MATURE MATTERS (C) – Page 4

FLU SHOT OR NOT – KEY FACTS – INFLUENZA ACTIVITY IN NORTHWEST – UPDATE

Influenza Activity as Assessed by State and Territorial Epidemiologists

During week 51, the following influenza activity was reported: • Widespread activity was reported by four states (Alabama, Florida, Georgia, and Mississippi).
• Regional activity was reported by twelve states (Indiana, Iowa, Louisiana, Maryland, Massachusetts, Nevada, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, and Texas).
• Local activity was reported by the District of Columbia and five states (Connecticut, Hawaii, Michigan, Minnesota, and Wisconsin).
• Sporadic activity was reported by New York City and 25 states (Alaska, Arizona, Arkansas, California, Colorado, Delaware, Idaho, Illinois, Kansas, Maine, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oregon, Rhode Island, South Dakota, Utah, Virginia, Washington, West Virginia, and Wyoming).
• No influenza activity was reported by one state (Vermont).
• Three states did not report (Kentucky, Missouri, and New Mexico).

What is Influenza (Also Called Flu)?

The flu is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death. The best way to prevent the flu is by getting a flu vaccination each year.

Every year in the United States, on average:

5% to 20% of the population gets the flu;
more than 200,000 people are hospitalized from flu complications, and;
about 36,000 people die from flu.

Some people, such as older people, young children, and people with certain health conditions, are at high risk for serious flu complications.

Symptoms of flu include:

fever (usually high)
headache
extreme tiredness
dry cough
sore throat

runny or stuffy nose
muscle aches
Stomach symptoms, such as nausea, vomiting, and diarrhea, also can occur but are more common in children than adults

Complications of flu can include bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes.

Flu viruses spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose. Most healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 days after becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.

The single best way to prevent the flu is to get a flu vaccination each year. There are two types of vaccines:

The "flu shot" – an inactivated vaccine (containing killed virus) that is given with a needle. The flu shot is approved for use in people 6 months of age and older, including healthy people and people with chronic medical conditions.
The nasal-spray flu vaccine – a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAIV for “Live Attenuated Influenza Vaccine”). LAIV is approved for use in healthy people 5 years to 49 years of age who are not pregnant.

About two weeks after vaccination, antibodies develop that protect against influenza virus infection. Flu vaccines will not protect against flu-like illnesses caused by non-influenza viruses.

October or November is the best time to get vaccinated, but getting vaccinated in December or even later can still be beneficial since most influenza activity occurs in January or later in most years. Though it varies, flu season can last as late as May.

In general, anyone who wants to reduce their chances of getting the flu can get vaccinated. However, certain people should get vaccinated each year either because they are at high risk of having serious flu-related complications or because they live with or care for high risk persons. During flu seasons when vaccine supplies are limited or delayed, the Advisory Committee on Immunization Practices (ACIP) makes recommendations regarding priority groups for vaccination.

People who should get vaccinated each year are:

1. People at high risk for complications from the flu, including:

Children aged 6 months until their 5th birthday,
Pregnant women,
People 50 years of age and older,
People of any age with certain chronic medical conditions, and
People who live in nursing homes and other long term care facilities.

2. People who live with or care for those at high risk for complications from flu, including:

Household contacts of persons at high risk for complications from the flu (see above)
Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)
Health care workers.

3. Anyone who wants to decrease their risk of influenza.

Use of the Nasal Spray Flu Vaccine

Vaccination with the nasal-spray flu vaccine is an option for healthy persons aged 5-49 years who are not pregnant, even healthy persons who live with or care for those in a high risk group. The one exception is healthy persons who care for persons with severely weakened immune systems who require a protected environment; these healthy persons should get the inactivated vaccine.

Who Should Not Be Vaccinated

Some people should not be vaccinated without first consulting a physician. They include:

People who have a severe allergy to chicken eggs.
People who have had a severe reaction to an influenza vaccination in the past.
People who developed Guillain-Barré syndrome (GBS) within 6 weeks of getting an influenza vaccine previously.
Children less than 6 months of age (influenza vaccine is not approved for use in this age group).
People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen.

