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COVID-19 Vaccine Side Effects

COVID-19 Vaccine Side EffectsLike any medication that someone might be prescribed, people will no doubt have questions about any potential side effects that may be attributed to them. That is also no different when it comes to the vaccines that are available to help prevent COVID-19. While there are certain risks that have been associated with the vaccines – most notably AstraZeneca and Johnson & Johnson, where there have been reported cases of rare blood clots associated with both – the vaccines are, overall, generally well-tolerated, and health officials worldwide continue to watch for any reports of adverse events associated with these particular vaccines (in addition to the Pfizer and Moderna vaccines) and act accordingly.

When it comes to side effects associated with the COVID vaccines, this is not unheard of. In fact, it’s more common to experience mild side effects as a result of receiving a vaccine than not. Among some of the most common side effects associated with the COVID-19 vaccines include:

• Pain or swelling around the site of injection
• Mild fever and/or chills
• Nausea and/or vomiting
• Headache
• General body aches and pains

These symptoms will usually develop within the first day or two following your vaccination and will typically last for up to 2 or 3 days (although in some cases they may last longer.) These symptoms are nothing to be alarmed about and are a sign that your body recognizes the vaccine and is developing an immune response – in other words, it’s doing what it is supposed to be doing. If you received the Pfizer, Moderna or AstraZeneca vaccine, you will also be required to receive a second dose for adequate protection from COVID-19. As such, you can expect to experience these same symptoms following your booster shot. However, it’s not uncommon for symptoms to be more intense after receiving the second vaccination. This is because the body’s immune response following the first dose is usually quite strong – and, as a result, the cells in your body are already prepared to respond. That being said, not everyone will develop side effects to the vaccine – however, this doesn’t mean that your immune system is not responding. Whether someone does or doesn’t develop side effects generally depends on how robust one’s immune system already is. For example, a younger person’s immune system tends to be more robust than that of someone who is elderly – therefore, side effects may be felt as a result.

If your side effects persist after 7 days, you should consult with your physician. Furthermore, while these mild, temporary flu-like symptoms are to be expcted, COVID-19 vaccines do not cause side-effects such as sore throat, couching, or chest pain – and these could be indicators of other illness, such as a viral infection, or even COVID-19 itself. As it takes several weeks before your body to become protected by the vaccine, it’s still possible to develop COVID-19 even after you’ve been vaccinated. Therefore, if you are experiencing any other symptoms, you should book a COVID-19 test and self-isolate until you receive your results and you are without symptoms.

The Health Triangle

The Health Triangle | Dr. Ali GhaharyThere are three main aspects when it comes to our overall health and wellbeing:

• Physical health
• Mental health
• Social health

This is also referred to as “the health triangle.”

When it comes to your physical health, there are several key aspects that we all need to take into consideration. For example, we need to ensure that we’re getting enough sleep. Maintaining a regular sleep cycle is important as adequate sleep us what helps us to stay alert and focused through the day. When you don’t get enough sleep, this can lead to an increase in fatigue and sluggishness, in addition to having problems concentrating, as well as increased susceptibility to illness as your immune system can become compromised. Staying physically active is another important part of our physical health. You don’t have to engage in high-impact exercise every day, but it’s important that you keep yourself moving – whether it’s going for a walk each day, or engaging in low-impact fitness (i.e., yoga) in the comfort of your own home. In order to stick to a regular fitness routine, it’s important to find an activity you enjoy doing. You also need to make sure you have a healthy, well-balanced diet. In particular, fruits and vegetables, lean meats, and whole grains – as well as drinking plenty of water These particular foods provide the body with the essential nutrients it needs in order to thrive.

It’s also important to prioritize and protect your mental health. While sleep is an important factor for our physical health, it’s also important for mental wellbeing for the same reasons mentioned above – in addition, if you don’t get proper sleep, you may also find yourself increasingly agitated or angry. Exercise can also improve mental health by alleviating low self-esteem and reducing things like anxiety and depression. To further improve mental health, you can benefit from practicing new skills, being mindful, as well as helping others. Staying in tune with your mental health is important and something that everyone should practice. If you are struggling with your mental health, it’s important to reach out to someone you trust as well as utilize the different resources that are available.

