Radiation... what you need to know.

Chernobyl

What radiation levels are considered safe?



The first step is to determine what your estimated annual radiation dose level is. There are many sources of radiation, some natural, and some man-made. First, let's take a look at these sources:


Cosmic Radiation


This is radiation from outer space, from the Sun and other stars. It is partly blocked by the Earth's atmosphere, so the higher your altitude, the less air is present to stop it, and the higher the levels. It varies from around 25 mrem a year at sea level, to around 50 mrem a year if you live at an altitude of 1 mile. At two miles, it would be around 100 mrem a year.


This is the reason that you get a small radiation dose when you take an airplane flight. Planes fly at altitudes of several miles, though fortunately the length of a flight is only a few hours. A typical dose rate is 0.5 mrem per hour of flight.


Terrestrial Radiation


This is due to radiation from uranium, thorium, and other radioactive materials naturally found in the soil. An average value is around 30 mrem a year, though this can be much less along the coasts, around half as much. And it can be twice as much in states such as Colorado. This USGS map shows typical radiation levels around the USA.


Inhaled Radon is estimated at around 200 mrem a year.



If you live in certain parts of the world, like certain villages in India and Brazil that have high levels of thorium in local sands, the dose rate can be much higher. Kerala, India and Minas Garais, Brazil has rates of around 1,000 mrem a year.



Radiation in Food


Foods naturally contain Carbon-14 which is radioactive, as well as Potassium, of which a small amount is radioactive. This results in an average dose of around 20 mrem a year. Also, some plants and animals naturally accumulate radioactive materials, resulting in higher than background dose rates.


You and other People


You naturally contain Potassium, Carbon-14, and other radionuclides. This makes you radioactive. To the tune of around 40 mrem a year. Other people are also radioactive, so you get slight doses from being around other people as well.


Other Sources of Radiation


Nuclear weapons fallout is estimated to be less than 1 mrem a year.


Watching TV gives you a dose of about 1 mrem a year.



Porcelain false teeth or crowns give you around 0.1 mrem a year.


While it is true that there is a slight increase in radiation does due to living close to a nuclear power plant, typically on the order of 0.01 mrem a year (insignificant), the average dose from living near a coal fired power plant is three times as high! This is due to the release of uranium/etc naturally mixed in with the coal.


If you use a plutonium powered pacemaker, your yearly dose rate is about 100 mrem. If your spouse has one, you get around 7.5 mrem a year. Apparently there are only around 100 people in the USA with such a device.


Radiation from X-Rays and Medical Tests


According to the American Nuclear Society, the following are the typical dose levels from various medical tests:


Extremity (arm, leg, etc) Xray: 1 mrem


Dental Xray: 1 mrem


Chest Xray: 6 mrem


Nuclear Medicine (thyroid scan): 14 mrem


Neck/Skull Xray: 20 mrem


Pelvis/Huip Xray: 65 mrem


CAT Scan: 110 mrem


Upper GI Xray: 245 mrem


Barium Enema: 405 mrem


OK, so total them up. You'll probably end up with around 300 mrem a year, perhaps more, if you take a lot of airplane flights, or have a lot of medical x-rays or nuclear medicine procedures.



As you can see, the major source of your radiation dose rate is due to natural sources, radon, cosmic radiation, and terrestrial radiation. Man made sources of radiation are completely swamped by these natural sources in most cases.


The average total dose rate for the USA is 360 mrem a year. It has been estimated that your chance of dying from cancer increases 10% if you accumulate a total of 250,000 mrem. This would be over 3,000 mrem a year over 80 years, for example. This estimates presumably assume a linear risk factor between dose and the chance of getting cancer, and there are those who now dispute such assumptions, which means the risks from low levels of radiation may be overstated.

http://www.blackcatsystems.com/GM/safe_radiation.html


Radiation Dose

 The dose of radiation from a chest x-ray is very small (0.25 mRad). Although this unit of measurement is probably unfamiliar, we all receive approximately 100 mRad (400 times that of a chest x-ray) yearly from cosmic rays and the trace radioactive minerals in rocks and building foundations. However, improperly used equipment can markedly increase the radiation dose. In an FDA survey, the range of x-ray exposures varied widely – one unit exposed patients to a whopping 120 mRad per x-ray!


http://www.chestx-ray.com/GenPublic/GenPubl.html


http://www.nsc.org/issues/rad/exposure.htm


http://www.nci.nih.gov/cancertopics/causes/radiation-risks-pediatric-CT (risk in children)




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Source:  http://www.blackcatsystems.com/GM/safe_radiation.html

Maine follows some European countries with Cell Phone warning

Maine to consider cell phone cancer warning



By GLENN ADAMS, Associated Press Writer Glenn Adams, Associated Press Writer


Sun Dec 20, 12:07 pm ET


AUGUSTA, Maine – A Maine legislator wants to make the state the first to require cell phones to carry warnings that they can cause brain cancer, although there is no consensus among scientists that they do and industry leaders dispute the claim.