(adapted from cdc website: anticipate update by cdc after new data emerges)

ERTALES FROM THIS ER DOC * hugs rule

The little boy was literally climbing up the pantleg of his mother. "He's scared," she told me. "He had a bad time at his doctor's last time," the anxious mom added. Our eyes, the 5 year old's and mine, sized up each other – man to man, muscle to muscle, universe to universe. There would now be an internal debate of trustworthiness – on each side – of this heavy weight moment in time. His reluctance to be lifted on the exam table was obvious as the arms of safety were peeled by his mother from her neck. I sat and watched. Not a word. Quiet.

We drew our weapons. His, a stare of cold steel; mine, a shiny ear scope. Instead, as I sat, I asked to look at mom's ears. I did. I asked to look in mom's mouth, and pretendingly did. His evaluation of my performance was sharply etched in his mind's acute processor. I drew my stethoscope to his mom's back to listen to lungs. Then, I slowly, like the gunfight at the o-k corral, drew toward his watchful perched position of power, while me on the subordinate exam rollerstool.

He said, "I have a dog!" I said nothing, as it could be a ploy, a plot, a trojan horse comment to quickly surround me with ear piercing shrills and dashing speed to his circle of wagons, mom. I waited. My eye honed to his eye. He said the dog's name. I shook my head in approval. I drew my rollerstool closer and closer. His eye honed to my eye. Slowly, like the draw of the bow during the hunt, my otoscope entered his right ear. Then the left. The test of the tonsil lay in front of the medical warriors. "Can you eat an elephant?," I asked. He opened his mouth so wide I could see his appendix. He held the tongue blade. Not needed. His lungs were listened to with the kid-size stethoscope. No rash. "Tonsillitis," I said to him as my stealthy roller steed backed away. He looked at his support staff, his mom. "You will take the medicine for your mom?" and he shook his head affirmatively. The warriors were exhausted.

Celebratory and coexistent now. To the Tootsie Pop drawer, we went. Hand in hand from the exam table battlefield, to the oasis of sweets. His choice was deliberately selected with a keen appreciation for what was to be.

On the escort out of the exam area, with Tootsie Pop in hand, my leg became heavy. The small warrior's arm was hugging around my leg, just above the knee. Stride for stride, we were proudly successful. I said, "Do you want to give me a hug?" He put his arms up high, as I reached over to accept his offer of goodwill. We hugged. Mom smiled. I said to my newly made battlefield-weary friend, "Hugs are good." He said, "bye," as he secured his mother's hand to see the world.

IMMEDIATE CARE urgent care CLINICS – WHY WAIT IN THE ER * MINOR EMERGENCY WALK IN * URGENT CARE * INJURY ILLNESS – WORKER OCCUPATIONAL CARE – DRUG-FREE WORKPLACE TESTING – MRO REVIEW – SPORTS CARE – FAMILY CARE – URGENT CARE

OVER THE PAST DECADE AT LEAST 400 (FOUR HUNDRED) OR MORE EMERGENCY ROOMS HAVE CLOSED
GREATER 120 MILLION PEOPLE WERE TREATED IN ERS A FEW YEARS AGO – GROWING
GROWTH IS AN ALARMING 20-30% EVERY 5-10 YEARS
COMPLICATED PATIENTS CONTINUE TO GROW – AIDS, TB, CANCER, ADVANCED DIABETES, STROKE, HEART DISEASE COMPLICATIONS, TRAUMA, SHOOTINGS, DRUGS OF ABUSE
NEARLY 50 MILLION AMERICANS HAVE NO INSURANCE OR LIMITED ACCESS

click on link – http://www.nimcc.com

WHAT TO DO:

BRING A LIST OF YOUR ALLERGIES, MEDICATIONS, PAST MEDICAL HISTORY, EKG IF YOU HAVE IT, AND NAMES AND PHONE NUMBERS OF SIGNIFICANT OTHERS, AND INSURANCE INFO IF IN DATE

