfast portrayals, yet by and by, I locate the more prominent dimension of shadow perceivability that OnePlus and Huawei give me progressively helpful. Regardless they create wonderfully profound blacks, as all OLED screens do, when they need to. Yet, it's those last couple of shades before supreme dark that are somewhat more splendid with these two telephones.

OnePlus offers sRGB and DCI-P3 shading modes on the OnePlus 6T, with the previous repressing immersion and the last appearing to have quite recently its perfect measure. I'm not by any stretch of the imagination clear on how the versatile mode varies, it seems to cut intently to the P3 profile, yet whatever you do, make a point to get away from the default mode quickly. The default setting on the 6T is the screamingly oversaturated attack on the eyes that OLED screens have customarily been known for. Additionally worth recognizing here is OnePlus' Reading mode, which supposedly, remains a component extraordinary to this current organization's telephones. It turns the screen to a perusing upgraded monochrome, and it tends to be allocated to initiate when you're in sure applications. I find doing this with Twitter particularly supportive, as the dull appearance causes me escape the application quicker than I normally would.

Regarding that tear molded indent, I don't believe it's an advantage (by being littler than the challenge) or a weight (by existing). At first, I thought it'd be little enough for me to endure its reality, yet after some time, I thought that it was more noticeable than a compliment and more extensive score. So I flipped on the score concealing alternative and got a sensibly measured best bezel that happened to show my notices and status symbols. No, it doesn't coordinate the ebb and flow of the base of the screen, yet I'm not sufficiently punctilious to notice or think about that.

I am, be that as it may, very hypercritical about camera execution on telephones, and this is the place OnePlus again disappoints me. A year prior, I composed that the OnePlus 5T is the best telephone without an extraordinary camera, and nothing has changed about that circumstance. Truth be told, in a year when Apple, Google, and Huawei all stepped forward with their imaging, OnePlus chose to leave its OnePlus 6 camera equipment totally unaltered in the OnePlus 6T. The organization has made some product changes and enhancements: there are new de-clamor calculations, better edge discovery in picture mode, and enhanced scene recognition. The 6T will apply process pictures diversely relying upon whether it distinguishes their substance as content, sustenance, a night scene, or a shot loaded up with greenery. This is a simple type of the propelled AI counts that Huawei and Google's camera frameworks use.

OnePlus 6T with and without night mode empowered.

OnePlus 6T with and without night mode empowered.

OnePlus includes another night mode with its most recent camera programming, which intends to copy the organization's greater opponents, however neglects to awe. The 6T's night mode opens the screen for a fifth of a second, assembling more light than a customary shot and reestablishing some detail in the most contrasty regions. Giving it a shot in an evening time road setting, I enjoyed that it figured out how to paw back the blown features of enlightened road signs. Be that as it may, if as well as can be expected state about a night mode is that it's better at taking care of features, at that point you can rest guaranteed that it's a disappointing component. The camera, more than everything else, is the place you'll encounter the value delta between the OnePlus 6T and the pricier leads above it.

Shot at ISO 3200.

Representation mode at ISO 1000.

With Android 9 Pie preloaded on the 6T, OnePlus is presenting appropriate reparations in light of a year ago when it sent the 5T without the most recent rendition of Android on board. Far and away superior, the execution of Android 9 on the OnePlus 6T is a perfectly smooth and pleasurable experience. OnePlus' OxygenOS includes truly great and attractive things without removing anything from the center Android encounter.

I cherish that OnePlus isn't constraining Google's new signal put together performing multiple tasks with respect to clients, as showed on the Pixel 3 gadgets. Rather, it's depending individually duplicate of the iPhone X framework. (Let's face it, the iPhone is the best quality level in this classification). Google's present framework is unintelligible, apparently reluctant to resolve to motions as the widespread interface show. OnePlus, then again, has an extremely smooth and simple setup.

A snappy swipe up from the base of the showcase conveys you to the home screen, where a swipe up from the center prompts your application cabinet. A swipe up and ideal inside any application immediately changes you back to the recently utilized application — the movement for this is especially fulfilling — and to get to performing multiple tasks, you simply need to swipe up and hold for a beat. The back catch is supplanted with swipes up from the left and right base corners of the screen. Being used, these are quick, instinctive, and characteristic signals.

There's only one clash ruining the gathering here and that is the on-screen console. Since Gboard acknowledges swipe input, whenever I have my console up in an application and need to change to somewhere else, the upward swipe I use for performing various tasks is unavoidably enlisted by the console. So I will in general leave a group of applications with a "by" or a "cv" swipe-composed in. The workaround is that I need to cut the console down each time I need to leave an application, which isn't a prerequisite I used to have with a committed home catch (nor one that Apple clients, as yet pecking at each key independently, need to confront). I discover this just imperfect as opposed to a major issue, yet OnePlus gives you the choice to return to the old trio of Android routes catches, on the off chance that you so wish.

OnePlus' normally quick execution is especially in proof with the OnePlus 6T — in any event on the 8GB variation I have for audit — however the organization has ventured up the dimension of clean to an amazing degree. Where past OnePlus telephones were idiotically quick yet needed artfulness in their movements, the 6T gives an impression of both speed and solace. The ease of the client encounter here isn't only keeping pace with the world's most costly cell phones, it outperforms a significant number of them, on account of good plan choices from OnePlus. There's no moronic Bixby catch here, none of the asinine spam notices you'd get from Oppo or Huawei, and no infuriating subject stores that request you make a record just to have the capacity to alter your telephone's interface to your loving.

Utilizing an OnePlus telephone, for any individual who's needed to endure the grinding of managing other Android makers' product, is honestly freeing. Given the protection worries that OnePlus caused a year ago don't re-develop, I'd presumably pronounce this the best Android encounter accessible at this moment. Speed every step of the way, simple and adaptable customization of both the interface and application symbols, and valuable little in the method for inconveniences. I additionally didn't falter into any accidents or bugs amid my testing time with the 6T.

Actually, I've never been a major warning LED fan, so I don't miss that exclusion from OnePlus, which is counterbalanced by the alternative to demonstrate insignificant notices on the screen when messages or cautions come in. I likewise can't grieve the nonattendance of the now-left earphone jack, which isn't a thing I'd have said a half year prior. In any case, Google's arrival of the truly moderate and great Pixel USB-C earbuds and OnePlus' dispatch of the shoddy Bullets USB-C headphones have made USB-C sound feasible and alluring. On the off chance that we take the downfall of the committed earphone jack as guaranteed, I'd state OnePlus has made a decision about the correct right minute to do the switch. I likewise like the USB-C Bullets, and I wish OnePlus had made sense of an approach to package them in the case with the telephone. Rather, you get a connector dongle, which you'll have the capacity to know is from OnePlus in light of the fact that its short minimal link is in the organization's mark red shading.

The lost earphone jack, OnePlus lets me know, opens more space for the battery, which is the greatest OnePlus has yet put in any of its telephones. With batteries, greater is in every case better, and I do observe this to be the most solid OnePlus telephone I've yet utilized. The 6T keeps going that additional piece more than the 6, poking it from great to practically incredible battery life. I'd state it's on a standard with the Pixel 3 XL, however not exactly in indistinguishable classification from Huawei's interminable Mate 20 Pro, which has a similar size screen, yet can last any longer on account of Huawei's progressively productive 7nm processor, a significantly bigger battery cell, and some ultra-forceful power improvements.

For the customary client, the OnePlus 6T will endure multi day of serious use without an issue, regardless of whether you're gaming, gorging on Robert Sapolsky addresses on YouTube, or unfit to tear yourself from the web based life banters about the coming end times. What's more, it'll give you unerringly quick and liquid execution through those undertakings.

I have some sundry protests about the OnePlus 6T that will in general show the (few) corners OnePlus has cut. First up is the amplifier, which sounds extremely decent on this telephone, however is woefully deficient as far as volume. Indeed, even at max volume, it's just extremely valuable in a calm domain. A long-standing imperfection of base terminating speakers of this sort is likewise that you can impede their opening truly effortlessly, particularly when holding the telephone in scene for gaming. At that point there's the matter of remote charging and appropriate water opposition affirmation, the two of which the OnePlus 6T needs. Those are rapidly getting to be table stakes for lead cell phones, and their oversight from OnePlus' putting forth is just going to develop increasingly offensive with time.

The OnePlus 6T is one more great telephone from OnePlus. Indeed, even with some upheld changes, that probably won't satisfy each individual from the OnePlus people group, I believe it's a gadget that demonstrates advancement and enhancement. In any case, how huge is that advancement?

Without an extraordinary camera, without remote charging, and with a feature highlight that baffles, the OnePlus 6T isn't the unequivocal champ it may have been. It's only a decent telephone at a great cost. For the vast majority, that will be sufficient. Cleaned. Refined. These are the words that rung a bell when holding the Galaxy S9 Plus, the bigger form of Samsung's most recent Galaxy S9 leader cell phone. Samsung presented a crisp structure dialect with the Galaxy S8 in 2017 — a plan it's been setting out towards toward the previous couple of years — and it's not yet prepared to introduce something new. That is impeccably fine, on the grounds that the Galaxy S9 Plus remains verifiably hot. Are the minor plan and equipment enhancements worth the high sticker price? We suspect as much, since it's about the camera with the Galaxy S9 arrangement, and it positively impresses.
samsung galaxy s9 plus review back logo

Keen on the littler Galaxy S9? Look at our top to bottom Galaxy S9 survey.