Lastly, social health. This isn’t typically something that people will often consider as being part of their health, but it can play a significant role in your overall wellbeing. Social health can relate to everything from how you adapt in certain social situations, to your ability to form relationships and how you get along with others. Unfortunately, during the COVID-19 pandemic, much of the social interaction that we’re used to having has been significantly reduced or cut-off all together. For some, this has led to an increase in anxiety and depression. While you may not be able to spend time with people face to face right now, it’s important to continue social interactions in other ways – such as through e-mail, text message, and video chats.

Stigma and Mental Illness

If we have any type of illness or broken bone, our natural instinct is to seek treatment. When it comes to mental health, however, one study found that, globally, as many as 70% of people with mental illness did not receive treatment – and there are many factors that go into why someone might avoid or delay getting that help – including lack of knowledge surrounding mental illnesses, lack of knowledge surrounding how to access treatment and the resources available to them, as well as the stigmatizing of those diagnosed with mental illness constantly have to face, which can lead to feelings of shame, fear and hopelessness. Stigma also commonly leads to discrimination, which can be subtle or direct. For example, someone might make a negative remark about mental illness, or they may try to intentionally avoid you because they might consider you unstable or dangerous due to having a mental illness. In addition to causing one to avoid seeking help, the harmful effects associated with stigma also include causing one to have fewer opportunities for things like work, schooling, or social activities, as well as an increase in experiencing harassment, bullying, and physical violence.

When it comes to reducing stigma, it’s important to be educated about mental illness. The Centre for Addiction and Mental Health (CAMH) has a large course site that features different tutorials on mental health, including depression and addiction, that you can find by clicking here. It’s also important for everyone to be aware of their attitudes (such as judgemental thinking about mental illness) and actions surrounding mental health, and to choose words carefully (i.e. avoid using negative adjectives when discussing mental health conditions) – as depending on how one speaks about mental health, this can have either a negative or a positive impact on those who are struggling. If you know someone who is having a difficult time, always remember to show compassion and offer them as much support and encouragement as you can.

While you may be reluctant to reach out for help, don’t let stigma or the fear of being labelled with a mental illness prevent you from getting the help that you need. Speaking to someone you trust, such as a friend or a family member, is important in getting the support you need. It’s also equally as important to discuss how you’re feeling with your physician. By reaching out for help, this puts you on the right path towards identifying the underlying cause of what might be troubling you, receiving a proper diagnosis, and getting the right treatment. It can also be helpful to join a support group which are offered by various local programs and are not only available to those who are diagnosed with a mental illness, but also available for families and to the general public. Speaking out against stigma and expressing yourself in writing or by speaking at events can also be therapeutic, as well as a way to ingrain hope and courage in individuals who may be facing similar challenges, and a way to help further educate the public about the importance of taking care of their mental health.

If you or someone you know is struggling, immediate help is available from the below resources:

Crisis Service Canada – www.crisisservicecanada.ca
1-833-456-4566 (or by texting 45645)

Kids Help Phone – www.kidshelpphone.ca
1-800-668-6858 (or by texting “CONNECT” to 686868)

You can find more mental health and wellness resources here.

COVID-19 Q&A: Part 13

“When am I eligible for the COVID vaccine?”
Vaccine rollouts vary from province to province. Here in British Columbia, the COVID-19 vaccine rollout happens in four different phases. Currently, our province is in phase 2 of its immunization plan. You can learn more about British Columbia’s immunization plan and eligibility by clicking here.

“How do I book my COVID vaccine?”
Seniors will need to call to book their COVID vaccine. Vaccine call centres are open 7 days a week from 7 AM to 7 PM PST. The number you need to call will be based on the region that you reside in.

Fraser Health: 1-855-755-2455 (or book online by clicking here)
Vancouver Coastal Health: 1-877-587-5767
Interior Health: 1-877-740-7747
Northern Health: 1-844-255-7555
Island Health: 1-844-348-4787

“Can I set up a vaccine appointment for a friend or family member?”
If you know someone who might have trouble with calling to book their own COVID vaccine appointment, you are certainly able to call on that individual’s behalf as long as you provide their first and last name, date of birth, postal code, and personal health number. You may also be asked to provide an e-mail address or cell phone number so that a confirmation message can be sent.