GO TO IMMEDIATE CARE IF UNSURE – IF NOT SEVERELY ILL OR INJURED

IF YOU MUST GO TO THE ER, GO IN THE MORNING…LESS BUSY USUALLY

WHEN IN DOUBT – IF ILLNESS OR INJURY IS SEVERE…CALL 911

TELL THE TRIAGE NURSE YOUR SYMPTOMS…ALL OF THEM

KNOW THE CREDENTIALS OF YOUR DOCTOR…EXPERIENCE

IS THE EMERGENCY PHYSICIAN RESIDENCY TRAINED IN EMERGENCY MEDICINE

IS THE EMERGENCY PHYSICIAN BOARD-CERTIFIED IN EMERGENCY MEDICINE

BRING AN ADVOCATE TO WATCH, LISTEN, AND ASK QUESTIONS – ESPECIALLY IF VERY ILL

MANY IMMEDIATE CARE CLINICS CAN TAKE CARE OF MANY ILLNESSES AND MINOR EMERGENCIES – CALL IF UNSURE

MANY IMMEDIATE CARE CLINICS CAN STABILIZE AND TRANSFER TO THE HOSPITAL

MANY IMMEDIATE CARE CLINICS HAVE BOARD CERTIFIED ER DOCS AND ER EXPERIENCED DOCS

CARBON MONOXIDE (CO) POISONING EPIDEMIC * prevention – WARNING – CAUSES – SYMPTOMS – THERAPY – GOAL – LONG TERM EFFECTS – **mandatory reporting effort by Washington State Public Health and Washington Posion Center

Preventing Carbon Monoxide Poisoning * Emergency

(fires photos from: nifc.gov)
(product photos from: web general sites)
(house photo from: kltv, texas)

Generators, grills, camp stoves, or other gasoline, propane, natural gas, or charcoal-burning devices should never be used inside a home, basement, garage, or camper – or even outside near an open window.

Every home should have at least one working carbon monoxide detector. The detector’s batteries should be checked twice annually, at the same time smoke detector batteries are checked.

Carbon monoxide (CO) is an odorless, colorless gas that can cause sudden illness and death if inhaled.
When power outages occur during emergencies such as hurricanes or winter storms, the use of alternative sources of fuel or electricity for heating, cooling, or cooking can cause CO to build up in a home, garage, or camper and to poison the people and animals inside.

Every year, more than 500 people die in the U. S. from accidental CO poisoning.
CO is found in combustion fumes, such as those produced by small gasoline engines, stoves, generators, lanterns, and gas ranges, or by burning charcoal and wood. CO from these sources can build up in enclosed or partially enclosed spaces. People and animals in these spaces can be poisoned and can die from breathing CO.

How to Recognize CO Poisoning
Exposure to CO can cause loss of consciousness and death. The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain, and confusion. People who are sleeping or who have been drinking alcohol can die from CO poisoning before ever having symptoms.

Important CO Poisoning Prevention Tips

Never use a gas range or oven to heat a home.
Never use a charcoal grill, hibachi, lantern, or portable camping stove inside a home, tent, or camper.
Never run a generator, pressure washer, or any gasoline-powered engine inside a basement, garage, or other enclosed structure, even if the doors or windows are open, unless the equipment is professionally installed and vented. Keep vents and flues free of debris, especially if winds are high. Flying debris can block ventilation lines.
Never run a motor vehicle, generator, pressure washer, or any gasoline-powered engine outside an open window, door, or vent where exhaust can vent into an enclosed area.
Never leave the motor running in a vehicle parked in an enclosed or partially enclosed space, such as a garage.
If conditions are too hot or too cold, seek shelter with friends or at a community shelter.
If CO poisoning is suspected, consult a health care professional right away.

Educational materials

Flyers and door hangers http://www.bt.cdc.gov/disasters/co-materials.asp
Public Service Announcements http://www.cdc.gov/co/psa.htm
CO Poisoning Prevention Guidelines http://www.cdc.gov/co/guidelines.htm
(Available in 16 languages)

(adapted from CDC website)

Indications for Hyperbaric Oxygen

Hyperbaric oxygen therapy is a specialized medical treatment in which the patient breathes 100 per cent oxygen while inside a chamber at increased atmospheric pressure. HBO is used for specific medical conditions. HBO has long been (PHOTO: hcmc hbo ctr) recognized as vital in the resolution of critical medical conditions such as gas gangrene, carbon monoxide poisoning, air embolism due to diving, trauma, or surgical procedures, and decompression sickness. It is also an important adjunct for specific wound healing conditions.