 The now-ubiquitous devices carry such warnings in some countries, though no U.S. states require them, according to the National Conference of State Legislators. A similar effort is afoot in San Francisco, where Mayor Gavin Newsom wants his city to be the nation's first to require the warnings.


Maine Rep. Andrea Boland, D-Sanford, said numerous studies point to the cancer risk, and she has persuaded legislative leaders to allow her proposal to come up for discussion during the 2010 session that begins in January, a session usually reserved for emergency and governors' bills.


Boland herself uses a cell phone, but with a speaker to keep the phone away from her head. She also leaves the phone off unless she's expecting a call. At issue is radiation emitted by all cell phones.


Under Boland's bill, manufacturers would have to put labels on phones and packaging warning of the potential for brain cancer associated with electromagnetic radiation. The warnings would recommend that users, especially children and pregnant women, keep the devices away from their head and body.


The Federal Communications Commission, which maintains that all cell phones sold in the U.S. are safe, has set a standard for the "specific absorption rate" of radiofrequency energy, but it doesn't require handset makers to divulge radiation levels.


The San Francisco proposal would require the display of the absorption rate level next to each phone in print at least as big as the price. Boland's bill is not specific about absorption rate levels, but would require a permanent, nonremovable advisory of risk in black type, except for the word "warning," which would be large and in red letters. It would also include a color graphic of a child's brain next to the warning.


While there's little agreement about the health hazards, Boland said Maine's roughly 950,000 cell phone users among its 1.3 million residents "do not know what the risks are."


All told, more than 270 million people subscribed to cellular telephone service last year in the United States, an increase from 110 million in 2000, according to CTIA-The Wireless Association. The industry group contends the devices are safe.


"With respect to the matter of health effects associated with wireless base stations and the use of wireless devices, CTIA and the wireless industry have always been guided by science, and the views of impartial health organizations. The peer-reviewed scientific evidence has overwhelmingly indicated that wireless devices do not pose a public health risk," said CTIA's John Walls.


James Keller of Lewiston, whose cell phone serves as his only phone, seemed skeptical about warning labels. He said many things may cause cancer but lack scientific evidence to support that belief. Besides, he said, people can't live without cell phones.


"It seems a little silly to me, but it's not going to hurt anyone to have a warning on there. If they're really concerned about it, go ahead and put a warning on it," he said outside a sporting good store in Topsham. "It wouldn't deter me from buying a phone."


While there's been no long-term studies on cell phones and cancer, some scientists suggest erring on the side of caution.


Last year, Dr. Ronald B. Herberman, director emeritus of the University of Pittsburgh Cancer Institute, sent a memo to about 3,000 faculty and staff members warning of risks based on early, unpublished data. He said that children should use the phones only for emergencies because their brains were still developing and that adults should keep the phone away from the head and use a speakerphone or a wireless headset.


Herberman, who says scientific conclusions often take too long, is one of numerous doctors and researchers who have endorsed an August report by retired electronics engineer L. Lloyd Morgan. The report highlights a study that found significantly increased risk of brain tumors from 10 or more years of cell phone or cordless phone use.


Also, the BioInitiative Working Group, an international group of scientists, notes that many countries have issued warnings and that the European Parliament has passed a resolution calling for governmental action to address concerns over health risks from mobile phone use.


But the National Cancer Institute said studies thus far have turned up mixed and inconsistent results, noting that cell phones did not come into widespread use in the United States until the 1990s.


"Although research has not consistently demonstrated a link between cellular telephone use and cancer, scientists still caution that further surveillance is needed before conclusions can be drawn," according to the Cancer Institute's Web site.


Motorola Inc., one of the nation's major wireless phone makers, says on its Web site that all of its products comply with international safety guidelines for radiofrequency energy exposure.


A Motorola official referred questions to CTIA.


[More on this in an upcoming article by Dr. Saleeby on EMF Radiation]

No End in Sight for Doctor Shortage

AOL News

(Dec. 16) -- The nation is short of thousands of primary-care doctors. Medical schools plan to add 3,000 first-year students by 2018, but that won't be enough to meet the need, according to a report from Bloomberg.com.

Though schools plan to educate more doctors, the demand for physicians is expected to soar if Congress passes a health care reform plan aimed at getting insurance to 31 million more Americans. The bill is being debated at a time when government-funded training for doctors has been frozen for 12 years, Bloomberg reported.

Skip over this content

Joe Raedle, Getty Images

A doctor, center, speaks during a cardiology class at the University of Miami. Medical colleges have added 1,500 seats since 2005 and plan to add 3,000 more by 2018.

"Do the math," said Steven Safyer, president and chief executive officer at New York's Montefiore Medical Center. "You give millions more people insurance, and it adds up to a much worse shortage."