“How many types of vaccines are available, and can I choose which one I get?”
Currently, there are four different types of COVID-19 vaccines available, including:

• Pfizer-BioNTech
• Moderna
• AstraZeneca
• Johnson & Johnson

However, you won’t be able to choose which vaccine you receive. Instead, it is recommended that you take the vaccine that is offered to you. Each of these vaccines have been approved in Canada and are considered to be safe and effective.

“What should I expect once at the vaccine clinic?”
Once at the vaccine clinic for your scheduled appointment, you will complete a check-in process where your personal information will be confirmed. You will then receive your first dose of the COVID-19 vaccine. Once the vaccine has been administered, you will then be asked to wait in an observation area for approximately 15 minutes to ensure you are feeling okay and have no adverse reaction. In total, you can expect to be at the vaccine clinic for approximately 30 to 60 minutes.

“Can I stop wearing a mask once I have been vaccinated?”
Even if you have been vaccinated against COVID-19, it’s important to continue to follow public heath orders (such as mask wearing and physical distancing when in public settings.) While the vaccines are considered effective, they don’t provide 100% immunity from the virus – and even those who are vaccinated could be asymptomatic spreaders and may pass it on to those who are not vaccinated and at higher risk of contracting COVID-19. It also takes some time before the vaccine itself actually kicks in and starts doing what it’s supposed to do in terms of protecting you from COVID-19.

COVID-19: One Year Later

On March 11th, 2020, the WHO (World Health Organization) officially declared COVID-19 a global pandemic. Below is some insight into how the virus has impacted Canadians, how it has shaped the way we live our lives, how vaccines are now crucial in helping prevent transmission, and what we can take from everything we’ve learned in the last year as we move forward.

First Case of COVID-19 in Canada

The first case of SARS-CoV-2 was found in a Toronto man who had recently travelled to Wuhan, China – the epicentre of the COVID-19 outbreak – and was announced by Health Canada on January 25th, 2020. As a result, new screening measures were implemented at several Canadian airports (Vancouver, Toronto and Montreal) for any passengers who were exhibiting flu-like symptoms.

On January 28th, 2020, British Columbia became the second Canadian province to confirm a case of COVID-19 – also related to travel. On March 5th, 2020, B.C. announced its first case of community transmission, followed by a State of Emergency declaration on March 18th (which remains in effect.)

Social Connections, Shutdowns and Travel

As scientists learned more about COVID-19, it was discovered that one of the easiest ways the virus was transmitting was through having close contact with an infected individual – through respiratory droplets and aerosols that are created when the infected person talks, coughs, sneezes, shouts, sings, etc. While we were all used to having close social connections with others – whether at work, home, school, or elsewhere in the community – those very social connections had to be significantly limited, with the recommendation that individuals keep at least 6 feet (2 metres) apart from others. As the virus progressed, health orders were put in place across many Canadian provinces and other parts of the world that limited or restricted social gatherings and who we could spend time with.

Many popular events, such as Vancouver’s PNE (Pacific National Exhibition), as well as live concerts, did not go as planned and had to be cancelled or postponed indefinitely, while retailers closed temporarily, and restaurants switched to a takeout-only model. For a list of British Columbia’s current restrictions, click here.

When it comes to travel, several provincial and territorial restrictions are in place along with other Canadian border restrictions. In British Columbia, it is recommended that non-essential travel be avoided for the time being.

The Impact on Mental Health

With certain restrictions in place, many individuals found the lack of social connection with others to have a significant impact on their mental health – exacerbating things like stress and anxiety, as well as causing individuals to feel isolated. As a result, Canada saw a significant uptick in requests for mental health services. If you or someone you know is struggling with their mental health, the Canadian Mental Health Association has a list of national programs and services available on their website at CMHA.ca.

Vaccines

The vaccines created to help prevent the spread of COVID-19 were some of the quickest that any vaccine had been developed. While there are several different types of COVID-19 vaccines, those currently approved for use in Canada include the Pfizer-BioNTech vaccine, Moderna vaccine, the AstraZeneca vaccine, as well as the Johnson & Johnson vaccine – with others under review. Each province has its own vaccine plan. You can find British Columbia’s vaccine plan, and information on how to register for your vaccine, by clicking here.