The Hyperbaric Oxygen Committee of the Undersea and Hyperbaric Medical Society (UHMS) lists the following indications: approved uses for Hyperbaric Oxygen therapy:

Air or gas embolism
Carbon monoxide poisoning and smoke inhalation
Clostridial myonecrosis (gas gangrene)
Crush injury, compartment syndrome, and other acute traumatic ischemias
Decompression sickness
Enhancement of selected problem wounds
Exceptional blood loss anemia
Necrotizing soft tissue infections
Chronic refractory osteomyelitis
Radiation tissue damage (Osteoradionecrosis)
Skin grafts and flaps (compromised)
Thermal burns
Adjunctive HBO in intracranial abscess

(adapted from: HCMC HBO Ctr)

Carbon monoxide poisoning: Reporting required

Due to the ongoing severe cold weather conditions and associated increase in carbon monoxide (CO) poisoning among King County (PHOTO: hcmc hbo ctr) residents, Public Health is making suspected CO poisoning immediately reportable to Public Health by hospitals and healthcare provi
ders for seven days from today, through Dec. 24, 2006. This period will be extended if necessary.

The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain, and confusion. Inhalation of carbon monoxide gas typically leads to headache, dizziness, and confusion, which might progress to dyspnea, tachypnea, syncope, and metabolic acidosis. Laboratory criteria for diagnosis: A case in which carboxyhemoglobin concentration exists >5% in venous or arterial blood in nonsmokers and >10% in smokers, as determined by hospital or commercial laboratory tests. The typical range of carboxyhemoglobin concentrations in smokers is 6%-10%.

Advice regarding diagnosis and treatment management of CO intoxication is available 24/7 through Washington State Poison Center at 1-800-222-1222.

This health order impacts primarily emergency departments (ED) and the information should be disseminated to all ED staff in King County hospitals immediately. A designated person on each shift should be identified to report cases of CO poisoning to Public Health.

(adapted from the Seattle/King County Public Health Announcement)

THE CONTROVERSY CONTINUES: DOES THE HYPERBARIC OXYGEN HELP?

Current assessment and treatment of CO poisoning in the
emergency department is grossly inadequate to prevent serious
neurologic complications. HBOT speeds removal of CO from
tissues and counters a number of its deleterious effects. Past studies
have demonstrated efficacy of HBOT for reducing the incidence of
neurologic sequelae, even though only three sessions of HBOT
were used. Clinical experience such as that reported here shows that
HBOTtreatment late in the course of established impairments from
CO can lead to clinical improvements. Improvement is documented
by evidence of increased brain metabolism on functional brain
imaging by SPECT after HBOT. Further study as well as wider
availability of HBOT, particularly for persons such as firefighters
who are at high occupational risk of CO poisoning, is warranted.

AND THESE TREATMENTS ARE NOT CONCLUSIVE IN MANY STUDIES THUS FAR…(editorial comment by castMD.com)

Richard A. Neubauer, M.D.
Virginia Neubauer
Alan Ko Chi Nu,
M.D. William S.
Maxfield, M.D., FACNM
, is Medical Director, Ocean Hyperbaric
Neurologic Center, Lauderdale-by-the-Sea, FL. is
Research Director, Ocean Hyperbaric Neurologic Center.
, is a hyperbaric physician practicing in Taipei, Taiwan.
, is a radiologist and Chief of Nuclear Medicine at
Ocean Hyperbaric Neurologic Center.

(adapted from: Journal of American Physicians and Surgeons Volume 11 Number 2 Summer 2006)

FIBER – SOLUBLE FIBER AND WEIGHT CONTROL DIETING WITHOUT PILLS, DRUGS OR METH HIGH VOLUME soluble FIBER SUPPLEMENTS happy healthy holidays

Over the past 20 – 30 years, fiber has been a leading dietary factor connected to worsening weight control. Less fiber, less control has been the health risk. You should have noticed on "The Biggest Loser" tv show in 2006 that dietary fiber amounts were noticeable. So this idea of weight control and dieting with its relationship to fiber intake is not a new idea. The real concern with increasing obesity, diabetes, cancer, and childhood obesity and its complications, is the amount of fiber, and the type of fiber that is of special focus today.

