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Flu vaccine 2017-2018 … for those 65 and over

October 10th, 2017 · Comments Off on Flu vaccine 2017-2018 … for those 65 and over · Uncategorized

Dear Patients,

Please read the guidelines below. If you are 65 or over, you have a choice between the government provided vaccine, Fluviral, or a “high-dose” vaccine(Fluzone High-Dose) made by Sanofi (not government funded). The latter is slightly more effective (see diagram below). If you are under 65, you should be receiving the usual vaccine.

2017-2018 NACI GUIDELINES FOR FLU VACCINATION

Adults ≥65 years of age

Four types of vaccine are available for use in adults ≥65 years of age: standard dose TIV, high dose TIV, MF59-adjuvanted TIV, and QIV.

Choice of vaccine product for adults ≥65 years of age

In choosing a vaccine product, it is important to consider the relative burden of influenza disease caused by the various influenza subtypes (i.e., influenza A(H1N1), influenza A(H3N2) and influenza B) in this age group, as well as the efficacy, immunogenicity and safety profile of the available vaccines.

A study focusing on estimates of deaths associated with influenza in the USA has established that the average annual rate of influenza-associated deaths for adults aged ≥65 years was 17.0 deaths per 100,000 (range: 2.4–36.7) . The study also states that deaths among persons aged ≥65 years accounted for 87.9% of the overall estimated average annual influenza-associated deaths with underlying pneumonia and influenza causes. When influenza-related deaths were estimated using underlying respiratory and circulatory causes, these estimates increased to 66.1 deaths per 100,000 (range: 8.0–121.1) and 89.4%, respectively.

Canadian surveillance data shows that hospitalization rates among individuals ≥65 years of age were higher during the 2014–2015 season, a season in which A(H3N2) circulation predominated and there was a vaccine mismatch with the circulating A(H3N2) strain, compared to the previous five influenza seasons and also compared to the 2012–2013 season when A(H3N2) also predominated. Similar to the hospitalization rates, death rates among seniors were highest in the 2014–2015 season compared to the previous five seasons and compared to the previous A(H3N2) season in 2012–2013. Deaths rates among other age groups were similar to or lower than the previous five influenza seasons. Laboratory detections over this same time period showed that influenza seasons predominated by Influenza subtype A(H3N2) disproportionally affected adults ≥65 years of age while seasons with greater A(H1N1) detections  resulted in a higher prevalence of positive cases in younger age groups.

Based on the available evidence, NACI concludes that there is evidence that high dose TIV should provide superior protection compared with standard dose TIV for adults ≥65 years of age.

flu

Considering the burden of disease associated with influenza A(H3N2) and the evidence of superior efficacy of high dose TIV compared to standard dose TIV, it appears that high dose TIV would provide the greatest benefit to the ≥65 years age group.

This high dose flu vaccine is not provided by our Ontario government. It can be purchased from the pharmacy or at my office for $80.

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Potpourri

October 1st, 2017 · Comments Off on Potpourri · Uncategorized

I was 14 years old when JEOPARDY! first appeared on TV. I was a regular, and my favourite category, aside from Sports, was Potpourri. Today’s blog, after another sabbatical, is some potpourri.

Travel medicine continues to be plagued by vaccine shortages… not just for yellow fever, but also typhoid, Twinrix (hepatitis A and B) and rabies. Yellow fever vaccine is being doled out in fractions, according to my past blogs. Organizing travelers who need, or might want, or might not want, the yellow fever vaccine is no easy matter.

The world isn’t growing any more countries or mountains or ancient ruins. So people continue to be off to the usual destinations, Peru and Machu Picchu with a dip in the Amazon, southern Africa including Kruger National Park, Botswana, Namibia and Zimbabwe (someone brought be the lovely gift of a tick, which he had found on his ….), and Southeast Asia including Thailand, Cambodia, Lao and Vietnam.

Many of the same issues popup every day, including:

  • do I really need that typhoid shot
  • I hear the antimalarials make you psychotic
  • I can’t remember whether I got the booster
  • my brother-in-law had the shot downtown
  • isn’t it better just to let the diarrhea run its course
  • is there anything other than DEET

…. and much more.