Ed Salsberg, an official with the American Association of Medical Colleges, told the news service that the nation may be short of 159,300 doctors across all practice areas by 2025.

How should the shortage be resolved? Medical school officials have differing opinions. Read about them at Bloomberg Report.

ORAC

goji berries

ORAC

by JP Saleeby, MD

ORAC or Oxygen Radical Absorbance Capacity is a unit of measurement that gives us a value or score on different foods and supplements as to the free-radical or oxidative load fighting capacity.  Those with higher ORAC units have a better antioxidant effect than those with lower scores.  The ORAC scale was developed by scientists at the national Institutes of Health, and while the exact relationship between a food's ORAC value and its health benefit has not yet been well established, it does imply that a higher score does more effectively reduce oxidative load.  Oxidative load or free-radicals are what is theorized in the free-radical theory of aging (as proposed by Dr. Denham Harman) as the causative agent for degenerative disease ranging from arthritis to coronary disease and cancers.  For a rather extensive list of ORAC values of foods and supplements visit www.oracvalues.com.

A few examples include:

Vitamin A  1.25 mmTE/g
Vitamin E  1.25 mmTE/g
Lycopene  58 mmTE/g
Astaxathin  51 mmTE/g
coQ10  11 mmTE/g
Chia  70 for white seed and 98 for dark seed mmTE/g
Krill  378 mmTE/g

More on ORACs to follow


source:  http://www.oracvalues.com/

Leptin: Good for the Brain & Midsection

Leptin

by JP Saleeby, MD

Leptin is a protein hormone seeing a lot of attention recently in the press.  The December 16th, 2009 issue of Journal of American Medical Association (JAMA) published an article relating Leptin levels and the incidence of Alzheimer's disease.  Leptin has in recent years been linked to obesity and fat metabolism.  The word leptin is derived from the Greek word leptos which means thin.  It is a 16 kilodalton protein derived from adipose tissue and associated with the Ob(Lep) gene on chromosome 7 in humans.  One of the main functions of Leptin is that it relays a message to the brain satiety centers when fat stores are low as seen during starvation.  Leptin levels respond quite rapidly going up when we over-feed and put on more adipose tissue and drop when we under-feed and loose adipose tissue.  The brain's response to this chemical messenger when we drop body fat and levels ofleptin are reduced is to shut down our satiety centers causing us to overeat.  This feed back system is what most researchers feel is responsible for theyoo-yoo dieting problems of "keeping the weight off" when we drop a lot of fat while dieting and exercising. 

In 2005 Dr. Rosenbaum and his team of researchers published research in the Journal of Clinical Investigation showing that injections of leptin in those fasting kept them from gaining back the unwanted fat after they had dieted.  Leptin's primary goal then is to defend and support body fat stores by increasing food seeking behavior when levels are too low.  The more fat cells you have the higher your leptin levels are.  It would be great to have a "leptin pill" that you could take to help thwart the rebound weight gain one often sees after dieting.  However, this is impractical for several reasons.  One, leptin in a pill form is useless as stomach acids will quickly destroy it before it gets absorbed.  Injecting leptin would be the alternative, but one would have to do it daily and for life to avoid weight gains and this would be cost prohibitive.  The way around this would be to "trick" the body into believing it was well fed by having "cheat days" or overfeeding days once or twice a week to produce enough leptin in the blood stream to prevent an over-eating frenzy.  According to the JAMA study with regards to serum leptin levels and Alzheimer's disease, it was shown that circulating leptin was associated with a reduced incidence of dementia and Alzheimer's disease in normal older adult test subjects.  Further research will be needed to determine how we can maintain health levels of leptin for our brains without having to become obese in the process.

References: 

Wolfgang, L., et. al, Association of Plasma Leptin Levels with Incident Alzheimer Disease and MRI measures of Brain Age., JAMA 2009;302(23):2565-2572

Rosenbaum, M. et. al, Low-dose leptin reverses skeletal muscle, autonomic, and neuroendocrine adaptations to maintenance of reduced weight., J. Clinical Investigations 2005;115, 3579-86

----------

Addendum:

The herbal Garcinia cambogia was shown in a 2003 study by Dr. Hayamizu, et. al. studying the effects of G. cambogia extract on serum leptin and insulin in mice found that this extract has leptin like effects.  G. cambogia also known as Brindle Berry the rind of which is uses in India as a component in curry may be helpful as a leptin like modifier and weight loss supplement as one of its components is hydroxycitric acid (HCA) which in other studies has shown to reduce weight in subjects. Further trials will be necessary to prove effectiveness and safety since there are issues with HCA and hepatoxicity.  Although a study by Dr. Stohs, et. al as recently as the summer of 2009 showed no evidence of toxicity with HCA.