Refined structure

On the off chance that you have utilized or seen a Galaxy S8 Plus, you'll experience considerable difficulties recognizing the distinctions of the Galaxy S9 Plus at a brisk look. From the front, the two telephones appear to be identical. The Galaxy S9 Plus is insignificantly shorter, while holding the equivalent 6.2-inch screen. That is conceivable on the grounds that Samsung shaved down the bezels encompassing the presentation marginally, enhancing the screen-to-body proportion. The variety of sensors and iris scanner on the highest point of the S9 Plus are currently scarcely unmistakable. That board stood out like a sore thumb on the S8, yet we didn't think that its jostling. All things considered, it helps make the S9 Plus look somewhat sleeker.

samsung system s9 in addition to survey back logo

samsung system s9 in addition to survey dependably in plain view

samsung system s9 in addition to survey holding up

samsung system s9 in addition to survey memoji

The power catch is in an ideal position on the correct edge of the telephone, however the volume rocker is on the left edge over the Bixby catch. We'll get to Bixby later, yet we've effectively killed the catch's usefulness. Since Samsung doesn't let you remap it to whatever else, the catch sits unused, which is baffling. We'd incline toward the volume rocker on the correct edge with the power catch, since it is somewhat difficult to press without moving the entire telephone lower, diminishing your hold.

Flip the telephone to its back, and you'll begin to see all the more distinctive highlights. There's the "World S9+" mark on the base, obviously, but on the other hand there's a double camera framework — a first for the Galaxy S arrangement. The glimmer sits on the correct side of the camera.

Like the Galaxy S8, the S9 Plus feels like a smooth rock equipped for skipping crosswise over water.

The unique mark sensor, which drew a great deal of feedback on the Galaxy Note 8 and Galaxy S8 Plus, is beneath the camera, in an undeniably more open position. While we value the new area, despite everything we think Samsung could refine it more, as it's anything but difficult to smirch the camera focal point. The sensor feels excessively little for our fingers, however it's brisk to respond, and does the activity well. You can even utilize unique mark signals to pull down the warning cabinet with a swipe on the sensor, which is helpful for such a vast telephone.

The 6.2-inch screen is incredible for recordings. To upgrade the experience, Samsung out of the blue has included stereo speakers tuned by AKG — the best earpiece works couple with a base terminating speaker — and bolster for Dolby Atmos innovation. Music can fill a huge room at most extreme volume. There's not much bass, but rather the sound is clear and rich. Unfortunately, we once in a while secured the base terminating speaker when holding the telephone in scene mode (double forward looking speakers, anybody?).

Like the Galaxy S8, the S9 Plus feels like a smooth stone fit for skipping crosswise over water. The telephone fit serenely in our palms, yet it might be clumsy if your gloves aren't as enormous as our own. We do love the telephone's bended edges, as they make it feel littler and ergonomic. The back glass effortlessly draws in fingerprints, which we're not devotees of, so ensure you have a microfiber fabric consistently, or seize a case. We've discovered the midnight dark shading alternative uncovers more fingerprints, which is the reason we suggest obtaining the lilac or coral blue. There's likewise now a Sunrise Gold shading accessible, if that gets you going.

Delightful Infinity Display, incredible execution

The Infinity Display hasn't changed much from a year ago's Galaxy S8 Plus, however it's as yet a champion element. The Galaxy S9 Plus' AMOLED screen helps Quad HD+ (2,960 x 1,440) goals, packing 529 pixels into each inch. The outcome is a fantastically sharp, brilliant screen.

Hues are flawless, and they don't feel oversaturated, as we've seen with past Samsung boards. Watching HDR10 content in applications like Netflix is a gorge watchers dream, as the enhanced difference truly makes dull shows pop. This is without a doubt the best screen on a cell phone at the present time.

samsung world s9 in addition to audit maps

Julian Chokkattu/Digital Trends

Do note, however, that Samsung sets the default goals to 2,220 x 1,080 pixels when you first start up the telephone, prone to help monitor battery life. You can build it in showcase settings, which is additionally where you can change the screen's shading to your loving.

The Galaxy S9 Plus is the first cell phone we've completely tried with Qualcomm's new Snapdragon 845 processor, and its enhanced designs execution appears. Diversions like Tekken, The Sims: Mobile, and Sonic Forces keep running without imperfection, offering a liquid ordeal.

Everyday execution is incredible, with applications opening rapidly, and smooth split-screen activity. We noticed an uncommon stammer, which helped us to remember Samsung's TouchWiz UI days, however we're content with what the Snapdragon 845 offers. The S9 Plus accompanies 6GB of RAM, which is all that anyone could need for nearly everybody, except you should know the standard S9 just has 4GB.

Here are the outcomes from a couple of benchmark applications:

AnTuTu 3D Bench: 263,591

Geekbench 4 CPU: 2,415 single-center; 8,191 multi-center

3D Mark Slingshot Extreme: 4,552 OpenGL; 3,685 Vulkan

The S9's scores are amazing. For instance, the Galaxy S8's AnTuTu score is 155,253, and the iPhone X's 206,010 — the S9 Plus is a long ways ahead.

That doesn't really mean limitlessly enhanced genuine execution, however. We found the product encounter somewhat more liquid on the Google Pixel 2 and the iPhone X. Be that as it may, every one of these telephones are massively quick and have no issue managing even the most requesting applications. The Samsung S9 Plus faltered a bit more frequently, however not sufficiently about to be a negative mark.

The S9 Plus accompanies 64GB of interior stockpiling, however you can likewise capture a model with 128GB or 256GB. A MicroSD card space gives you a chance to include progressively on the off chance that you require it.

Reconsidered camera; taking out commotion

The feature highlight of the Galaxy S9 is the "rethought" camera. Both the S9 and the S9 Plus have a 12-megapixel focal point with a variable opening. We've clarified what that implies in our inside and out guide, yet here's the nuts and bolts.

The camera has two round plates on the focal point which contract the measure of light the camera can retain. One is a f/1.5 gap, which implies the gap is more extensive, permitting all the more light in for better low-light shots. Be that as it may, the camera can change to f/2.4 gap, choking the opening so less light comes in, which is extraordinary for most lighting conditions amid the day. The smaller the opening (or gap), the more keen the photo. That is the reason photos taken with a f/1.5 gap are not as itemized or sharp as photos taken with the f/2.4 opening. That is the reason the camera dominatingly utilizes the f/2.4 opening, and just consequently swaps to the f/1.5 gap in poor lighting.

samsung cosmic system s9 in addition to survey camera tests nourishment

samsung cosmic system s9 in addition to survey camera tests bottles

Fortunately, you don't have to know any of that to snap great photographs. Everything happens consequently, and the client encounter remains unbelievably straightforward. In the event that you truly need to control the opening yourself, in any case, there's a Pro mode that gives you a chance to swap it physically. The camera application has been updated for simplicity of us, somewhat impersonating the application on an iPhone. It's quick to respond, and we've seen for all intents and purposes no shade slack.

Shouldn't something be said about the outcomes? Photographs caught amid the day are definite, with great shading precision. Be that as it may, low-light photos caught with the f/1.5 gap are the place the Galaxy S9 Plus sparkles. Indeed, there's a decent measure of detail lost and some photographs can have all the earmarks of being excessively fluffy, yet we've taken photographs of dull articles around evening time, and the S9 Plus still figures out how to deliver a photograph worth sharing. We took some photographs with the Pixel 2 XL for correlation, and the S9 Plus eclipses the Google telephone in shading precision (however not really in detail).

Pixel-2-xl-system s9

samsung system s9 in addition to audit camera tests house of God

Pixel 2 XL

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1. Pixel 2 XL 2. Cosmic system S9 Plus 3. Pixel 2 XL 4. World S9 Plus

Pause, there's additional! Samsung has additionally included a highlighted called 'multi-outline commotion decrease.' It's a picture preparing system that takes 12 photographs in the meantime when you tap the shade catch, at that point accumulates them all to wipe out however much clamor as could reasonably be expected. In the event that you take a gander at all the Galaxy S9's photographs and contrast it with the opposition, the distinction in graininess and commotion is dazzling. The photograph of Barcelona Cathedral above, for instance, demonstrates an unmistakable, even sky. Most cell phone cameras, similar to the Pixel 2, would add significant clamor to that shot, adding grain to the sky's smooth angle.

For more photographs taken with the Galaxy S9 Plus, look at our test at Mobile World Congress, and a low-light follow up in Barcelona.

samsung cosmic system s9 in addition to audit camera tests optical zoom house of God

samsung cosmic system s9 in addition to audit camera tests optical zoom building

The S9 Plus additionally has a second, 12-megapixel camera that offers 2x optical zoom and a Live Focus mode, which is much similar to Apple's Portrait Mode on the iPhone. This double camera framework is nearly equivalent to the Galaxy Note 8. The optical zoom photographs are all around nitty gritty, and it's a convenient component to have for articles that are far away. Look at the photographs above.
The Galaxy S9 Plus snaps extraordinary photographs, and its low-light capacities is best-in-class. The Super Slow Motion video highlight is a fun expansion, and we continually utilize the 2x optical zoom for far off articles. The jury is still out on Live Focus. On the off chance that you couldn't care less much for 2x optical zoom or Live Focus, you're in an ideal situation purchasing the littler Galaxy S9 as it doesn't accompany that second camera. Despite everything you gain admittance to Super Slow Motion, and additionally the variable gap, and multi-outline commotion decrease picture handling.

Regardless we think the Pixel 2 XL keeps its title as the best camera telephone, yet Samsung effectively beats Google's telephone in testing lighting conditions, and regularly wins out in shading exactness — it's a nearby race.

A lot of programming customization

The Galaxy S9 Plus runs Android 8.0 Oreo, with the Samsung Experience 9.0 UI layered over. It looks smooth, insignificant, and much-enhanced over the scandalous TouchWiz UI on more seasoned Samsung telephones. Android 8.0 Oreo presents a large group of highlights, for example, picture-in-picture mode, new identifications on application symbols for new warnings, a streamlined settings application, and that's only the tip of the iceberg. The product encounter on the Galaxy S9 Plus is better than anyone might have expected.

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samsung cosmic system s9 in addition to survey screen capture right board

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samsung world s9 in addition to survey screen capture camera

samsung world s9 in addition to survey screen capture camera android

There's a lot of customization choices to make your telephone feel special. For instance, you can browse an assortment of clock structures for the dependably in plain view, and you can even pick any shading from a shading wheel for further personalization. A great many people won't jump into these choices, however we're glad to see it accessible.

Samsung has made considerable progress, and we're adoring how the product looks.