Some people have called enquiring about a new “super-resistant” malaria in Southeast Asia. To read more about, read this. To clarify, the strain of P. falciparum malaria in the Mekong region is resistant to certain treatments, but not to prophylaxis with either Malarone or doxycycline. The majority of travelers to this region are at very low risk of contracting malaria.

We may not be out of the woods yet with Zika in the Caribbean and Latin America, but it seems to have declined. The 2/6 rules continue to be in place (see CDC), that is, if you are travelling there, do not plan to become pregnant for 2 months (for women), and don’t plan to impregnate someone for 6 months (for men).

On a personal note, I continue to study jazz piano. If you would like to hear my teacher, Brian Rudolf, plan Tuesday night dinner at Santo’s Restaurant in Thornhill.

Once again, I made a whirlwind trip to Ottawa with my children, this time Benjamin, who his 35, and his son Jonah, who is 4. After a lovely train ride from Kingston to Ottawa, we quickly got ensconced in The Chateau Laurier Hotel (paid for with Aeroplan points), and in 24 short hours, visited Parliament Hill where we tossed the baseball, The Pirate Adventure at Mooney’s Bay, Byward Market for a pizza and a Beavertail, the piano bar at The Chateau, and The Museum of Natural History. That is Karsh’s magnificent portrait of Churchill in the background. I highly recommend this trip for everyone. No shots needed!

churchill

I will stop there for now. Happy Thanksgiving to everyone.

Mark

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So what’s new?

May 6th, 2017 · Comments Off on So what’s new? · Uncategorized

Firstly, we survived Cuba – no sunburns, diarrhea, abrasions or muggings. We were at the Pestana Resort in Cayo Coco. Great pool, lovely beach and ocean, a baby grand piano, red wine and the food was good enough for us! Great pizza! We will go back one more time with our children and grandchildren. sails

We are still experiencing a shortage of yellow fever vaccine. Not all travel clinics are able to provide the vaccine, and those who are like me are trying to use fractional doses as recommended by WHO and PHAC. Shortages of vaccines, and other medications, are nothing new in the medical field. Rabies vaccine for high risk travelers is no longer available, for now. Stay away from dogs and monkeys!

The incidence of Zika seems to have declined in Latin America and the Caribbean. However we are still “stuck” with the “2/6” guidelines. Women, don’t become pregnant for two months after being in a Zika area. Men, don’t impregnate anyone for 6 months after possible exposure. Use your insect repellent, containing DEET, or a new option, Picaridin, if you can find it. MEC has it!

My wonderful receptionist, Indi, is off to Peru this week. Hopefully she will dodge diarrhea, dog bites and altitude sickness. (see Nov. 2016 blog). While my short term memory seems to be on the wane (I can’t remember from which side I served in squash), my memories of that trip remain clear as a bell. The infectious, healing springs at Aguas Calientes seem like yesterday. The juice blended by the ladies in the market. We didn’t have to pay for a hotel at Machu Picchu. We camped illegally on the terraces. The sunrise was spectacular. I bought a helluva lot of alpaca stuff! mp

A Canadian lady and her American companion were murdered in Belize last week. Does that now make Belize a dangerous destination to avoid? Not quite. Our government advises us to exercise a “high degree of caution” in most countries in the world, besides Canada and Switzerland. As one who notices these gruesome headlines, I find that they can pop up anywhere. Personal safety is probably the most important issue for travelers, with diarrhea and Zika interesting, and not fun, but perhaps less of a concern.

My next trip is to Ottawa with my grandson Jonah, to stay at the castle-like Chateau Laurier Hotel with its lovely piano bar, to wander around the Byward Market, and hopefully get on the pirate ship at Mooney’s Bay.

May is devoted to lots of squash, singles and doubles, and a plethora of family birthdays and Mothers’ Day. Pharmacies are now able to give travel advice and administer travel vaccines. We will see where that goes!

I realize that the ability to travel is a bonus.

Mark

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Off to Cuba

March 17th, 2017 · Comments Off on Off to Cuba · Uncategorized

Column 1

Column 2

Tomorrow I am off to Cuba with my wife Gayle, my children Benjamin and Ros, and their two lovely kids, Jonah, 4, and Noah, 2. We will be in Cayo Coco at the same Pestana resort we visited last year with a different set of kids.