~JP 

Krill Oil Article

Krill Oil the New Omega-3FA Benchmark

By JP Saleeby, MD

Krill oil is an Omega-3 Fatty Acid (n-3FA) rich oil harvested from a very small marine crustacean.  Krill are small shrimp like animals ranging from about ½ to 2 inches in length and are one of the most abundant animals in the ocean.  Krill is at the bottom of the ocean’s food chain and are eaten by a host of other animals from fish to squid to seals and whales.  They in turn feed on phytoplankton which occupies the bottom rung of the food chain.  The commercial fishing of krill occurs primarily in the northern Pacific Ocean and southern oceans along the coasts of Canada and Japan.  In Japan, krill is fished directly for food and is considered by the Japanese a delicacy called okiami.  But other commercial uses include use in aquaculture, sport fishing bait and the production of very high quality n-3FA oils.

In addition to it useful source of a high quality, krill oil shows a lower contaminant level of heavy metals and toxins.   For this reason n-3FA is becoming popular as a supplement.  Another reason is because of a unique antioxidant that it contains.  Astaxanthin is a type of antioxidant that occurs in this marine animal that can protect the human body from the damages of free radicals and oxidative load.  The characteristic red-pink color attributed to krill and other crustaceans (like shrimp and lobster) comes from the red pigment in astaxanthin, and is due to the type of algae that the krill ingest.

As we know, antioxidants protect our body from harmful highly reactive substances called free-radicals that are implicated in human disease and degenerative disorders.  One unique property of astaxanthin not found in many of the other antioxidants is that it crosses the blood-brain barrier, thus protecting the brain, eyes and our central nervous system where other antioxidants cannot.

Krill oil may become a favorite for those supplementing with n-3FAs as it may be preferred over fish oil (derived from a higher food chain ocean animal) that can accumulate higher levels of mercury and other toxins because they live longer.  Another reason is because krill oil does not come with the fishy taste often associated with fish oil.  Flax oil is a vegetarian form of n-3FA but there are those people who do not possess a critical enzyme that converts the substrate fatty acid to the desired n-3FA.  Remember, krill oil also contains a higher amount of astaxanthin than does fish oil.  Flax seed oil contains no astaxanthin.

Krill oil in one scientific study of 120 people with elevated LDL-Cholesterol compared with placebo showed a reduction in LDL by 34% and an increase in HDL (good cholesterol) by 43.5%.  When fish oil was compared it had less of an effect on LDL and HDL.  Krill also was shown to lower Triglycerides.

Pro-inflammatory conditions such as the discomfort common in premenstrual syndrome and arthritis were relieved by krill oil.  Krill oil at a dose of 300mg daily was effective in reducing arthritic symptoms in a study published in the Journal of American College of Nutrition.

Those with allergies to seafood should use caution when taking krill oil as there may be reactions.  With the use of any n-3FA, one can realize an increase in bleeding time and thus those on blood thinners or those going in for elective surgery should refrain from use.  Additionally, people using blood thinners, anti-platelet medication or NSAIDs must use caution and only use high doses of krill oil under physician supervision.  Herbs such as garlic, ginkgo biloba and ginseng can also increase bleeding times.

_References:

_{Bunea R, El Farrah K, Deutsch L.Evaluation of the effects of Neptune Krill Oil on the clinical course of hyperlipidemia. Altern Med Rev. (2004) 9.4: 420-428.}

_{Deutsch L. Evaluation of the effect of Neptune Krill Oil on chronic inflammation and arthritic symptoms. J Am Coll Nutr. (2007) 26.1: 39-48.}

http://altmedicine.about.com/od/herbsupplementguide/a/krilloil.htm (last viewed 12/15/2009)