Another approach to see the sheer measure of choices is with the biometric opening advancements accessible on the telephone. You can utilize the iris scanner, unique mark peruser, or facial acknowledgment to open the S9, or utilize them all in the meantime. Our most loved is Intelligent Scan, which fundamentally utilizes the iris scanner as the primary method to open the telephone, however it falls back to facial acknowledgment whether iris doesn't work. The experience feels a ton like opening the iPhone X with FaceID. It's not as quick as the unique mark sensor and it doesn't work constantly, however it's sufficiently dependable to feel helpful.

In our testing, the Google Pixel 2 still offers the most liquid Android encounter on a cell phone, likely on the grounds that Google can improve the equipment and programming. All things considered, Samsung has made some amazing progress, and we're adoring how the product looks. Our greatest dissension is with updates. The Galaxy S8 and S8 Plus are in the beta procedure for Android 8.0 Oreo, over 7 months since Google discharged the new Android rendition. The principal designer review of Android P is currently accessible and ought to authoritatively dispatch in August, however it's pitiful that we likely won't see it on the S9 and S9 Plus until right on time one year from now. On the off chance that you need the quickest security or form refreshes, purchase a Pixel 2 or an iPhone.

Bixby remains an aggravation

When we discussed execution, we referenced the intermittent falter. The simplest method to see this is to slide ideal from the home screen to open Bixby. Opening Bixby Home is moderate, and there's a considerable measure of slack. The falsely insightful was first presented on the Galaxy S8 as an approach to perform telephone explicit capacities by means of voice. Following a year since dispatch, despite everything we feel no longing to ask Bixby to do anything, not on the grounds that it can't, but rather in light of the fact that it's bulky, and doing things physically is frequently quicker.


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Pocophone F1 by Xiaomi

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Asus Zenfone 5Z

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Moto Z3 Play

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LG G7 ThinQ

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Feline S61

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Moto E5 Plus

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Nokia 7 Plus

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Alcatel 3V

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Motorola Moto G6

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Asus ZenFone 4

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Huawei Mate 10 Pro

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Alcatel Idol 5

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HTC U11 Life

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Google Pixel 2

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LG V30

The new augmentations in Bixby Vision are highlights we'd probably never utilize, regardless of whether they are flawless. Our top picks are moment dialect interpretation, which can be somewhat wonky, and additionally the Makeup instrument, which layers cosmetics from Sephora and Cover Girl over your face so you can give items a shot. The Food instrument gives you a chance to assess calories when you point the camera at sustenance, however it isn't precise, which shielded us from utilizing it reliably.

By and large, we like the new augmentations to Vision, yet we additionally wouldn't see any problems at all if Samsung just erased Bixby and every one of its highlights in its next telephone. There's simply very little to like, and Google Assistant is more solid and quicker.

Day-long battery life

In case you're a power client, you'll likely need to juice up the telephone a little towards the day's end.

The Galaxy S9 Plus' battery life is about normal, if not a little on the low side, when contrasted with most cell phones in its class. In the wake of taking the telephone off the charger at 7:30 a.m., we wound up with 39 percent at 3:45 p.m., and 25 percent by 6 p.m. That is with the telephone on max goals and 50 percent brilliance, with substantial utilization including YouTube, video calls, photography, and web perusing.

In case you're a power client, you'll likely need to juice up the telephone a little towards the day's end. If not, you should see it last you for an entire day. There's likewise an approach to advance the battery for your requirements in the gadget the board settings, so you can get the most measure of time with your telephone.

The Galaxy S9 Plus backings quick remote charging and quick wired charging, so it doesn't take long to energize.

Value, accessibility, and guarantee data

The Galaxy S9 Plus expenses $840 opened from Samsung, and there are a lot of approaches to buy the telephone by means of a regularly scheduled installment plan, or through all U.S. transporters. Look at our purchasing guide for more subtleties. It's accessible for pre-arrange now, and will authoritatively go at a bargain on March 16. There are a lot of frill you might need to look at to add to your buy.

Samsung offers a 1-year guarantee on the S9 Plus, and that covers fabricating surrenders. You can buy Samsung Premium Care for a service agreement and different advantages.


The Galaxy S9 Plus brings a refined plan, yet it's the 'rethought' camera that makes this telephone emerge, and worth the high sticker price.

Is there a superior option?

Perhaps. In case you're searching for stock Android telephone, the Google Pixel 2 XL is as yet our best proposal. Updates are imperative to us, and on the off chance that you suspect as much as well, getting the Pixel implies you'll get quick security and variant updates. We think the product encounter is cleaner on the Pixel 2 XL, also, and it's more liquid. The Pixel 2 XL has an outstanding camera, and keeping in mind that the Galaxy S9 may beat it in low-light photography, there are a lot of different regions where the Pixel 2 ends up as the winner. Light photographs, and even some evening time shots, are more definite, and Portrait Mode produces dazzling pictures.

Clearly, iOS fans should investigate the iPhone X. From its lovely structure, solid camera, and liquid programming, there's bounty to like with Apple's most recent lead. On the off chance that these telephones are out of your financial plan, look at our best modest telephones control for a lot of other incredible alternatives.

To what extent will it last?

The Galaxy S9 Plus will last you around three years, maybe more. It's IP68 water-and residue safe, which implies it can endure dunks in water, yet it is sandwiched in glass, so you'll need to ensure you have a case or a screen defender. Samsung will probably offer programming refreshes up to two years.

Would it be advisable for you to get it?

Indeed. The Samsung S9 Plus is an announcement of best-in-class equipment.

Refreshed on June 20: We've included data about the Sunrise Gold shading alternative, and also the 128GB and 256GB models that are accessible.
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Tuesday, 26 March 2019

New urine test predicts high-grade cancer

Double dippers are everywhere – the 4th of July barbeque, family reunions, Super Bowl parties, anywhere chips and dip are a staple. These are the people who take a bite and dip their chips a second time when they think no one is looking.
Just ask George

Leave it to George Costanza on Seinfeld to make double dipping a mainstream public health scare. The episode, which originally aired in 1993, brought shame to George as he was caught dipping a chip a second time at a wake. The partygoer objecting to this practice exclaims “That’s like putting your whole mouth right in the dip!”
But is double dipping really so bad?

Ever since that Seinfeld episode, the “health menace” of double dipping has been a mainstay of party conversation, high school science projects, and even high-level academic investigation. Perhaps the most influential was a 2009 study performed at Clemson University and published in the Journal of Food Safety, entitled “Effect of biting before dipping (double-dipping) chips on the bacterial population of the dipping solution.” The title alone may be enough to make you lose your appetite.

The researchers carefully analyzed bacterial contamination before and after a person double dips. Here’s what they found:

    Bacterial counts in the dip increased significantly after a person took a bite from a chip and then dipped again.
    The number of bacteria contaminating the dip varied depending on the dip – salsa had more bacteria after double-dipping compared with chocolate or cheese dips (perhaps due to differences in thickness and acidity of the dips).

Similar findings were noted when bacteria counts were measured after a bitten chip was dipped in water.
So just how risky is double dipping?

It’s important to note that this research was not designed to find people who became sick because someone else double dipped. And, considering that our mouths are normally packed with bacteria, it doesn’t necessarily follow that more bacteria in the dip means double dipping is dangerous.

However, this research does raise the possibility that a person who is sick (or about to be) might spread a disease by re-dipping a chip. Documented examples of this are hard to find – if you know of one, let me know! But even if the risk is hard to prove, the risk may be real. We know of many respiratory diseases that can be spread by contact with saliva, such as influenza (the flu) or whooping cough. Still, there are probably much bigger risks at your next office party than double dipping. You’re more likely to contract an illness from a sick person coughing or sneezing in your face or if they don’t wash their hands while sick than you are from a healthy double-dipper. So, while it’s reasonable to discourage double dipping, it’s unlikely to pose a major risk to your health.
And if you’re a double dipper…

And, for habitual double-dippers, I wonder about a more responsible option: turn the chip around to double dip from the unbitten end of the chip. Stand by – somewhere in America there is a high school kid setting up that experiment right now. As the 2016 summer Olympics get underway, we will see elite women athletes compete at the highest level of their sports. And as we cruise toward September, many more young women will return to the field, court, and pool on college and high school teams. We know that many women who don’t consider themselves athletes exercise more and restrict calories to lose or maintain their weight. This can be a formula for disaster.

The benefits of an active lifestyle and participation in sports are many. However, proper and adequate nutrition is paramount to a woman’s health — particularly for strong and healthy bones. This is especially true for female athletes.

After Title IX — which ensured athletic opportunities for women in programs that received federal financial assistance — was passed in 1972, the number of women participating in sports skyrocketed. About 20 years after Title IX, a group of physicians identified a set of three symptoms commonly seen in women athletes. The original definition of the female athlete triad consisted of eating disorders, irregular menstrual cycles, and reduced bone mineral density (weakened bone strength that can lead to osteoporosis). Malnutrition led to abnormalities in the menstrual cycle, which in turn affected bone density.

The triad was thought to affect primarily women participating in weight-dependent or judging sports, such as gymnastics, ice skating, or endurance running. However, many athletes remained undiagnosed because criteria for the triad diagnosis remained elusive. In 2007, the definition transitioned into a spectrum disorder involving “low energy availability” (inadequate carbohydrate intake), absence of menstrual periods, and decreased bone mineral density.

Most recently the International Olympic Committee has coined the term RED-S — Relative Energy Deficiency in Sport. This exemplifies the importance of fueling your body with the appropriate amount of energy (food) for the duration and intensity of activity performed. In other words, if you don’t eat enough, there will be repercussions, some serious. Poor nutrition and insufficient calories for the amount of exercise you do will lead to changes in your body’s hormone levels and directly affect bone density.
Why is it so important to balance activity and adequate nutrition?

Let’s talk about bone health. We know that we can build bone density until about age 25. After that we can only work to maintain what we’ve got. If young female athletes are losing bone density, it can never be replaced.

We also know that female athletes suffer from two to three times the number of stress fractures compared to male athletes. And women athletes with missed menstrual cycles (which can happen when activity outpaces calories consumed) have two to four times the risk of stress fractures compared to women with normal monthly menstrual cycles.