Preventing Nausea

Preventing Nausea | Dr. Ali GhaharyNausea can be a symptom that is associated with many different illnesses. Atop the list of most common include things like influenza (flu), food poisoning, headaches and migraines, as well as taking certain medications, cancer treatment (i.e., chemotherapy), drinking alcohol, overeating, and pregnancy. While nausea typically isn’t considered life threatening without other warning signs (i.e., chest pain – which you should call 911), it can cause unease and be quite debilitating. There are certain conditions where nausea may also co-occur with vomiting, such as concussions, meningitis, encephalitis, appendicitis, intestinal blockages, as well as brain tumours. If you suspect that your nausea/vomiting may be attributed to any of these things, then you should seek medical attention right away.

It’s also important to be aware that if you’re also vomiting, this can lead to dehydration. When it comes to dehydration, the signs in children and adults slightly differ. Children may develop dry lips, a dry mouth, sunken eyes, or have a rapid pulse and/or rapid breathing; while adults may feel fatigued, confused, or dizzy, as well as have dark-coloured urine or infrequent urination. To prevent dehydration, it’s important to increase your intake of fluid – especially water. In cases where dehydration is severe, you may require hospitalization for a fluid intravenous drip.

For cases where nausea and/or vomiting is mild, the good news is that there are some simple at-home and over-the-counter treatment methods that you can try to help make it subside.

Over the course of many decades, scientists have discovered that ginger stabilizes your digestive function as well as keeps your blood pressure at healthy, consistent levels which can ultimately help reduce that uneasy feeling. Because of this, ginger has become one of the most common and long-used – as well as safest – natural treatment methods for relieving nausea. Another food product that can help quell a queasy stomach are saltine crackers. Saltine crackers are high in starch, which can help absorb the stomach’s gastric acid. People also find them easy to digest when they feel sick as they’re void of strong smells or tastes that might otherwise cause one to feel increasingly nauseous. That being said, food of any kind may not be appetizing when you’re dealing with nausea. If that’s the case, you should keep yourself hydrated with clear liquids – either by drinking water or chewing on ice chips.

If trying some of the remedies mentioned above does not help ease your nausea, there are also certain medications that can help. Bismuth subsalicylate, which can be bought over the counter, is most commonly taken in liquid form and helps protect the lining of your stomach; while anti-medications like Dramamine and Ondansetron, available by prescription, can also both help to prevent nausea and reduce vomiting.

How Sleep Impacts Your Health

How Sleep Impacts Your Health | Dr. Ali GhaharySleep is one of the most important things you can allow your body to do. It doesn’t just improve your mental health – it improves your physical health, too, and can significantly reduce your risk of developing serious illness. In fact, getting adequate amounts of sleep each night is just as important as ensuring you get regular exercise each day as well as have a healthy, well-balanced diet. When you don’t get enough sleep, your body will give off warning signs. For example, you might feel lethargic the next day, be unable to follow through on important tasks, an inability to concentrate, and have poor performance at work or school. While failing to get seven to eight hours of sleep on a few occasions may seem insignificant in the grand scheme of things, it can become a serious problem over time and can have quite the domino effect on your health, putting you at an increased risk of certain medical conditions such as obesity, heart disease, high blood pressure, and diabetes – all of which can significantly reduce your quality of life, or even be fatal. Your immune system is also impacted by how little or how much sleep you get. When you don’t get enough sleep, your immune system can weaken. As a result, this makes you much more susceptible to developing viruses like the common cold, influenza, and even COVID-19.

Along with our physical health, sleep also plays a crucial role when it comes to our brains. As mentioned, you may experience issues with concentration or have what’s often referred to as “brain fog.” Inadequate sleep can also lead to problems with both short and long-term memory, as well as problem-solving skills. In addition, it can also affect your mental health. When you aren’t getting enough sleep, you may become more emotional, be quick-tempered, as well as develop anxiety or depression. If you are someone who is already struggling with their mental health, lack of sleep can exacerbate psychological problems.

In many cases, people often don’t realize just how important it is to get enough sleep. While you might be used to getting a shorter amount of sleep than what’s recommended, what you’re not able to see is the underlying negative build-up that it is potentially having on your overall health. That being said, there are also many common reasons why someone might not be getting enough sleep (that can easily be fixed), with technology being one of the biggest culprits. Things like computers, tablets, smartphones, and televisions emit blue light which can disrupt the brain’s production of melatonin, making it harder for you to fall (and stay) asleep. To prevent this, you should avoid using these types of devices at least two hours before going to bed. In addition, it’s also not recommended that you have a TV in your room, as this can be a distraction that prevents you from getting the sleep you need.