Sharon makes news in AARC.org

		Good Press: AARC Members in the News December 10, 2009 Check out our latest list of newsmakers— Deborah Pierce Dan Conyers Walt Wilson Janyth Bolden Joe Conley Robin Miller Lawrence Johnson Rick Carver click to link to Dr. Saleeby's web site Sharon Saleeby Walt Garant David Goswick Jody Adkins John Murray Joseph Sorbello Jim Perrine comments on a free COPD awareness event held at his hospital in this article in the Huntington, WV, Herald Dispatch. "A lot of people who have COPD aren't aware of their problems until they actually have a screening for it," he was quoted as saying. Ed Newton is noted for conducting pulmonary function tests during a health fair in this article in the Bainbridge, GA, Post-Searchlight. Deborah Pierce is cited as one of two keynote speakers for a program on COPD in this article in the Battle Creek, MI, Enquirer. Monica Moore comments on CPAP for the treatment of sleep apnea in this article on the WSBT-TV web site out of Mishawaka, IN. “Some people notice a change right away. They'll call the next day and say they haven't slept that well in a long time,” she was quoted as saying. Dan Conyers is noted for his appointment to the Respiratory Care Council in Kansas in this article on the WIBW web site out of Topeka, KS. Kate Collins is featured for being on hand at a local farmer’s market in this article in the Martha’s Vineyard Times out of Vineyard Haven, MA. Harlan Hanson comments on the benefits of quitting smoking in this article on the KPTH-TV web site in Dakota Dunes, SD. "The minute you quick smoking, the little cilia in your lungs come back to life and start cleaning your lungs back out," he was quoted as saying. Mark Lotz is noted for giving a talk on sleep to a heart disease support group in this article in the Hannibal, MO, Courier-Post. Walt Wilson writes about a partnership between his RT educational program and school nurses in this articlein the Natchez, MS, Democrat. Tammy Kurszewski, Ann Medford, and Jennifer Gresham talk about a “Bowling with Cold Turkeys” event they held to support the Great American Smokeout in this article and video on the KAUZ-TV web site out of Wichita Falls, TX. (Stay tuned to AARC Times for more on this unique event.) Janyth Bolden comments on the Great American Smokeout in this article in the Mount Shasta, CA, News. Joe Conley is recognized for receiving his alma mater’s Respiratory Therapist Outstanding Alumnus award in this article in the Wausau, WI, Daily Herald. Robin Miller tells what it’s like to go back to school while working full time in this article in Mississippi’s Clarion-Ledger. Justin Misuraca’s children’s book, Lizzy’s Big Trip, is featured in this article in the Charlotte Conservative News. Part of the proceeds from the sale of the book go to support the foundation at the Denver children’s hospital where Justin works as an RT. (We featured Justin and his book in AARC Times back in 2008.) Thomas R. Harvie is recognized for being named treasurer of the New York State Society for Respiratory Care in this article in the Albany, NY, Times Union. Kathy Calvo is noted for receiving the M. John and Drenda Heydel Respiratory Therapy Scholarship in this article in the Greenwood, SC, Today. John Seifert receives kudos for receiving the Charles W. Serby COPD Research Fellowship at the AARC International Respiratory Congress in this article in the Montana State University Mountains & Minds. Lawrence Johnson is featured in this article and Skype interview on the CBS affiliate out of Springfield, MA. His topic: breathing problems and how to cope with them. Jennifer Grimes’ recent experience as a contestant on Wheel of Fortune is outlined in this article in the Phoenix, AZ, East Valley Tribune. Lynette Boudreaux’s side business, called Momma’s Heart Rosaries, is the topic of this article and video on HoumaToday.com out of Louisiana. She and her daughter paint Catholic rosaries with themes ranging from butterflies to the New Orleans Saints and LSU Tigers. Donna Schmidt is noted for receiving a Spirit of Achievement Award from the Oklahoma Hospital Association in this article in the Edmond, OK, Sun. Rick Carver has been in two recent articles for two very different reasons: this one in the Maryville, TN, Blount Today notes the success of his latest Rhythm and Roll event to raise money for cystic fibrosis; this one in the Blount County Daily Times covers his candidacy for county commissioner. Sharon Saleeby is noted for helping her husband, a local emergency room physician, establish a mobile medical service for their community in this article  in the Charleston, SC, Post and Courier. Walt Garant is cited for his role in his hospital’s cardiopulmonary program in this article in the Cape May County Herald out of New Jersey. Frank R. Salvatore Jr. is noted for his election to the AARC Board of Directors in this article in the Hudson Valley Press out of New York. Brian Murphy, Jamie Ryan, Samantha Preihs, and Tammy Redasky share great information about the Sputum Bowl team from their school in this article in the Tucson, AZ, Daily Star. Another Sputum Bowl team receives coverage in this article in the Enid, OK, News & Eagle. Educators Deryl Gulliford and Jim Grantz couldn’t be prouder of team members Kaci Bliss, Abigail Padilla, Nick Almack, and Dante Clark, all of whom recently graduated from their RT program. David Goswick talks about his new respiratory therapy educational program in this article on KentNewsNet.com out of Kent State University in Ohio. "The Respiratory Therapy program covers so many aspects that you're pulling from all different types of academia. It is a demanding field, but it's also a very rewarding field because you get to save lives," he was quoted as saying. Jody Adkins explains how a workforce retraining program helped her become an RT after she was laid off from her job at a stamping plant in this article on the West Virginia Metronews Network web site. Jody graduated May 8 and started her new job as an RT on May 21. Lance Lothert talks about the World COPD Day @ the State Capitol event hosted by the Minnesota Society for Respiratory Care in this article in the Redwood Falls, MN, Gazette. The MSRC held the event in response to an AARC request to the state societies to take COPD screening and information to their state capitols and/or state department of health buildings on November 18. You can read more about this effort in an upcoming issue of AARC Times. Cindy Soares writes about the expense involved in using nicotine replacement products to quit smoking in this letter to the editor in the Rome, NY, Sentinel. Cindy suggests a couple of organizations in her community that provide free assistance to people who want to kick the habit. Walt Wilson writes about a partnership between his school program and local school nurses in this article in the Natchez, MS, Democrat. John Murray is noted for presenting an abstract at Sleep 2009 in this article on Seacoastonline.com out of Maine. Joseph Sorbello comments on a new RT educational program in this article in the Watertown, NY, Daily Times. And last but not least, AARC President Tim Myers this articlein HomeCare. comments on the Association’s support for legislation that would end DMEPOS competitive bidding in
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Integrative Medicine featured in Natural Awakenings Magazine

Keep you eyes out for the January issue of Natural Awakenings Magazine.  The issue is dedicated to "Integrative Medicine".