A stress fracture occurs when the bone is subject to more stress or impact than it can handle. This may simply be due to overtraining, or increasing training too quickly without giving the bones adequate time to adapt. Stress fractures can also be due to a lower bone mineral density, which means it takes less force to cause damage. This often is the result of the female athlete triad — a direct result of not eating enough, or not eating enough of the right foods. If we can educate our youth on the importance of maintaining a healthy diet and supplying their active bodies with the energy they need, then we can prevent many of these injuries and maybe even reduce the chances that a woman develops osteoporosis later in life.

We know exercise is important. We know that a healthy weight is important. But what may not get enough attention is the fact that eating healthy calories to replenish and fuel the body is vital to athletes’ health, in particular for strong and resilient bones. Remember, bones are also a girl’s best friends. And they should be like diamonds — strong and dense. We need to work to make sure they are. Suspicious findings from prostate cancer screening are often followed by a procedure most men would prefer to avoid: a prostate biopsy. But what if biopsies actually could be avoided on the basis of non-invasive test results? Screening tests are moving in that direction, with some intriguing results. One of them, the Prostate Health Index blood test, combines measures of three forms of prostate-specific antigen (PSA) into a score that helps doctors predict if a cancer is likely to progress, with an aim to circumvent biopsies that aren’t necessary. Another non-invasive test, called the PCA3 assay, measures genetic evidence of aggressive cancer in urine samples, and generates a score designed to help doctors assess the need for a repeat biopsy. Though approved by the Food and Drug Administration, these tests aren’t perfect, and experts question the reliability of the PCA3 test in particular.

Now researchers are considering the value of a new test that also looks for evidence of high-grade prostate cancer in urine. The results were reported in the Journal of the American Medical Association last April. Called the “urine exosome gene expression assay,” it measures not just PCA3 but also two other genes associated with high-grade disease: ERG and SPDEF. The test combines those measures into a diagnostic score that “could help determine if an initial prostate biopsy is warranted,” said its co-developer Dr. Michael Donovan, a pathologist and researcher at The Mount Sinai Hospital in New York. According to Donovan, the goal is to limit the number of prostate cancer biopsies, which are costly, painful, and prone to hospital-acquired infections.

The study enrolled 1,563 men from 22 community and academic urology clinics in the United States. According to results with a final grouping of 519 men, assay scores over a “cut-off” value of 15.6 predicted high-grade cancer correctly 92% of the time. The assay didn’t always get it right: 12 men were misdiagnosed as having low-risk cancer when they in fact had higher-grade disease.. But most of those tumors, Donovan said, fell into an intermediate-risk category that some doctors would consider eligible for active surveillance instead of treatment.

The genes measured reside in small vesicles called exosomes that are secreted by prostate cells. For the test, men have to provide a “first-catch” urine sample. That’s because prostate exosomes are concentrated in the initial stream and numbers decline as urination continues. “In our view, the assay can be combined with other standard-of-care factors during clinical decision making,” Donovan said. “Right now, it’s designed for men who have never had a biopsy, but we’re also moving towards studies that will assess its use in other settings, such as active surveillance.”

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of, cautioned that while the number of non-invasive tests for prostate cancer diagnosis is growing, these are still early days in their development. “Until we better understand how these tests correlate with the behavior of the prostate tumors they can help diagnose, they remain very much in the research sphere,” he said.
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The dangers of this potent “man-made” opioid

In recent years, the media has been awash with information on the health benefits of exercise. Exercise is known to boost mood in adults. But what about younger members of society? Based on recent, high quality survey data, we can estimate that about 11% of adolescents are depressed. Sadly, this means that one in 10 adolescents between the ages of 12 and 17 experienced a major depressive episode during the year of the survey. These numbers should raise alarm bells for both parents and doctors.

Depression makes teens feel awful, but being depressed as a teen may also have life-long consequences, including being depressed as an adult. Depressive episodes in teens can contribute to poor grades, poor interpersonal relationships, and worse physical health. Depression can also increase the burden of care for parents. In a recent post, I discussed how a teen’s social network can impact his or her chances of becoming depressed. There, we explored how having friends with good spirits could exert a positive influence on a teen’s mood. We have also previously touched on some of the concerns with giving teens antidepressant medication. Today we will tackle the hot topic of exercise and depression in adolescents.
A carefully conducted analysis of exercise and depression in teens

A recent study attempted to delve into the data behind exercise as a treatment for depression in teens. The authors initially screened 543 studies and found 11 to include in their analysis. Of those 11, only eight yielded good data to use for more specific calculations. In general, although not always, these types of analyses are particularly powerful because the authors use rigorous criteria when deciding which studies to include.

The teens included in this analysis were 13 to 17 year olds, who did not have any major physical health problems, such as obesity. The data from the studies compared the use of exercise as treatment for depression against a psychosocial intervention, an educational intervention, treatment “as usual”, or no treatment at all. After combining data, the authors eventually concluded that exercise appears to lead to moderately improve depression in adolescents, particularly in those already receiving some formal treatment. But, treatment “as usual” was not well defined, and we don’t know, for example, how many of these teens were taking antidepressant medication.
Will exercise really help teens suffering with depression?

So, should we conclude from this study that all teens with depression should be treated, to some extent, with exercise? It is tempting to say yes. However, concluding that all teens with depression should be treated with exercise would over-simplify the results of this study.  A person (adult or teen) with depression will likely find that exercise helps improve symptoms to some degree. However, this study doesn’t support the statement that exercise is the best cure for depression. Instead, it would be more accurate to say that in teens who are already undergoing treatment for depression, exercise appears to be a strategy with modest benefits and little downside. This particular study is a wonderful addition to our knowledge base, in that it puts another tool into a doctor’s toolkit to help treat patients with depression in clinical settings. Every day, about 10 people die from drowning — and two of them are children. Not only that, for every child that dies from drowning, five more are treated in emergency room for injuries from drowning, which can include permanent and severe brain injuries.

Here are the five things all parents and caregivers need to know about drowning:

    Drowning can be silent. When we think about drowning, we think about flailing arms and calls for help, but that’s not how it usually works. What usually happens is that people take the biggest breath they can and go down — and don’t come back up again. They can’t flail and they can’t yell. You could miss it. To learn more about this, check out the great post, “Drowning Doesn’t Look Like Drowning.”
    Drowning can happen where there are lifeguards. In 2011, a woman slid to the bottom of a guarded public pool in the Boston area and drowned — and her body wasn’t discovered for two days because the water was murky. While that may be an extreme case, people drown where there are lifeguards all the time. Lifeguards can’t always see everything, especially when drowning can be silent — and they can get distracted just like anyone else. Just because there is a lifeguard doesn’t mean you don’t have to watch your child.
    Drowning can happen in very little water. All it takes is enough water to get your face in. Children can drown in a kiddie pool, a bathtub, a bucket of water, or a toilet bowl.
    Good swimmers can drown. They can get tired, they can get a cramp, they get can caught in a rip current or in something underwater — or they can bump their head. Just because your child is a good swimmer doesn’t mean something bad can’t happen.
    Drowning is preventable. Here’s what you can do:

    Teach your child to swim. Sign them up for a swimming class — look for one that teaches water safety skills, too.
    Learn CPR. It’s easy to learn, and saves lives.
    If you have a pool, make sure it is completely fenced all around — and has a self-latching or self-locking gate.
    Use lifejackets whenever you go out on the water, on anything.
    Teach your children what to do if they get caught in a rip current: instead of fighting it and trying to swim back to shore against it, swim parallel to shore and ease your way out of it.
    Keep your eyes on your child at all times when they are in any kind of water. This includes bathtubs and kiddie pools; if you need to take your eyes off them, take them out of the water. At the beach or pool, keep your eyes on your children even if there is a lifeguard. You can read or look at your phone later. Nothing is more important than your child’s life.
In July, the Centers for Disease Control and Prevention announced that a woman in Miami-Dade County in Florida had tested positive for the Zika virus. Follow-up to this case led health officials in Florida to report a total of 15 cases in the area. These weren’t the first people in the United States, or even in Florida, to contract Zika. But these cases were unique in one important way –– they were likely caused by mosquitoes in the United States.

The CDC promptly issued a travel warning for pregnant woman and their partners, warning them not to visit the small community of Wynwood, just north of Miami, where these Zika cases first occurred. This is the first time the CDC has ever issued a warning to pregnant women about traveling to a place within the United States because of the threat of infectious disease.
It’s no surprise that local mosquitoes carry Zika

For many health officials it wasn’t a question of whether Zika was going to get to the United States, but rather when it would arrive. Currently, there are more than 1,400 travel-related Zika cases in the United States, and U.S. territories like Puerto Rico are grappling with more than 3,800 cases. Also, parts of the United States are home to the Aedes aegypti mosquitoes that carry the virus, with southern states like Texas and Florida bearing the greatest risks for outbreaks due to their warmer climates.

The news that mosquitoes in the United States have been found to carry Zika is certainly concerning, but experts say that Zika likely won’t spread here as it has in countries in Central and South America. “Our housing is generally better here, and since we’re more likely to have AC, we can keep our houses sealed off better,” says Dr. John Ross, an infectious disease expert and professor of medicine at Harvard Medical School. “We also tend to have more robust healthcare in the U.S. than in other places, so we can track and treat these cases more effectively.”
How do you know if you have Zika…and how can you avoid it?

The CDC reports that only about 20% of people who get the virus go on to show symptoms, which are usually mild and typically include a low-grade fever, sore or aching joints, conjunctivitis (“pink eye”), and a rash. However, the virus does pose a greater danger to pregnant women and their unborn children, as studies have shown that Zika may cause microcephaly. Microcephaly is a birth defect in which a baby’s head is unusually small. Often, the brain has not developed properly, which can result in neurological and developmental problems. Current research estimates that 1% of all pregnant women with Zika will give birth to a child with these neurological issues.