Your diet can also play a role in how much sleep you’re getting or not getting. Data has shown that those who consumed unhealthy foods that were high in sugar and saturated fats tended to have inadequate sleep compared to individuals who had healthy, well-balance diets that were rich in vitamins and minerals (i.e., fruits and vegetables.) To make sure you’re not kept awake at night you should also avoid caffeine, as this is a stimulant and can cause disruption to your sleep cycle.

By making small lifestyle changes, you should be able to improve your sleeping habits. If you’re still having difficulty sleeping, whether it’s having trouble actually falling asleep or feeling like you’re not getting enough of it, you should discuss this with your physician.

Open-Angle Glaucoma

Open-Angle Glaucoma | Dr. Ali GhaharyYour eyes are one of the most important parts of your body. As such, seeing your optometrist for regular eye exams is important to ensure optimal eye health and rule out any eye disorders and diseases that could have an impact on your vision, such as refractive errors, cataracts, diabetic retinopathy, age-related macular degeneration, and more.

Another common eye condition, known as glaucoma, affects as many as 400,000 Canadians and 80 million people worldwide. Glaucoma can occur in people of all ages – including babies and teenagers, as well as younger and older adults. However, certain individuals are at higher risk of developing glaucoma than others. Some of those risk factors include the following:

• Being over the age of 60
• Race
• Having high intraocular pressure
• Extreme nearsighted or farsightedness
• History of eye injuries
• Previous eye surgery
• Certain medical conditions (i.e., heart disease, diabetes, high blood pressure, sickle cell anemia.)
• Certain medications (i.e., corticosteroids)
• Having a family history of glaucoma

There are also different types of glaucoma that one can be diagnosed with. These include open-angle glaucoma, angle-closure glaucoma, normal-tension glaucoma, congenital glaucoma, and other variants (such as secondary glaucoma, pigmentary glaucoma, pseudo-exfoliative glaucoma, traumatic glaucoma, neovascular glaucoma, uveitic glaucoma, as well as irido corneal endothelial syndrome.)

Open-angle glaucoma (also known as primary or chronic glaucoma), the most common form of glaucoma to be diagnosed (accounting for as many as 90% of all cases), tends to develop slowly. As a result, it is also one of the most commonly undetected forms of glaucoma – particularly in its early stages – as it is typically painless, and therefore an individual may not initially realize they have it until it has moderately progressed. In order to accurately diagnose open-angle glaucoma, it is recommended that pupil dilation is done during an eye exam. To do this, eye drops will be administered which will increase the size of the pupils so your doctor or optometrist can properly examine the health of your eyes – including the optic nerve and retina. Another test that is often done to help detect any changes in your peripheral vision and to diagnose glaucoma is something called visual field testing. For this particular type of test, you will be seated in front of a machine and asked to stare ahead at different blinking lights (with one eye covered at a time.) If it has been confirmed that you have glaucoma, this is a test that will usually be repeated to determine if your glaucoma has stabilized or if it is getting worse.

While glaucoma cannot be reversed, there are certain things you can to do help slow vision loss if caught early enough. The most important thing when treating glaucoma is to lower your intraocular eye pressure. The most common treatment method for this usually begins with prescription eyedrops; while other treatment methods may include oral medications, or, in some cases, laser treatment or surgery. Different foods and food components have also been linked to increased intraocular pressure, such as caffeine, trans fats, and saturated fats, so you should avoid or limit your intake of these and opt for healthier eating habits.

To learn more about glaucoma and how it is diagnosed and treated, visit the Glaucoma Research Society of Canada website at www.glaucomaresearch.ca.

If you happen to be a British Columbia resident, you can find an optometrist in your area by visiting http://bc.doctorsofoptometry.ca/find-a-doctor/.

Sensitivity to Scents

Sensitivity to Scents | Dr. Ali GhaharyCertain fragrances are something that are part of our everyday lives – whether it’s things like perfumes, air fresheners and other scented products (i.e., cosmetics, detergents), flowers, or different air pollutants and chemicals (i.e., cleaning products, pesticides, etcetera.) These are all things that we live with day to day, and for many people they will not be bothersome. However, for some individuals, they can wreak havoc and become disruptive to the point where their health may be affected.