So, from the travel medicine perspective, we are all protected against hepatitis A, the kids not yet B. No Dukoral for the family – just don’t feel that it is that effective or worthwhile or pleasant to take or cheap! I think Health Canada feels the same way.

I have packed some oral rehydration salts in case the kids get diarrhea, and a short course of Zithromax, powder and pills, in case someone gets a really bad case of the runs. In my mind, that might mean going to the washroom every 20 minutes all day, diarrhea associated with fever and chills, and diarrhea just not getting better after a day or two. On a very brief trip, I might be more prone to use the antibiotic, even just for a day, as there isn’t much time built into a seven day holiday for rest and rehab. You are welcome to unlimited probiotics! Small amounts of Imodium are also an option for mild diarrhea.

What else? Tylenol, sunscreen, insect repellent, Gravol, Polysporin, books, cashews, baby powder, puzzles, a hat, sunglasses and a passport.

Zika, dengue fever, chikungunya and even malaria are likely all a threat in Cuba. We will apply our DEET containing repellent, probably less than religiously. No more children or grandchildren on the horizon from this group, so the precautions regarding future pregnancy are not an issue. There is a new non-DEET based repellent called Icardin, or Picardin. It is now available at Mountain Equipment Coop, in Canada, for the less DEET-inclined.

These days, I tend to worry more about accidents and injuries in my patients than exotic infectious diseases. We will watch our steps, as I would advise you to do as well.

I have outgrown the need to shop for others on my vacations. My closet is full of colorful clothing from Burkina Faso and pillow covers from Rajasthan that have gone unwanted. But I do have a friend in need of some Cuban cigars. Nothing better than a trip with a mission!

BOATdadpiano

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a musical interlude

February 19th, 2017 · Comments Off on a musical interlude · Uncategorized

When not talking about diarrhea and yellow fever vaccine shortages, I enjoy playing squash (singles and doubles) and piano. They have much in common with each other, and life. Here is a sample of my piano… Blue in Green, by Miles Davis, or perhaps Bill Evans.

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Yellow fever vaccine shortage … again!!!!

February 1st, 2017 · Comments Off on Yellow fever vaccine shortage … again!!!! · Uncategorized

February 1, 2017

 

Dear Travel Patients,

 

There is currently a shortage of YELLOW FEVER vaccine, across Toronto, Canada and the world. This also occurred recently in the summer of 2016, due to production problems and outbreaks in Africa. There is a new outbreak in Brasil. At that time, WHO (World Health Organization), along with CDC (USA) and PHAC (Canada) developed the following regulations and recommendations:

 

  1. Doses of 0.1 cc, rather than the usual .5 cc, have been shown to be perfectly effective in preventing yellow fever.
  2. In the event of a shortage of YF vaccine, the smaller dose should be used in order to conserve supplies and to vaccinate and protect the maximum number of travellers.
  3. In view of a lack of longer term studies, this smaller dosage, for the time being, should be considered protective for at least 1 year, rather than the lifetime duration of the full dose of vaccine.
  4. Everyone receiving either dose of vaccine will receive the YELLOW CARD showing that you have been immunized.
  5. Because of logistical reasons, it may be necessary to “clump” people receiving the YF vaccine together.
  6. People who are not at risk of YF, or those with additional medical conditions or those over 60, should discuss with their provider as to whether YF vaccine is warranted.
  7. Recall that it is now felt (by WHO) that previous yellow fever vaccine confers lifetime immunity.

Further information regarding this issue can be found on my website/blog (www.drwisetravel.com – May 2016), at CDC, WHO and PHAC.

Mark Wise MD DTM&H (London)

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My family practice

January 29th, 2017 · Comments Off on My family practice · Uncategorized

Travel medicine aside, here is what I have written to my family practice patients this new year.

 

Dear Patients,

I hope this letter finds you rested from the holidays and in good health. I realize, being your doctor, that this unfortunately might not be the case. My family is well, including my four wonderful grandchildren, now aged two to eight. When I am not in the office, I can usually be found at Tim Horton’s, the library, at a piano, playing squash or asleep in bed.

I hope you appreciate my staff as much as I do – Indi, Lilliana, Karon and Dolly. I think they are the kindest and best at what they do.