In addition to their travel advisories, doctors at the CDC have also provided information about how to prevent mosquito bites and decrease the risk of developing Zika:

    Avoid areas with Zika. Women who are pregnant or who are trying to become pregnant should avoid areas with known Zika cases.
    Use insect repellant. It’s a simple and maybe obvious step — using insect repellant helps deter mosquitoes and prevent bites.
    Wear clothing that provides coverage. Long sleeves and long pants protect your arms and legs from mosquitoes and help prevent bites.
    Practice safe sex. Zika can be spread through sex, so it’s important to use a condom to prevent sexual transmission. If you have been anywhere with an outbreak of Zika, doctors recommend that you use a condom for 8 weeks after your return if you don’t show symptoms of Zika, and for 6 months if you do show symptoms in order to prevent transmission to you sexual partner.
    Travel safely. If you are traveling to an area with known cases of Zika, take the proper safety precautions and watch for travel advisories. Doctors may recommend vaccines or other medications.

Although it’s concerning to see cases of Zika in the United States, they don’t necessarily signal the beginning of a widespread epidemic. “We always need to be vigilant,” says Ross. “The good thing is that people are aware of the dangers of Zika, and we have the tools we need to limit and monitor its spread.” As we watch the devastation of the opioid crisis escalate in a rising tide of deaths, a lesser known substance is frequently mentioned: fentanyl. Fentanyl’s relative obscurity was shattered with the well-publicized overdose death of pop star Prince. Previously used only as a pharmaceutical painkiller for crippling pain at the end of life or for surgical procedures, fentanyl is now making headlines as the drug responsible for a growing proportion of overdose deaths.
So what is fentanyl and why is it so dangerous?

Fentanyl is a synthetic opioid, meaning it is made in a laboratory but acts on the same receptors in the brain that painkillers, like oxycodone or morphine, and heroin, do. Fentanyl, however, is far more powerful. It’s 50-100 times stronger than heroin or morphine, meaning even a small dosage can be deadly.

Its potency also means that it is profitable for dealers as well as dangerous for those who use it, intentionally or unintentionally. Increasingly heroin is being mixed with fentanyl so someone who uses what they think is heroin may in fact be getting a mixture with — or even pure — fentanyl. More recently, pills made to look like the painkiller oxycodone or the anxiety medication Xanax are actually fentanyl. This deception is proving fatal. It would be like ordering a glass of wine and instead getting a lethal dose of pure ethanol. While many people don’t know they are getting fentanyl, others might unfortunately seek it out as part of the way the brain disease of addiction manifests itself into compulsively seeking the next powerful high.
Helping people who use fentanyl

The way to help patients who are using fentanyl is the same as for other forms of opioid use disorder: to provide effective addiction treatment. However, the first and most important step is helping patients stay safe and stay alive until we can get them that treatment.

It’s worth remembering that dead people don’t recover.

To stop the deaths, we must provide immediate access to lifesaving treatment on demand. While any opioid use is risky, fentanyl has raised the stakes. Every single episode of fentanyl use carries the risk of immediate death. This highlights the need to change how we think about treatment. Many of the traditional models of addiction treatment were designed for alcohol use disorder. Misuse of alcohol can be fatal, but it usually takes many years or even decades to kill someone. In contrast, opioid addiction is imminently fatal, so waiting for treatment is and should be considered unacceptable. We must try to initiate treatment at every opportunity — in the emergency department, at the hospital bed, or even on the street. The best evidence we have shows that a combination of medication and psychosocial treatments is most effective for opioid use disorder. A study of MassHealth patients found that patients on medication treatments like methadone or buprenorphine are 50% less likely to relapse. Other studies have shown that patients treated with these medications are 50% (or more) less likely to die. And yet significant stigma and misunderstanding still exists around these medications. We have treatment programs (and doctors) that don’t offer these medications and patients who are doing wonderfully in recovery thanks to them, but who are also scared to speak out and say they are on medication because the stigma is so pervasive.

Even with our best efforts, it can take time for some people to be open to treatment. In those cases, our priority is to keep them alive and to keep working with them on their readiness to consider treatment. This requires access to naloxone, the antidote to overdoses. But it also includes other education and harm reduction services. People who have loved ones who are actively using and those who are using themselves need to know how to stay safe. There is very concrete education that can reduce the risk of overdose and we need to ensure it is getting to those at the greatest risk.
Moving forward

In Massachusetts alone, deaths due to fentanyl overdose have risen to 57% between 2015 and the first half of 2016. These deaths are yet another symptom of the broader epidemic of opioid addiction. Just as deaths from AIDS are due to untreated HIV, deaths from overdose are frequently due to untreated addiction. Prince’s death is a reminder that opioid addiction is a disease that can and does affect people from all economic classes and all walks of life.
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Monday, 18 March 2019

How to Answer Exam Questions Correctly

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Related Post: How to Answer Exam Questions Correctly

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See: How to Study for Exams in Less Time 2019

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Monday, 11 March 2019

Teens who use flavored e-cigarettes more likely to start smoking

Are you taking care of someone who seems to be against you? This can be the experience of taking care of a family member with post-traumatic stress disorder — PTSD — and it can take a huge toll on everyone involved. At the same time, caring for a person with PTSD can be an act of love and courage.
What causes PTSD?

PTSD can develop when people experience massively stressful events that involve childhood physical or sexual abuse, being sexually assaulted, or narrowly escaping getting killed or severely injured, whether from accidents or violence or military combat. PTSD can also be caused by witnessing these kinds of things, by them happening to a close friend or relative, or by learning about them in the course of one’s work, such as being a first responder or a social worker helping victims of abuse.
What are the effects of PTSD?

Whether caused by experiences during military service, abuse as a child, being the victim of assault as an adult, or as a side effect of jobs that deal with trauma, the effects can be lifelong. It’s a medical problem, not a weakness. Adrenaline levels stay elevated, causing anxiety, irritability, and hypervigilance (being on guard even in safe places). People with PTSD may become snappy and even physically aggressive. Little, everyday sounds may make the person jump. The ability to feel positive emotions like love and happiness is diminished, and people with PTSD may drink or use drugs to avoid painful feelings and memories. People with severe PTSD may isolate themselves, lashing out and showing little affection toward people they care about, and who care for them. Conflict with family members and coworkers is common.
Caring for a person with PTSD

It can be hard for caregivers not to take it personally. They feel that their loved one doesn’t love them anymore (and indeed it’s difficult for some people with PTSD to feel and express love). The fun is gone, and in romantic relationships so is the intimacy. The family member with PTSD may not be comfortable going out in public or being touched. Caregivers can feel lonely and abandoned, and divorce is common in relationships where a partner has PTSD.

Watchwords for caregivers are self-care, limits, and realistic expectations. It’s a balance: you want to help your loved one but you can’t do that if you’re impaired yourself. So, self-care is important. Figure out what you need to have a happy and healthy life and make an effort to keep those things in your life. Eat right, get exercise, take time off from caregiving, see friends. When you’re healthier, you’ll be better able to help your family member to be healthier.

Set limits. You want to offer gentle support, but not tolerate things that are out of bounds for you in any other relationship, such as abusive language or actions, or heavy substance abuse. Couples therapy can be tremendously helpful when one member of the couple has PTSD.

Expectations need to be realistic. Just as other medical disabilities can limit the activities of people who have them, you may need to adjust your expectations about your loved one’s engagement in “regular” family things like going on outings, to restaurants, to parties, to your kids’ games. You may need to take more of a lead in the relationship than you used to or expected to, such as in managing finances, making plans, and getting things done.
The good news? There are effective treatments for PTSD

The good news is that we live in a time when effective PTSD treatment exists. PTSD is best treated through cognitive behavioral therapies, particularly exposure therapy and cognitive processing therapy. These are specialty treatments and not all mental health clinicians are trained in them. A loved one with PTSD may be reluctant to seek treatment, and gentle encouragement can be helpful. You can find therapist referrals at the International Society for Traumatic Stress Studies and the Association for Behavioral and Cognitive Therapies.

PTSD symptoms may not completely go away, but they can be reduced. Just like turning down a volume knob, constantly high levels of anxiety or irritability can be lowered, and the power of memories and reminders of trauma can be reduced. Just like in the rest of your body, advancing years can take a toll on your brain function. Much of this slowing down is predictable and can be chalked up to normal aging. However, when thinking skills become increasingly fuzzy and forgetfulness gets to be a way of life, an early form of dementia known as mild cognitive impairment may be setting in.

Often, the first reaction is to attribute these changes to the beginning of Alzheimer’s disease. But blood flow problems may be to blame, as well. “An estimated one-third of all cases of dementia, including those identified as Alzheimer’s, can be attributed to vascular factors,” says Dr. Albert Hofman, chair of the department of epidemiology at the Harvard T.H. Chan School of Public Health.
Heart health and brain health are connected

Vascular — blood vessel — problems include atherosclerosis (the buildup of fatty plaque in the arteries) and arteriosclerosis (the stiffening of arteries with age). Both are well-known contributors to heart disease. These same processes can also damage brain function by interfering with the steady supply of oxygen-rich blood that nourishes brain cells.

In the case of a stroke, sometimes called a “brain attack,” large swaths of brain tissue die when a blood clot in a major brain artery abruptly halts the flow of blood. In addition to suffering immediate damage from a stroke, roughly one in three stroke survivors will eventually develop dementia.

More subtle injuries are caused by tiny blockages in the small vessels deep within the brain. These silent strokes are 10 to 20 times more common than overt strokes. The microscopic damage they leave behind also raises the risk that dementia will emerge at a later date.

Having blood vessels compromised by plaque buildup can also pave the way for Alzheimer’s. The accumulation of deposits of a protein known as beta-amyloid — the hallmark of the disease — is a direct consequence of what doctors call hypoperfusion. This means the brain is not getting a sufficient supply of blood over the long term. Because of these overlaps, says Dr. Hofman, it doesn’t make sense to draw sharp distinctions between Alzheimer’s and vascular dementia.
Protect your heart and your brain

As with heart health, a key step in maintaining your cognitive abilities is to reduce your major cardiovascular risks. This includes getting regular physical activity, quitting smoking, managing blood sugar and blood cholesterol levels, eating a healthy diet, and maintaining a healthy weight.