Physician Recruitment and Retention in Rural SC

Incentives for Recruitment of Physicians and Problems of Retention

In Rural South Carolina

Case in Point: Marlboro Park Hospital and Surrounding County, Bennettsville, SC

Sharon K. Saleeby, RRT
College of Health Professions
Medical University of South Carolina

Abstract

Recruitment of physicians to rural areas is a difficult task. The federal government recognizes that rural health care recipients need physicians to serve in medically underserved areas; therefore they have devised monetary incentives to help accomplish the task of physician placement. The state government is involved with recruitment initiatives in a similar capacity. Rural hospitals, such as Marlboro Park Hospital in Bennettsville, SC are constantly seeking new physicians to expand their services and to replace those that have left or retired. The high physician attrition rate in the county is due to multiple factors. The inability to keep physicians in the county has multiple effects from community perceptions on the availability of health services to the long term viability of the hospital.

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A persistent and pervasive problem facing small town community based hospital systems is the recruitment and retention of physicians. With the current downturn in the economy, the already arduous task of recruiting physicians has become even more difficult. While there are federal, state, and local initiatives to bring physicians into the community, retention of those physicians remains a constant problem, particularly to small community hospitals, like Marlboro Park, in Bennettsville, SC. The inability to keep doctors in the community effects the community’s perception of the hospital, causes rising visits to the Emergency Department for primary care issues, and will often force those same citizens to seek care outside of the county. Recruitment can be accomplished, but there are no easy answers and no quick fixes on how to keep these physicians in the county. The information in this paper is based on conversations held with the Director of Human Resources at Marlboro Park Hospital, the Director of Recruitment at the South Carolina Office of Rural Health, and through journal articles dealing with recruitment and retention of physicians to rural areas, not just in South Carolina, but nationwide.

Marlboro Park Hospital (MPH) is a private for profit hospital located in the town of Bennettsville, South Carolina. MPH has 102 beds, 18 active physicians, 28 physicians with courtesy privileges, 183 employees and 35 contracted employees. Dietary, Rehabilitation Services, and Biomedical are all contracted services. Additionally, the physicians staffing the Emergency Department are contracted. There are 12 specialty services (Family Practice, general surgery, Ob-Gyn, urology, radiology, pediatrics, internal medicine, nephrology, orthopedics, pathology, urology, and pulmonary medicine) and 2 consulting specialties (cardiology and gastroenterology). Some of the services that the hospital provide are: telemetry, cardiopulmonary, 24-hour Emergency Room, ICU, Imaging, Labor and Delivery, Laboratory, Pharmacy, and Surgical Services. They also have Post Anesthesia Care, EEG, Occupational Therapy and Physical Therapy Rehabilitation Care. Owned by Community Health Systems (CHS), which is based in Franklin, Tennessee, the company’s focus is on small rural hospitals. CHS provides recruitment services to these hospitals and management guidance. CHS’s mission, through MPH, is to build a strong community-hospital relationship. They currently own five rural hospitals located in the upstate region of SC. (C. Meggs, personal communication, October 4, 2009)

The Human Resource Department of MPH, as with many small rural hospitals, is staffed by one person. While Christi Meggs is responsible for overseeing the hiring of new employees, benefit packages and orientation of new employees, her main objective is recruitment of physicians and marketing for MPH. She is credentialed as a Senior Professional in Human Resources. It is through interviews with Mrs. Meggs that I am able to put the pieces of recruitment and retention into proper perspective and appreciate the difficulty involved.

The town of Bennettsville is located in Marlboro County, just north of Darlington, SC. The population of the county, based on 2008 census reports, is 28,021, of which 52.3% is black, 42.5% is white, and 3.7% is Native American. Sixty percent of the population has a high school education; 8.3% has a Bachelor’s Degree, and 8.9% have professional degrees. The school system in the county is ranked as one of the lowest in the state, based on Palmetto Achievement Challenge Testing results compared with state averages. (Great Schools, 2008) The median household income is $29,229 vs. $43,508 for the state and $42,000 US median. The unemployment rate is one of the highest in the state at 21.7%. (U.S. Census, 2008)

Nineteen percent of the population has no health insurance. Seventeen percent qualify for Medicare and 32% are Medicaid enrollees. (South Carolina Department of Health and Human Services, SFY 2008) While these are simply numbers on a census table, the stark reality is that 27.5% live below the poverty level in Marlboro County and these facts have a tremendous impact on the success of the hospital. (U.S. Census, 2008) Not only must MPH survive amid this, but they are faced with five competing hospitals within a 45-mile radius, and all with similar issues and competing for the same revenue base.