The most common reactions that someone will have as a result of fragrance sensitivity are often respiratory or skin-related in nature.

Respiratory-related reactions may include:
• Nasal congestion
• Runny nose
• Sneezing
• Breathing difficulty (including wheezing or triggering of asthma.)

Skin-related reactions may include:
• Contact dermatitis (redness, itching, or burning of the skin.)

Other symptoms that can also occur include itchy, watery, or burning eyes, nausea, headaches, or migraines. Remember, not all fragrances will affect every individual the same way, therefore the recurrency as well as the severity of reactions will differ from person to person. It can also sometimes be difficult to pinpoint the exact cause of what’s causing the irritation; therefore, you may need to reduce or all together avoid certain products, then slowly re-introduce them one by one to get a definitive answer as to what the offending substance is and why your body is reacting to it.

Nowadays, many offices and other public places have fragrance-free policies as allergies and sensitivities to these types of substances are quite common. If you are going to be attending a place where you know other people may be, you should try to avoid wearing things like heavy perfumes or colognes. If you are someone who is sensitive to scents, you should try to avoid exposure as much as possible. Where it is not possible to avoid exposure to fragrances (i.e., in certain workplaces – particularly those where the general public may be coming in and out of), different options may be able to be explored – such as moving your workspace to a different area of the office where fragrances may be less prevalent.

If you find yourself experiencing allergic-like responses to different scents more often than not, then you may need to take a regular antihistamine to keep symptoms like sneezing, nasal congestion, and itchy, watery eyes at bay. If you experience severe discomfort or illness related to different smells/odours – even those that are mild – then you may have what’s known as hyperosmia. Hyperosmia is a condition that changes the way in which you perceive different scents, and is linked to a variety of different medical conditions including autoimmune diseases, Lyme disease, migraines, neurological conditions (including Parkinson’s, Alzheimer’s, MS, and epilepsy), and even pregnancy.

Liver Health

Liver Health | Dr. Ali GhaharyYour liver, which is located on the right side of the abdomen, is one of the most important organs in your body, and plays a critical role in your health (performing over 500 vital functions) such as:

• Metabolizing alcohol, drugs, and other chemicals
• Neutralizing and destroying poisonous/toxic substances
• Producing, storing, and supplying glucose
• Producing, storing, and exporting fat
• Transporting substances in your blood
• Clotting of your blood
• Helping the body resist infections
• Regulating thyroid, cortisone, and adrenal hormones
• Regulating cholesterol
• Aiding digestion
• Regulating the body’s supply of essential vitamins and minerals

What is Liver Disease?

Liver disease affects as many as 1 in 4 Canadians. There are several different types of liver-related diseases, including hepatitis A, B and C, fatty liver disease, cirrhosis of the liver, inherited diseases such as hemochromatosis and Wilson diseases, as well as liver cancer.

Symptoms of Liver Disease

Symptoms of liver disease will vary from person to person. In some cases, an individual may not experience any symptoms at all. However, among the most common are:

• Abdominal swelling
• Swelling of the legs
• Bruising
• Changes in color of urine and/or stool
• Jaundice (yellowing of the skin and eyes)

Risk Factors

One of the most common myths that is often associated with liver disease is that many people are under the impression that they can only get it if they drink alcohol in excess. This, however, is wrong. While heavy alcohol consumption is one of the contributing factors for liver disease and should therefore be avoided, there are also many other factors that can put an individual at risk of developing liver disease, such as having type 2 diabetes, obesity, illicit drug use/sharing needles, blood transfusions (prior to 1992), unprotected sex, and exposure to other people’s blood and/or bodily fluids.

To prevent liver diseases, it’s important to be aware of the critical role your liver plays in your overall health and wellbeing, as well as ensure you’re making healthy lifestyle choices to prevent it from occurring – such as reducing/avoiding alcohol consumption, avoid mixing alcohol with with medication (i.e., acetaminophen), getting vaccinated against hepatitis A and B, practicing safe sex, and make food choices that optimize the health of your liver (i.e., drinking 6 to 8 glasses of water each day, eating healthy meals (i.e., increased consumption of fruits & vegetables while limiting consumption of saturated fats and sugar, consuming vitamin D fortified dairy products.)

For more on liver health, visit the Canadian Liver Foundation website at www.liver.ca