Of particular importance is keeping high blood pressure in check, especially in middle age. High blood pressure is the leading cause of stroke. It is also thought to stimulate the growth of micro-injuries in the white matter of the brain. The presence of these lesions can slow thinking and hasten the loss of cognitive function that accompanies Alzheimer’s. When I talk to teens in my practice about cigarettes, what I hear from lots of them is that the smell is what keeps them from smoking. They don’t want to smell like cigarette smoke, and they don’t want that taste in their mouth, either.

But what if the smell, and the taste, were good? What if they tasted like bubble gum, or chocolate?

In a study published in the journal Pediatrics, researchers looked at data from the 2014 National Youth Tobacco Survey. They found that among teens that had never smoked cigarettes, 58% of those who had used flavored e-cigarettes planned to start.

That number was 20% for teens who had never used e-cigarettes. It was 47% among those who had used non-flavored cigarettes, which is a high number too. Clearly, teens that use e-cigarettes are more likely to start smoking.

But when the e-cigarettes were flavored, the teens were less likely to think of tobacco as dangerous.

E-cigarettes and tobacco are different, of course. E-cigarettes do not have many of the carcinogens that cigarettes do, and could be useful for smokers who are trying to quit. But for teens that have never smoked, it’s a different story. The “vapor” of e-cigarettes doesn’t have to contain nicotine, but it can (it does contain chemicals such as formaldehyde that could have long-term health consequences) — and nicotine is addictive. Using e-cigarettes is physically close enough to smoking cigarettes that moving from smoking one to smoking the other could easily happen.

The use of e-cigarettes among youth has grown tremendously over the past few years — and e-cigarettes are being marketed to them. We don’t know what the consequences of this will be. It could be that we will end up with more smokers — or that we’ll end up with fewer if teens decide to stick with e-cigarettes, especially if they choose to stick with the nicotine-free kind. But we can’t just sit back and wait to see what happens.

Recently the Food and Drug Administration extended its tobacco regulations to include e-cigarettes and other nicotine delivery systems, which among other things, requires that there be warning labels and that you have to be at least 18 years old to buy them. This is a good start, and will help us look more carefully at how e-cigarettes are being marketed, too.

We need to do more research to understand the short-term and long-term effects of e-cigarettes on our youth. We need more information in order to make the best policy and parenting decisions.

All of us who are raising or interacting with teens need to talk with them more about e-cigarettes. We need to understand how teens think about them, and why they might choose to use them; when it comes to teens, listening is really important. And along with listening, we need to help teens understand the risks involved. We can’t let them get distracted or seduced by marketing and flavoring; we need to help them make the best choices for their health.
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Friday, 8 March 2019

Parents: How smart are you about antibiotics?

One of the more typical reasons for a trip to the emergency department on Thanksgiving Day (and most days, frankly) is accidental cuts to the hands. Be careful cutting up that turkey! Always use a carving fork, and although the household might be busy, try to avoid distractions when working with knives. Thankfully most such injuries can be repaired in the ED, but occasionally are bad enough to warrant being seen by a hand surgeon. For simple cuts to the hand, we generally place non-absorbable stitches that need to be removed in about 10 days. Most of the time, antibiotics are not needed — just a really good washout and cleaning prior to stitching.

Everyone “knows” about the dangers of cooking turkey, yet somehow nationwide, each year, the rate of residential fires more than doubles during this time frame. Never leave the house with the oven on, and check on the turkey frequently. If you choose to deep-fry a turkey, always do this outside, and always make sure the turkey has thawed first. Placing a frozen turkey into a deep fryer can cause explosions of hot oil, which can lead to third-degree burns and other serious injuries. If you’re frying a turkey, always wear good footwear, practice fire safety, and monitor children in the area.

Most birds carry bacteria, and the turkey is no exception. The most common pathogen is Salmonella. If cooked properly, this poses no harm. Under-cooked, the bacteria can cause diarrhea, vomiting, fever, and general illness that ranges from uncomfortable to life-threatening. The recommended temperature for a cooked turkey is at least 165° F, and should be checked by thermometer. Did you know that if you have any questions about cooking your turkey, you can call the Butterball hotline? Even on Thanksgiving Day! (800-BUTTERBALL/800-288-8372)

Delicious holiday foods are usually well seasoned …with salt. For most adults this does little more than make you thirsty, but for people with congestive heart failure or chronic edema (water retention), extra salt can place increased stress on the body. If you have these conditions, please be careful with what and how much you eat. Inevitably, we will see a few patients with episodes of worsening heart failure in the emergency department … usually the day after a holiday.

Last but not least, be careful about driving. It’s all too common to see drunk drivers during Thanksgiving time. It is historically the most dangerous time of the year for car accidents and subsequent fatalities. Monitor how much you drink, and remember that even if you are sober, unfortunately not everyone else out there is. Be extra attentive. Drive safe! When we think of anxiety disorders, we generally think of them as uncomfortable emotional responses to threat. These responses may include symptoms such as palpitations, shortness of breath, sweating, trembling, or absolute paralysis. While there is nothing inherently wrong in thinking about anxiety this way, a recent study pointed out that there is an entirely different way of thinking about anxiety that may be even more helpful. According to psychologist Kalina Christoff and her colleagues, anxiety may be more appropriately thought of as “mind-wandering gone awry.”
The advantages of mind-wandering

In your brain, there are circuits that promote mind-wandering and they are not all bad. In fact, these very circuits help you maintain a sense of self, understand what others are thinking more accurately, become more creative, and even predict the future. Without your mind-wandering circuits, your brain’s ability to focus would become depleted, and you would be disconnected from yourself and others too.

In addition to the natural and frequent tendency for your mind to stray, it also has automatic constraints too, to ensure that it does not stray too far. When daydreaming during a boring lecture, for example, your brain may jerk you back into reality.
When mind-wandering goes awry

One of the things that a wandering mind is in search of is meaning. By connecting the past, present, and future, it helps you compose a narrative to connect the dots in your life. This narrative is constantly being updated. But sometimes, the wandering mind can encounter threats. Rather than proverbially “whistling in the dark,” the brain can overreact to these threats.

In the brain of an individual with generalized anxiety disorder, for example, the anxiety processor (the amygdala) is disrupted. Although it has strong connections to the “inner eye” (attention), it lacks a connection to the brain circuits that signal how important or significant a threat is. Without the ability to assess the significance of threats, they can all feel the same.

As a result, the “inner eye” gets fixated on negative thoughts. This fixation is a way of constraining the mind too, but it is not actually helpful. Anxious people focus more on external threats in an exaggerated way. They become glued to the threats. Anything from being teased to being ticked off feels much more troubling than it would to someone without an anxiety disorder. And it’s not just conscious threats that grab your attention. It’s subliminal threats too! Threats, of which you are completely unaware, capture your brain’s attention. A mind, once free to wander, is desperately forced to stop in its tracks in what can be construed as a catastrophic confusion of constraints.
Let your mind wander away from perceived threats

When your brain has automatically grabbed your wandering mind, and fixed your attention on threat, rather than getting a proverbial “grip” on reality, you actually have to loosen your grip on your threat-focused reality — allow your mind to wander! As Christoff and colleagues put it, you de-automatize your constraints.

Because your brain’s inner eye has its resources fixed on the threat, it gets progressively exhausted too. You can’t really summon it to help you suppress the anxiety, or get your mind off of it. Instead, you have to reactivate your mind-wandering circuits to give your attention a break.

Practically speaking, there are a few ways to do this. First, identify the negative spiral that has occurred like a pothole into which you have fallen on a mind-wandering journey. Simply name the feeling you are feeling and recognize that you need a mental reset. Rather than deliberately trying to suppress the feeling, accept that your mind is wandering, and that the fixation on threat is not the constraint solution you are looking for.

To counter this constraint, up the ante on the mind wandering — wander even more. If you’re at work, you could keep a knitting kit and start using it just when anxiety strikes, or if at home, you could go out and do some gardening. Meditation is also an effective way to get out of the fixed threat hole.

So when you’re next feeling anxious or wired, try allowing your mind to do what it naturally does — wander! You can bring it back to task gently, without fearing that you have lost your way. Or you can expect that it is wired to switch between wandering and focused states, and it will eventually come back on its own. The more you mindfully interact with this switch, the more adept your brain will become at initiating it. A pair of recent studies provides useful information to men facing challenging decisions about what to do after being diagnosed with early prostate cancer. Researchers tracked men for 10 years and found that virtually none died of the illness, even if they decided against treating it.

Early prostate tumors confined to the prostate gland often grow slowly and may not need immediate treatment. Instead, these tumors can be monitored and treated only if they begin to progress.

In one of the studies, British researchers randomly assigned 1,643 men with early prostate cancer into three groups: one group had surgery to remove the prostate, another had radiation treatment, and a third had “active monitoring,” meaning that doctors tried to predict if the cancer was spreading by measuring their prostate-specific antigen (PSA) levels every few months. Treatment could start if PSA levels jumped by 50% or more over the course of a year. It’s important to note that active monitoring differs from “active surveillance” for early prostate cancer, which relies on routine biopsies as well as PSA measurements to monitor for spreading cancer.

After 10 years, only 1% of the men had died of prostate cancer, regardless of which group they were assigned to. But tumors did spread, or metastasize, more frequently in the active monitoring group. According to the results, the cancer progressed in one in five men being monitored, compared to less than one in 10 men who received surgery or radiation. Some of the men in the monitoring group had what’s known as “intermediate-risk” prostate cancer that has a higher grade and progresses more often than low-risk prostate cancer. Laurence Klotz, a professor at the Sunnybrook Health Sciences Centre, in Toronto, Canada, who was not involved in the study, says it’s likely that most of the men who progressed on active monitoring were in the intermediate-risk category, although the authors did not report this. As time went on, more and more of the monitored men wound up being treated.

In an accompanying study with the same group of men, those treated with surgery reported more long-term problems with sexual performance and urinary continence. Conversely, the radiation-treated men reported more bowel problems, while the urinary and sexual side effects from radiation treatment typically resolved within six months. Both the monitored and treated men reported the same amount of anxiety and depression.