I wasn’t sure what to write this year. I also wasn’t sure if anyone reads these letters, as I get very little in the way of feedback. In any case, let me list for you the most commonly heard comments and questions that I get in my office. Next year I will provide the commentary on each one!

  1. But I never had this before.
  2. Why is it just on one side?
  3. Is it my age?
  4. Is it contagious?
  5. I saw this on the Internet!
  6. So you’re saying there’s nothing wrong?
  7. My naturopath / chiropractor / massage therapist says I need all of this blood work / an MRI.
  8. Shouldn’t I be on an antibiotic?
  9. Do I really need all of these pills?
  10. You know …the little green ones!
  11. But I got the flu after the flu shot.
  12. But I can’t afford it (physiotherapy, counselling, medications …).
  13. What do you mean my appointment isn’t until May?
  14. Are there any side effects?
  15. Do I need to take all of these vitamins?
  16. When are you planning to retire?
  17. Can I e-mail you? (preferably not)

A reminder – please keep up to date, with my help, with your vaccinations (including shingles and pneumonia), and age (and sex) appropriate screening for colon cancer (FOBT or colonoscopy), osteoporosis (BDM), cervical cancer (Pap smear), and breast cancer (mammogram). There is no shortage of controversy regarding screening for prostate cancer (PSA) and everything else in medicine. I am happy to discuss these issues with you.

I look forward to a good year for us all.

Mark Wise MD, DTM&H (London)

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Year End

December 25th, 2016 · Comments Off on Year End · Uncategorized

It is time to wax eloquently over the past year, with respect to travel medicine and otherwise.
It has been a good year.

While my travels are no longer far flung, I have visited Cayo Coco in Cuba, Apsley and Silent Lake Provincial Park, the Rideau Canal and Ottawa, St. Johns, Newfoundland, Kingston, and Paris. I am glad that I waited sixty-six years to see Paris. It made it that much more stunning. Playing the grand piano at the Gare du Nord stands as one of the highlights of my life. I plan to return to Cuba in March with my children and grandchildren, “before the Americans get there”, as so many of my patients say.

Travel medicine has not changed that much. We have run out of destinations and diseases, with the exception of new arrivals like Zika. Vaccine shortages have become a way of life. Mefloquine or Lariam has had a resurgence of bad publicity. No destination is immune to natural disaster or terrorism. Vaccine costs in North America continue to present a barrier for many travelers. The next meeting of The International Society of Travel Medicine is next May in Barcelona. I look forward to seeing that beautiful city, renewing old acquaintances  and finding out what is new.

In Ontario, pharmacists have now been granted the right to provide travel medicine advice and vaccines. Needless to say, in spite of my obvious bias or conflict of interest, I don’t feel that this is in the best interest of the traveler. More to say about that in the new year.

I am also a busy family doctor. My aging practice, along with its aging doctor, is overwhelmed with high cholesterol, diabetes, heart disease, addiction, aches and pains, leaky valves, cognitive impairment, depression and cancer. Wait times for diagnostic testing and specialist consultations are usually, though not always, longer than I and my patient would hope for. Guidelines, drug interactions, side effects, natural remedies and patient demands are part of my daily life. I am blessed to lie geographically halfway between Sunnybrook and North York General Hospital. I am also fortunate to have a caring and superb staff, who look after and care for me as much as my patients. That would be Indi, Karon, Lilliana and Dolly. Lesson for young doctors – surround yourself with excellent colleagues (or work alone like I have for the past 15 years), but more importantly, staff.

We are in constant conflict with the Ontario government, with only imposed solutions rather than negotiated settlements. Our health minister, himself a physician, seems to despise us. The future will likely bring more bureaucracy, more scrutiny and less freedom. No surprise that the thought of retirement marinates in my mind.

I have lost many people this year, as we have all. Family, friends, colleagues and patients. Christy Afuwape, my Nigerian travel nurse and treasured friend, passed away unexpectedly this year. I subscribe to The Globe and Mail. While I wouldn’t call it my favourite section, the Obituaries is where I turn to first, to learn about the accomplished and loving lives that people have led.