Generally, obese men and women have less fiber in their diets. In fact, overweight persons generally consume about one-half of the fiber that is recommended. Many times, programs for weight loss find that the "client" is not using enough fiber to assist in weight loss management, therefore causing increased risk of failure of the weight loss program.

Many persons do not like high-fiber in general. Why? Foods like beans, whole grains, fruits, and vegetables can cause bloating and gas; and they just do not like that feeling. Many jokes of such problems exist, but what really happens is tolerance to fiber does occur…it gets better.

High-fiber diets help your body making contents inside the bowel bulkier with water holding properties. It helps distend your stomach, small and large bowel – helping you feel fuller longer. It also causes the feeling of hunger to go away.

Soluble fiber especially causes a viscous suspension. (See previous castMD detail at the link http://www.castmd.com/?p=36 . These slurries delay stomach emptying and allows nutrient absorption. Hunger pains are minimized. In addition, some fats are held in the fiber, allowing yet the proteins and carbohydrates to be absorbed. This slowing, and delaying, and changing the food load is called "spreading the nutrient load."

Fiber helps change the hormones that control food metabolism. Sugar in your system is more stable, and even; and the metabolism is more controlled with insulin avoiding the highs and lows of sugar and its rebound in the blood stream.

With this better and longer control of your glycemic load, energy is maintained on lesser calories. There are fewer "hunger signals" to the appetitie centers, allowing more work with less calories. You're not eating as much and you are using calories already "on board."

Many parents with CAD (coronary artery disease) have overweight children. And those kids had more complications of health risks that other kids. With the addition of high-fiber, better control of weight, cholesterol, blood sugar, and insulin release was maintained. Risk of "metabolic syndrome" or "syndrome X" goes down with high-fiber supplementation. With this, insulin resistance goes down; – while hyperlipidemia, hypertension, hypercholesterolemia and type 1 and type 2 diabetes all have improvement.

Obesity continues as diets are high in fats, high in added sugars, and low in soluble fibers.

At least 25 to 30 grams of soluble fiber is recommended daily, slowly added from about 5 grams per day over 2-3 months – to maintain a healthy weight.

IN SUMMARY: ENJOY THE HOLIDAYS HEALTHIER *

SOLUBLE FIBER HELPS SLOW DOWN THE RATE THAT FOOD NUTRIENTS ARE ABSORBED

SOLUBLE FIBER HELPS YOU FEEL LESS HUNGRY

SOLUBLE FIBER HELPS REDUCE THE AMOUNT OF CALORIES YOU TAKE IN

SOLUBLE FIBER HELPS PROTECT YOU FROM THE RISKS OF SEVERAL SERIOUS DISEASES.

(excerpts from: Soluble Fiber – Saving Your Health, Saving Your Money. Winter & Crane)

Wii INJURIES – UNIQUE STORIES 911 COMMENTARY OF nintendo Wii EMERGENCIES * EXCITED, RABID, FROTHING – TELL YOUR STORY

MANY PERSONS AND STORIES OF PERSONS HAVE RELATED UNIQUE AND FUNNY STORIES OF THIS HOT DEVICE IN THE NEXT NEO-GAMING LEVEL OF ENTHUSIASM. SOME ARE EMERGENT, SOME REQUIRE IMMEDIATE CARE, AND SOME ARE NON-EMERGENT. FUNNY, UNUSUAL, AND CHAOTIC !

WHAT IS YOUR STORY………CLICK ON COMMENTS BELOW AND WRITE TO THE BLOGOSPHERE !

UPDATE: After adding your emergency story or injury in comments below – go to www.wiihaveaproblem.com as it is hilarious!