Over the past three years, MPH has been unable to hire a psychiatrist and therefore have had to close their Adult Mental Health facility. They have lost a gastroenterologist and had to close their GI suite. Two family medicine physicians employed by the hospital have relocated, which resulted in the reconfiguring of the hospital based Rural Health Clinic. The hospital has had a turnover of five CEOS and three Directors of Nursing. Though these problems seem insurmountable, Christi Meggs, prods forward and is enthusiastic in her endeavors to restore a semblance of stability within the hospital. These issues are not unique to Marlboro County; they are pervasive throughout the country.

When we speak of “rural”, we are referring to counties in which there is no metropolitan area with more than 50,000 residents. Fifty-three percent of SC is considered rural and only 9% of physicians practice within this rural area. Here we find our most susceptible and underserved populations. (Hancock, 2009) Statistics reported by the Center for Disease Control (CDC), state that those living in rural areas have “higher death rates from unintentional injuries, higher incidences of chronic obstructive pulmonary disease, and higher rates of suicide.” (Escarce, 2009, p.625) Heart disease, obesity, tobacco, alcohol and drug abuse are also higher than non-rural areas. Unfortunately, this vulnerable population is least likely to seek care, thus contributing to the high mortality rate.

In response to the need for rural health care access, the Federal Government has tried to set in place initiatives to aid in the recruitment of physicians to rural areas. In 1987, the Medicare Payment Incentive Program was initiated in the attempt to retain existing physicians in rural areas and to provide funding to offset the cost of relocation and costs associated with opening new practices. In that same year, the Omnibus Budget Reconciliation Act was passed. (U.S. Department of Health and Human Services,[DHHS] Office of Inspector General, 1994) This provided for bonus payments to physicians for a five percent increase (now a ten percent increase) to the amount paid by Medicare for their services. This bonus was allocated providing they worked in areas designated as medically underserved. To establish guidelines in defining what regions actually qualified for funding, the Department of Health and Human Resources Service Administration, under the Public Service Act 1976, ( Sec. 215 of the Public Health Service Act, 58 Stat. 690 (42 U.S.C. 216); sec. 332 of the Public Health Service Act, 90 Stat. 2270 - 2272 (42 U.S.C. 254e) categorized areas as Health Professional Shortage Areas (HPSA). There are three subcategories of HPSA. Geographic HPSA must have a physician patient ratio of greater that 3,000:1. Low income HPSA is an area living below the poverty level. Facilities HPSA are non-profit medical facilities such as Community Health Centers, Rural Health Centers, and correctional institutions. The designation of these areas is determined by the states.(South Carolina Department of Health and Environmental Control, [SCDHEC]) In SC, it is determined by the SC Department of Health and Environmental Control’s Office of Primary Care after a Health Care Access Analysis is done. To achieve a designation of a Medically Underserved Area (MUA) or Medically Underserved Population (MUP), the U.S. Department of Health and Human Services will analyze the ratio of primary care physicians per 1,000 populations, the infant mortality rates, percentage of those living under the poverty level, and percentage of those over the age of sixty five. (U.S. Health Resources and Services Administration, [HRSA]) These designations make it possible to establish federally qualified Health Care Centers, rural health care clinics, and HPSA Medicare programs (due to the complexity of Medicare and Medicaid reimbursements to physicians, I have opted to only make mention of their existence.)

Recruitment of physicians is directly affected by HPSA or MUA/P designations in that it will determine federal funding. Thirty state and federal programs use the HPSA/MUA designations to establish eligibility for loan repayment programs, scholarships programs for medical students, and J-1 visa programs for international students. (SCDHEC) There are three specific federal programs available whose focus is rural area recruitment. The Health Resources and Service Administration Loan Repayment Program is funded through the National Health Service Corp. The program is aimed at primary care physicians that are U.S. citizens or naturalized citizens and requires the recipient to work in HPSAs that accept Medicare and Medicaid. Usual sites for placement of recipients are rural health clinics, public health departments, hospital-affiliated primary care offices, managed care offices, and prisons. Compensation varies by state. Presently, the limit is set at $35,000 for a two year commitment, but can be extended beyond the two year period with added compensation. All funds are tax exempt and medical malpractice is covered. Applications go through the DHEC Office of Primary Care. (DHHS,National Health Service Corp, [NHSC])

The National Health Service Corp provides both a loan repayment program and a scholarship program. The loan program is available for physicians whose specialties are Family Practice, Internal Medicine, Ob-GYN, Pediatrics or General Practice. This program also requires that the recipient make a commitment of at least two years to practice in a HPSA. The amount of repayment is up to $25,000 and up to $35,000 for third and successive years. Furthermore, physicians are given additional income (39% of the amount) to offset the tax liabilities of the funding. (American Association of Medical Colleges, 2009) The scholarship program requires the recipient to be a U.S. citizen attending an accredited medical school in this country. A future residency in a primary care field is required and a one year commitment for every year of aid is expected.