I feel fortunate to have a wonderful family, with children and grandchildren that make me proud, thankful and happy. My spare time, or perhaps my primary time, is filled with squash (the racquet sport), piano, sample here,  (jazz), coffee (double cream and sweetener), reading and dear friends. I dislike Toronto traffic and endless passwords.

I wish you a happy and health New Year, and hope some of that pleasure comes from travel.

Mark

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Getting high!

November 19th, 2016 · Comments Off on Getting high! · Uncategorized

With the legalization of marijuana just around the corner, or already there, I thought I should write about getting high. Perhaps cannabis is a cure for altitude sickness, or perhaps one just wouldn’t care if he or she has a splitting headache and is vomiting incessantly on Kilimanjaro! The following is what I give to my patients. I hope you find it useful. Please refer to the links at the end.

The High Altitude Handout

Congratulations. You are about to get high! Here is some information regarding altitude sickness (AS).

Altitude sickness may occur at levels above 7,000 feet. Your likelihood of getting AS depends upon:

  1. How high you go (especially how high you sleep)
  2. How quickly you go high (are you flying to 12,000 feet or going by bus over a few days)
  3. How well hydrated and warm you stay
  4. The amount of exertion involved (i.e hiking vs taking the train)
  5. Luck, or your personal predisposition – those who have had AS in the past are more prone; age and fitness have little to do with it

Most people will feel a bit unwell – short of breath with exertion, lightheadedness, loss of appetite at high altitudes. This should go away within a few days. Some people also experience “periodic breathing”, or trouble catching your breath at night. The types of altitude sickness include:

  1. Acute mountain sickness (AMS) – headache, nausea, vomiting – usually beginning usually within 24 hours of arriving at your new altitude. Sounds a bit like a hangover!

If left untreated or if one continues to ascend with symptoms …

  1. High altitude pulmonary edema   (HAPE) – shortness of breath at rest, trouble lying down flat, cough and blood tinged sputum … this can be fatal!!!
  2. High altitude cerebral edema (HACE) – headache, confusion, difficulty walking a straight line, coma (this can also be fatal!!!)

To minimize your risk of getting AS, either mild or severe, consider the following:

  1. Getting to your destination gradually is preferable to suddenly flying to a high altitude. One does not always have this option!
  2. Taking it easy when you reach your high altitude …. consider sightseeing around Cuzco for a day or two before you hike the Inca Trail. On your trek, go slow…go slow…go slow!
  3. Drink lots of water (preferably clean water!)
  4. Consider the local remedies such as coca tea in The Andes or garlic soup in Nepal.
  5. Keep warm.
  6. Limit the change in your sleeping altitude to no more than 1,500 feet per day, and consider a day of rest every 3-4 days (applies to longer treks in Nepal)
  7. Don’t continue to ascend with symptoms of AMS. Descend if you are very sick or not getting better.
  8. Take along Diamox (acetazolamide) to use either preventatively (start the day before ascent) or if needed. It has three side effects – you will pee more often,  you might experience some tingling in your hands, feet and around your mouth, and carbonated drinks might taste funny… It may be used just for the first few days, or continuously if you continue to climb higher.
  9. Other meds, such as Decadron (steroids, for HACE) and Zofran (an antinauseant) and nifedipine (Adalat) (for HAPE) should be reserved for the minority of climbers on more dangerous expeditions, or those who are medically responsible for others.

For further information, read my website www.drwisetravel.com or The CIWEC Clinic in Nepal – www.ciwec-clinic.com
Photos below .. Machu Picchu in person, Kili and Everest from the air!

See my blog July 2011 Machupicchumania / March 2012 re Advil!

Mark Wise MD, DTM & H

mpkilimanjaro-2everest                                                                            

 

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Paris and plantar fasciitis

November 5th, 2016 · Comments Off on Paris and plantar fasciitis · Uncategorized

As a doctor and parent and volunteer and adventurer and student, I have visited more places than most. Somehow Paris has escaped me. Last week I am happy to say that it was taken off my bucket list. Here are some of my thoughts and suggestions.

Airfares from Toronto to Europe are quite reasonable. If you are an Aeroplan member, however, the regular fare is about the same as the taxes on your “free flight”. So I used my Aeroplan miles for my hotel instead.