PHARMACEUTICAL ADVERTISING TO THE PUBLIC – GAO WEIGHS IN ON THE FDA – WWW GROWTH TOO FAST – PATIENTS SMOTHERING IN DRUG ADS

WWW.CASTMD.COM HAS BEEN HOT TRACKING THIS ONGOING MASSIVE PATIENT BOMBARDMENT.

NOW YOU TOO CAN READ THE WARNING LETTERS FROM THE FDA SITE.

http://www.fda.gov/cder/warn/warn2006.htm

http://www.fda.gov/foi/warning.htm

LIKE PREVIOUS CASTMD.COM BLOGS, http://www.castmd.com/?p=86 THIS LEVEL OF MARKETING PLACES RISK ON PATIENTS AND PHYSICIANS THROUGH THE USE OF THE OLD MARKETING PLOYS AND SILENT ADVERTISING – "SUBLIMINAL SUGGESTION." http://www.castmd.com/?p=79

FDA officials are issuing fewer offense warnings to drug companies for false and misleading advertisements and are taking longer to do it, a congressional report says.

Annual spending on direct-to-consumer drug advertisements at $4.2 billion and growing, the government has limited ability to curb distribution of ads that violate federal rules, according to the report being released Thursday.

From 2002 through 2005, it took the FDA four months on average to draft, approve and send warning letters and other correspondence to companies that were in violation of the rules, government auditors said.

Between 1997 and 2001, before FDA lawyers began reviewing the letters as a matter of policy, it took just two weeks on average to issue the letters. The number of letters fell off by about half between the two time periods.

The GAO also said the FDA lacks an effective way to screen, review and track the more than 10,000 ads and Web sites brought to the agency's attention each year. The amount has doubled in just four years.

(adapted from fxnws/fda/gao)

smokers CALL 911 * LIFE-SAVING DISTANCE ADDED TO SMOKERS BAN BUBBLE – SOME SMOKE IS HEALTHIER THAN OTHER SMOKE IN COEUR D ALENE AND THE IDAHO LEGISLATORS AND LOBBYISTS

AS CASTMD.COM HAS OPINED PRIOR ON THE ONGOING LUNG ASSAULT FROM THE AGENTS OF FIELD BURNING IN NORTHERN IDAHO AND OTHER CLOSE AREAS, NOW THE COUNTY COMMISSIONERS ARE ADDING "LIFE-SAVING" DISTANCE TO THE CIGARETTE SMOKERS BANNED AREAS.

I BELIEVE, IDAHO STATE LAW STATES THAT SMOKING IS ALLOWED ONLY BEYOND 20 FEET FROM A PUBLIC DOORWAY OR ENTRANCE. THE KOOTENAI COUNTY COMMISSIONERS CHANGED IT TO 20 FEET FROM ANY BUILDING.

ONE OF THE LOCAL PAPERS QUOTED A COMMISSIONER SAYING, "IT'S AN EMPLOYEEE, RISK MANAGEMENT ISSUE."

WHAT IS THIS? THE COMMISSIONERS CONTINUE TO ALLOW FIELD BURNING SO PATIENTS, EVEN WITH SEVERE LUNG DISEASE AND HEART DISEASE AND KIDS WITH CYSTIC FIBROSIS, ASTHMA, AND ALLERGIES – CAN BREATHE POLLUTED AIR IN THE BEAUTIFUL SUMMER AND FALL MONTHS.

IN THE LOCAL PAPER, THE STORY CONTINUED THAT SOMEONE EVEN STATED IT [THE SMOKE] "PERMEATES THE BUILDING." AMAZING TO SAY THE LEAST……

RISE UP FOLKS…DO THE FIELD BURNING AND THE FOREST FIRES BOTHER YOU? CALL YOUR LEGISLATORS ABOUT THE THOUSANDS OF TONS OF PARTICULATES CREATED AND THAT YOU MUST INHALE WITH THOSE PROBLEMS. (SEE PREVIOUS BLOGS FROM WWW.CASTMD.COM)

SO, IT IS NOT A MYTH. IT IS TRUE.

IN IDAHO'S LEGISLATORS AND LOBBYISTS, SOME SMOKE IS HEALTHIER THAN OTHER TYPES. SIMPLY AMAZING !