Taken together, the studies bolster a growing consensus that men with organ-confined prostate cancer can safely avoid treatment for some period of time. The results show that one case of metastatic cancer was prevented for every 27 men treated with surgery and every 33 men treated with radiation. “These studies again confirm the lack of evidence that treatment interventions for so-called early prostate cancer lead to any meaningful benefits in survival,” 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 “Additional analyses will be required to see if we can identify those men in each group who did develop metastases and then design treatment programs to see if we can modify that risk.” I come from a long line of skilled soup makers. In the late 1800s, my great-grandmother Enrichetta Cavagnolo, newly arrived from northern Italy, was a soup chef at Delmonico’s in New York City. Enrichetta’s daughter and granddaughters (my grandmother, mother, and aunts) were talented soup makers as well, to the delight of our well-fed family.

But the soup-making gene seemed to skip me. I was never interested in boiling bones for broth, chopping mounds of vegetables, and stirring soup — with love — for hours. It was too much fuss, I thought — until I learned the shortcut.
Fast and healthy

Turns out, making a delicious batch of soup doesn’t require homemade bone broth or all-day simmering. Just boil your favorite vegetables and spices in some water and low-sodium (store-bought) soup stock. There’s no right or wrong combo of ingredients; it’s whatever appeals to you. Want a small batch? Use two cups of liquid. Want a big batch? Use four. Add more liquid to make it soupier, or less liquid to make a stew. Boil, add the ingredients, and you’re in business in about 20-30 minutes.

It’s also easy to go a step further, and make soup a complete meal. “Add protein such as lentils or beans, fish, extra-lean beef, turkey, or chicken,” says registered dietitian Kathy McManus, director of the Department of Nutrition at Harvard-affiliated Brigham and Women’s Hospital. She recommends increasing the nutrient power and fiber by adding as many vegetables as possible, such as peppers, asparagus, broccoli, spinach, onions, and carrots.
Too busy? Beware

Knowing the shortcut is important in an age when soup tops the list of culturally cool comfort food. It’s featured in trendy soup “bars,” tiny take-out windows, and all varieties of grocery stores. While it’s tempting to skip the stove and buy prepared soups, you should note that they often contain preservatives and other unhealthy ingredients. In particular, be on the lookout for these:

    Saturated fat. Any soup with a cream base, such as cream of tomato, is made with cream and butter, which contain unhealthy saturated fat. Too much saturated fat in your diet may drive up your cholesterol and lead to blockages in arteries.
    Sodium. Canned soups often contain high amounts of sodium. Too much sodium in your diet can lead to high blood pressure, heart attack, stroke, and heart failure. Federal guidelines limit sodium intake to 2,300 mg per day for most people.
    Sugar. Added sugar is found in chilled fruit soups and even some vegetable soups. The American Heart Association recommends limiting added sugars to no more than 24 grams per day for women and 36 grams for men.
    Calories. Soups are generally lower in calories than other entrée choices, but that changes when you top soup with cheese, sour cream, or croutons, or pair it with a piece of bread.

Keep it healthy

McManus recommends avoiding prepared soups for the most part. “They’re okay in a pinch and on occasion, as long as you set limits. Aim for less than 500 calories, 600 mg of sodium, 5 grams of saturated fat, and 5 grams of added sugar in a bowl of soup,” she says, “and cut that in half for a cup of soup.”

It’ll take some detective work to stick to those limits and find healthier prepared soups. Look at the nutrition information on a restaurant’s menu or website, or on a product’s Nutrition Facts label. If it’s too much work to hunt down healthy soups, then consider making the soup from scratch, like I do now. You’ll find some healthy soup recipes to get you started here. You can control the ingredients, and you can give it your own special flair. And trust me, it doesn’t take a soup-making pedigree to be good at it.
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Let’s recognize caregivers and make it easier for all of us to do the right thing

Recently I saw a young woman in my clinic for her annual exam. As usual, I asked her if she would like to be tested for sexually transmitted infections, and then we reviewed the “menu” of options: we could collect a swab of her cervix for chlamydia, gonorrhea, and trichomonas, and a PAP smear for human papillomavirus. We could collect blood for HIV, hepatitis C, syphilis, and herpes. We discussed the pros and cons and details of testing — not everyone wants every test. But she cheerfully consented to all of it, and when the results came back positive for chlamydia, she was shocked.

“But I had no symptoms!” she exclaimed.

Like most primary care providers, I am a huge fan of screening for STIs and believe every patient should be asked at every annual exam if they would like to be tested, even if they feel fine. Why? Because most people don’t even know that they are infected.
How many people actually have a sexually transmitted infection?

The Centers for Disease Control and Prevention (CDC) recently published its summary of reportable sexually transmitted infections in the United States over the past year, and it is not good. Rates of every reportable STI, which includes chlamydia, gonorrhea, and syphilis, have all increased significantly; all told, we are seeing a 20-year record high in the number of these cases.* What’s extra concerning is that it is the third year in a row that these rates have increased.

Chlamydia is king, with over 1.5 million cases in 2015, a 6% increase from 2014. Gonorrhea follows with 400,000 cases, a 13% increase. These infections can result in pelvic inflammatory disease, which is a major cause of infertility, ectopic pregnancy, and chronic pelvic pain. A pregnant woman with chlamydia can pass it to her baby; the baby can then develop serious eye and lung infections. The people at highest risk were young people between the ages of 15 and 24; they accounted for over two-thirds of the cases of chlamydia. This is why the CDC has been recommending that every sexually active woman under age 25 be screened.

There were 24,000 cases of syphilis, which may the most harmful of the three, and this was a whopping 19% increase. Gay and bisexual men remain at highest risk for syphilis and gonorrhea, though there were also significant increases in syphilis among women, as well as in congenital syphilis, which is spread from infected mothers to their newborns. Untreated syphilis can lead to blindness, paralysis, and dementia in adults, and seizures or stillbirth in babies. The CDC recommends that every pregnant woman be tested for syphilis, and sexually active gay and bisexual men should be tested for syphilis annually.
Barriers to preventing the spread of STIs

If someone doesn’t know that they are infected, they can’t get treated. If they don’t get treated, they may have sex with many partners, or without a condom, and spread the infection. So, screening tests like the ones we offer at the annual exam are important for the prevention of new infections.

Many people can’t access clinics like mine. They may be young people worried about what their parents may think. They may be uninsured, under-insured, or undocumented. That’s where the “safety net” comes in. These are the free or lower-cost clinics that focus on STI diagnosis, treatment, and prevention. But since 2003, there has been a slow and steady decrease in funding for these safety-net clinics, and we are paying a serious price for that now.

CDC officials blame the surge in STIs on these budget cuts: they point out that over 40% of health departments have reduced their clinic hours and tracking of patients, and at least 20 STI clinics flat-out closed in the past few years due to lack of funds.

Dr. Jonathan Mermin, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, points out that, “STI prevention resources across the nation are stretched thin, and we’re beginning to see people slip through the public health safety net.”

Combine this decrease in public health clinics with the rise in popularity of dating apps like Tinder and Grindr, and ongoing inconsistent condom use, and we have a huge problem.
Keys to preventing STIs

Chlamydia, gonorrhea, and syphilis can be prevented with condoms, and cured with antibiotics. And all can present with minimal symptoms, or none at all.

Sexual education programs that include instruction about condom use have been shown to help youth to delay first sex and use condoms when they do have sex. But, only 35% of U.S. high school students are taught how to correctly use a condom in their health classes. So it’s not surprising that among teens, only about a third of males and nearly half of females reported that they or their partner did not use a condom the last time they had sex.

What can we do about this? Obviously, we need to better fund our public health clinics. Anyone who is or has been sexually active needs to go get tested. We need to push for comprehensive sexual education in schools. Parents should talk openly with their kids about sex and STIs, and ensure that they have access to confidential medical care. We need to promote safe, protected sex through consistent condom use for everyone. These interventions are all cheaper and better than ongoing rampant infection.

*What about other STIs, like herpes and trichomonas? These were not included in the report, as they are not reportable in the same way. However, the CDC estimates that there are 20 million new STI cases yearly, costing the U.S. health care system approximately $16 billion. News last week about celecoxib shows how challenging it can be to understand the risks and benefits of newly developed drugs. This is particularly true when the findings of one study contradict those of past studies. And that’s exactly what has happened with celecoxib.
Anti-inflammatory medications: pros and cons

The FDA approved celecoxib (Celebrex) in 1999. This anti-inflammatory medication can be a highly effective treatment for arthritis and other painful conditions. It was developed with the hope that it would be at least as effective as other anti-inflammatory medications (such as ibuprofen or naproxen) but cause less stomach irritation. Developing a safer anti-inflammatory medication is a worthy goal, since stomach irritation can not only cause annoying pain or nausea, but it can also lead to ulcers, bleeding, or perforation. These medications can also increase blood pressure and cause kidney problems.

Celecoxib is known as a COX-2 inhibitor — that’s because it targets an enzyme (COX-2) involved in inflammation. Ibuprofen and naproxen (and many other anti-inflammatories) target COX-1 and COX-2. They’re called “non-selective” anti-inflammatory drugs. Because of where these enzymes are found in the body, the COX-2 selective medications seemed capable of dampening down inflammation while going easier on the stomach.

And that was true. Celecoxib — and other COX-2 inhibitors, such as rofecoxib (Vioxx) — did cause less stomach trouble. But soon after its approval, studies suggested other concerns: an increased risk of heart attack and stroke. Rofecoxib was removed from the market in 2004. And while the FDA allowed celecoxib to remain on the market, it required the manufacturer to issue additional warnings to patients. It also required additional study. And that’s why celecoxib is back in the news this week. The results of the PRECISION (Prospective Randomized Evaluation of Celecoxib Integrated Safety versus Ibuprofen or Naproxen) trial were released. And the news is good for celecoxib.
Results suggests lower cardiovascular disease risk — and fewer side effects — than expected

The PRECISION trial is a carefully designed and powerful study that analyzed the impact of celecoxib on cardiovascular disease. The study spanned 926 medical centers in 13 countries and enrolled more than 24,000 patients with two of the most common types of arthritis (osteoarthritis and rheumatoid arthritis). Each study subject had a higher than average risk for cardiovascular disease due to a history of high blood pressure or high cholesterol.