I used Uber for the first time. Truly a magnificent advance in service and at a lower cost. (I realize that there may be some downsides to it). Imagine if our medical system could be revolutionized in a similar way.

I stayed at the Best Western Anjou Lafayette, close to the Opera Garnier and Gare du Nord. gdnNot the most trendy location, and I was urged in advance to stay on the Left Bank, but it was a relief to get away from the tourist areas at the end of each day.

Immerse yourself in the Metro as soon as you can. Between their extensive “underground” or “subway” and buses, you can really navigate Paris with little difficulty and quite inexpensively. I bought the carnet of ten tickets, which almost lasted me five days. metro2

If you are asking for directions in a foreign country in your second language, it never hurts to get a second opinion!

There are several “passes” available, such as the Paris Pass, which will cover your transportation and admission (without the lineups) to most, though not all of the most popular attractions. I didn’t use one, and I think I came out ahead. If you do register on their website in advance, you will be blessed with daily e-mails encouraging you to sign up.

Much of Paris is free! The churches like Notre Dame and Sacre Coeur, the parks like Luxenbourg and Tulieres Gardens, walking along The Seine and sipping coffee or wine on the streets. lux1

There is no additional GST and PST (aka taxes) on stuff in Paris, and tipping is not expected. So, while Paris isn’t cheap and the Canadian dollar is a bit anemic, it’s not as bad as you may think.

Try the Batobus for a day or two. It’s relaxing, not too expensive, and a good way to get from one end of the city to the other. Yes, Paris is great for walking and you can indeed walk most of the city, but a boat or a bus or the Metro might save you time and be easier on your plantar fasciitis! img_0931

Perhaps you enjoy playing the piano, like me! There are public pianos in all of the train stations, at Charles de Gaulle airport, and Shakespeare and Company’s bookstore. Along with the Eiffel Tower and the Arc de Triomphe, finding and playing the piano at Gare du Nord was a highlight of my trip, and life!
tower3

Try and find the statue of Montaigne by the Sorbonne. toe1It is believed to be good luck for students to rub his bronze toe before an exam. The statue is not sideways in real life! From there you can visit one of the world’s great bookstores, Shakespeare and Company, to browse or tinkle their ivories or both. Next door is a pleasant café. toe

piano-cdg piano-gdn

The fallafel at L’As du Fallafel in the Marais district is really as good as they say. Don’t miss it.

I borrowed Rick Steeves’ guidebook from my local library. I would highly recommend it.

I don’t sleep on airplanes, nor do I get HBO at home. So I was well entertained by a full season of Veep on the way over, and The Night Of on the way back.

If you are planning on picking up your own wine in Paris, take along a corkscrew or get one there. There really isn’t much in the way of screwtop bottles over there.

I saw seven SLR cameras in Paris. Everyone is using a smart phone. Selfies are the norm, and selling selfie sticks seems to be a common occupation amongst newly arrived French persons.

Speaking French certainly comes in handy. Remember to say “bonjour” when you address people.

I suppose the end of October is a bit off season. It still seemed like a very crowded city, though the lineups at most attractions were short. The leaves were turning colours, just like back home.

I have a fear of heights, probably dating back to trips to New York in my childhood, and aggravated by canopy walks in Ghana with my children. That saved me shlepping up the Eiffel Tower. There is a beautiful, and free, view in all directions from the seventh floor of the Galleries Lafayette (take the escalators up). img_0990

I have never before been a fan of fine art, but the Monets, Manets, Chagalls, Van Goghs, Cezannes, Rodins and much more enthralled me with their beauty, as did the museums and galleries where they were displayed.
img_0715img_0728
You can go crazy before you go doing your research on Trip Advisor. Here you can find the best hotel, best restaurant, best crepe or croissant, piano bar, and I am sure much much more. pizza1Pretty helpful, but sometimes it’s best to stumble on your own finds, and then, if you must, review them on TA.

As the Travel Doctor, I am exhaustedly used to warning people about the food and water, the bugs and advising vaccines. None of that was necessary for Paris. I think it is the most beautiful place I have ever been.

And,  below, the best pizza in Paris, at La Villa Andrea, close to the elegant Gare du Nord.

There are several people who advised me and encouraged me to take this trip. I thank you.

Please excuse the picture layout. I don’t find this program easy!

Mark

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