Study subjects were divided into three groups who took anti-inflammatory medications every day: one group took celecoxib, one group took ibuprofen, and the last group took naproxen.

Study subjects taking celecoxib in moderate doses were

    no more likely than those taking ibuprofen or naproxen to have a fatal or non-fatal heart attack or stroke
    less likely than those taking ibuprofen or naproxen to have significant gastrointestinal problems, such as serious bleeding
    less likely than those taking ibuprofen to have kidney problems or hospital admission for high blood pressure.

What does this mean for you?

It’s rare that a single study provides a definitive answer or changes practice overnight. But this was a large, well-designed, and expensive study that is unlikely to be repeated any time soon. And, another study of lower-risk people came to a similar conclusion just last year.

Still, questions may yet come up regarding:

    The lack of a placebo group. As suggested by some prior research, it is possible that all three of the drugs used in this study increase the risk of cardiovascular problems; without a control group, it’s impossible to say.
    Dosing. Study subjects were allowed to take up to 400 mg/day of celecoxib if they had rheumatoid arthritis but only 200 mg/day if they had osteoarthritis. In real life doctors may prescribe a wider range of doses.
    Reason for treatment. This study only included people with rheumatoid arthritis or osteoarthritis. The results might be different if people with other conditions had been included.
    Other medical problems. The risks and benefits of celecoxib in people with other medical problems (such as significant kidney disease) are uncertain because this study excluded them.
    Other medical treatments. All patients in this study took a medication to protect the stomach; outside of studies, that’s not always the case.

While these issues are valid, I think this study does provide a significant measure of reassurance regarding the cardiovascular risks of celecoxib. And it may encourage doctors who thought the drug was too risky to prescribe it more often.

This new research shows in a dramatic way why “more research is needed” is not just a tagline at the end of so many medical news stories. And in the case of celecoxib, the result of the additional research is good news indeed. Since 2003, the Movember movement has been raising public awareness of testicular and prostate cancer. The common theme that links cancers of all types is that early detection tends to lead to better outcomes. Because cancer often has no symptoms in its early stages, screening for cancer has been an integral part of primary care routine visits.
I go for an annual physical every year. Do I really need to do self-examinations?

Although routine screening by a health care provider is critical, it does not alleviate the need for self-examinations. In terms of gender-specific cancers, breast cancer is one that receives a great deal of attention due to its prevalence, as one in eight women will develop breast cancer during their lifetime. It is the most commonly diagnosed form of cancer in women, and the second leading cause of cancer death in women. As with any form of cancer, early detection is critical, and the importance of routine breast self-examinations cannot be stressed highly enough. For these reasons, multiple foundations and even the National Football League promote awareness.
What is the deal with men’s health?

Far fewer people know the facts about prostate and testicular cancer. Regarding prostate cancer, about one in seven men will be diagnosed during their lifetime. It most often affects men over the age of 65, and it is the second leading cause of cancer death in men. Although there is no proven way to do self-exams, a digital rectal examination (DRE) performed by a health care provider is a useful screening tool in the detection of prostate cancer. During a DRE, a healthcare provider uses a gloved, lubricated finger inserted into the rectum to feel the prostate gland.

Testicular cancer is fortunately much less common than prostate cancer, as about one in 263 men will be diagnosed during their lifetime. Unlike prostate cancer, testicular cancer is a disease of young and middle-aged men, with about 7% of cases occurring in teens and young boys. Although the number of deaths from testicular cancer is far lower than breast or prostate cancer, it is estimated that about 380 men will die of testicular cancer in the U.S. in 2016. Early detection is critical, and we must stress the importance of routine testicular self-examinations.

Prostate and testicular cancers, especially when not detected early, can lead to difficult treatment, sterility, and potentially a lifetime of hormone replacement therapy. Men tend to be less likely in general to access the health care system, particularly for routine care, which further punctuates the need for awareness. Many men find the thought of a DRE or a testicular examination embarrassing, but such embarrassment can be lifesaving.
 Why is a neurologist so interested in prostate and testicular cancer?

A few years ago, I met a colleague who was similar to me in many ways, a relatively young physician and father of two with no health problems. That is, until he discovered a small nodule on one of his testicles during a self-exam. Follow-up tests confirmed testicular cancer. Fortunately, with early intervention, he was cured after the surgical removal of one of his testicles.

So when I heard about the Movember movement, I felt compelled to do my part to raise awareness.
So here are some of my Movember experiences…

For the past few years, I have grown out a full beard in October, and then shaved it down to a mustache on November 1. For a man who never wears a mustache to suddenly have one is very much an attention grabber. I fondly recall my daughter who is now 4 saying, “Papa, you look like Super Mario with that mustache.” Fortunately, some of the comments I received have been a little more flattering. After sharing the story of Movember with some coworkers, one of the nurses said, “That mustache reminds me of Tom Selleck’s mustache. The only difference is, he is Magnum P.I., which I guess makes you Magnum P.M. (my initials).” During Movember, I begin every patient encounter explaining why I have a mustache, the importance of prostate and testicular cancer awareness, and how early detection can be lifesaving. It has always amazed me how many patients reply with a personal story of their own about a brother, uncle, coworker, etc. who was diagnosed with prostate or testicular cancer.

I fondly recall one such patient, a woman in her 70s, later changing the subject by saying, “Dr. Mathew, do you know that it tickles very much to kiss a man with a mustache?” I replied with a big smile while shrugging my shoulders, “I wouldn’t know (implying that as a heterosexual married man, I have never tried to kiss a man with a mustache),” One of my most rewarding Movember experiences occurred when I had a female patient in the medical field ask me how to perform a testicular exam. I was initially shocked by the question, but then later elated that my mustache served its purpose and then some. Not only did I raise awareness of testicular cancer, but this woman may actually help detect a case, and save someone’s life.

Then came the difficult part … showing this woman how to perform a testicular exam. My mind quickly scrambled, and after scanning the room, I noticed an Angry Bird toy from a Happy Meal that my daughter did not want. As I picked up the rotund bird, and used it as a teaching prop, she seemed to grasp the concept perfectly. I then put the Angry Bird down, and I could not help but feel that one just flew over the cuckoo’s nes. I walked out of the doctor’s office, overwhelmed and paralyzed. My daughter had just been diagnosed with multiple food allergies from nearly all fruits, numerous vegetables, seafood, nuts, soy, wheat, and more. We headed straight to the grocery store to figure out what she could eat without wasting away from malnutrition, or so I thought.

Two hours later, we were still in the grocery store, reading every label.

You would think I would know what to do. After all, I am a doctor. But that day, I was simply a mom and a caregiver.

My problem was simple in the big scheme of things. Many years later, we figured out what my daughter can and can’t eat, how to go out to dinner, have friends over, and basically return to normal everyday life.

But for many of the more than 40 million caregivers in the USA today, it’s not so easy.
The costs of caregiving: health, time, and money

Fully 32% of family caregivers provide at least 21 hours of care per week with the average of 62.2 hours, according to a June 2015 AARP and National Alliance on Caregiving research report, Caregiving in the U.S. Those who provide caregiving 14 hours per week or for two or more years doubled the risk of developing cardiovascular disease and significantly increased the risk of developing high blood pressure and depression.

And it’s not just the time burden and health risks, but there’s also the expense.

A just-released AARP study, Caregiving and Out-of-Pocket Costs: 2016 Report, concludes that “family caregivers are spending roughly $7,000 in 2016 on caregiving expenses which amounts to, on average, 20% of their total income.” Some groups, including Hispanic/Latino, African American, and those caring for someone with dementia experience higher than average out-of-pocket expenses.

Many caregivers are forced to cut back on their own personal spending, reducing leisure spending or retirement savings, to accommodate caregiving costs.

When I think back to the day our family life changed, I am struck by how little doctors seem to know about the impact of our recommendations to our patients. My problem was minor — just changing grocery shopping habits and recipes.

But think about a new diagnosis of diabetes. It’s not just the recipes and grocery habits, but more trips to the pharmacy, tracking blood sugars, and follow-ups to doctors. According to a Harvard Medical School study, it takes two hours on average for one doctor visit for travel, waiting time, and visit. Even more time is spent if one needs public transportation or to arrange a ride.
Maybe it’s time to contemplate new measures for health care delivery

What if doctors and health systems were measured by how much they reduced the time, money, and the overall burden of care that patients, family, and caregivers need to follow recommended care? What if we told our patients, their families, and their caregivers not only what they “should do,” but “how to” with the least disruption to their everyday lives?

We need to make it easy to do the right thing.

Doctors care about having meaningful time with their patients. So, every time a new guidance or documentation rule is mandated, physicians understandably complain about the new time burden to incorporate the new tasks into the workflow of their practice.

Similarly, every time we give our patients and caregivers new recommendations to follow, we are disrupting the “workflow of their lives.” Is it any wonder that compliance is challenging for our patients? Do we address the daily changes that will be needed in everyday living? The Lasix prescription that means figuring out where all the nearest bathrooms will be when the fluid reduction pill takes effect. Or the cost of dressings, bandages, tape, and time to manage wound care at home? And the anxiety of not knowing if one just broke sterile technique at home? What a steep learning curve we expect from our patients following each visit!
A thank you from health care providers to caregivers

November is National Family Caregivers Month. Kudos to all family and friend caregivers, not only for “care taking” — ensuring your loved one is safe, taking the correct medications at the right time, preventing falls, making the right meals, and helping with bathing — but also for “care giving” – the giving of love, compassion, and care. You are spending your precious hours and your own money to do what you do best: sharing your love to your parent, your spouse, your children, or your friends. You are making a difference to our patients (your loved ones). It’s time we clinicians pay tribute, recognize, and thank you for being a caregiver, and not just a caretaker.
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