For international medical graduates, recruitment to HPSA is achieved through J-1 Visa programs. The minimum commitment time is three-years. For these graduates, they must first apply through the U.S. Department of State, then through the DHEC Office of Primary Care. Here in Marlboro County, J-1 Visa applicants work either at a local rural health office, also known as CareSouth, Inc. or at Evans Correctional Center (state penitentiary) or the Federal Corrections Institute (federal penitentiary). These same graduates will qualify for permanent residency status with an additional two year commitment to continue their work in underserved areas. (Pennsylvania Department of Health, 2009)

State incentives for recruitment are accomplished through a state incentive grant. This grant is sponsored through the SC Area Health Education Consortium (AHEC) and is co-sponsored by the Medical University of SC, and is managed by the Rural Physician Incentive Board. The purpose of this grant is to provide assistance to new physicians setting up practices or joining existing rural practices in the hopes that they will maintain a viable practice and commit to the area. Depending on state budget allowances, a maximum of $40,000 is awarded over a four-year period. First priority candidates of grant distribution would be SC natives that have attended medical school in SC. Recipients must agree to accept Medicare patients, Medicaid patients, and any other patient regardless of their ability to pay for services. The SC Office of Rural Health tracks the number of patients seen by the practice to ensure compliance with grant requirements. If default of the grant occurs, all funds must be returned. Additionally, there is a State matching Incentive program that was developed to help physicians start up a primary care office in an area designated at medically underserved. (SC Area Health Education Consortium, Recruitment and Retention Programs) This is both a federal and state plan in that funds from the federal government are matched equally by state funding. (Texas Medical Association, 2008)

Marlboro Park Hospital has its own incentives for recruitment. If the recipients of any of the loan repayment programs or J-1 Visa programs wish to continue service in the county after their commitment is over, MPH will often help them establish a hospital affiliated practice. This sets up a win-win situation in that it takes care of the physician, yet provides a revenue source for referrals to the hospital. (Norbut, 2004) As an added incentive, these physicians are given positions on hospital committees, such as the Hospital Utilization Board, Medical Executive Committee, and the Credentialing Committee. Studies have shown that physicians look favorably on being given leadership positions or expanding their administrative or clinical positions. (Deprez, 2004) Physicians are also offered commitment bonuses, varying from 10 to 30K, funds for Continuing Medical Education Credits (CME), and relocation packages. If there is no available physician to fill an opening, MPH can obtain help from the Department of Rural Health through membership services. The cost of membership is $3,000 yearly and the hospital is able to have access to their physician databases and recruitment services. (Stacey Day, Director of Recruitment, Office of Rural Health, personal communication, Oct 20, 2009) The corporate office of CHS also deals with recruitment by attending national conferences, direct mailings to physicians, accessing national databases, visiting medical schools, and referrals from other physicians. (C, Meggs, personal communication, Oct 4, 2009) While all of these programs exist to bring doctors into this community, it is quite another issue having them stay.

Once physicians are recruited to rural areas, there are problems inherit is continuing to live in small communities. Chief complaints for doctors usually revolve around educational isolation and long hours and frequent on call schedules. (Deprez, 2004) For instance, in Marlboro County there were six physicians sharing call for medicine patients, which means that the call schedule was rotated every six days; not necessarily different from an urban area. However, there is only one surgeon, so he is on call every day. There are three Ob-Gyn physicians, which necessitates a rotation schedule every three days. All three Ob-Gyns service the neighboring county, which is likewise a rural agricultural area. Attaining continuing medical education credits (CMEs), as required by the State Board of Medical Examiners, is difficult here as well. The hospital will periodically sponsor in-services and will reimburse for travel to programs, however, most rely on on-line programs. The South Carolina Area Health Education Consortium will frequently offer classes to ensure the attainment of required CMEs.

There are issues with medical insurance reimbursements, keeping in mind, there are high levels of uninsured patients, and those on Medicare and Medicaid. While there are government programs in place that aid in Medicaid payments, such as the Physician Incentive Bonus Payments, reimbursements tend to be low (mentioned previously, gives a 10% bonus to those treating Medicaid patients.) (Phillips, 1998) Specialty physicians are often concerned about the number of patients to support their practices. Financial viability is an extremely important consideration. (Deprez, 2004)

Issues with spouses and children, seems to be the largest disincentive to stay in the county. (O’Shaughnessy, 1997) This is especially true in cases where the spouse has left behind a successful career, described in HR and management literature as the “Trailing Spouse Syndrome”. (Phillips, 1998) Spouses often leave behind careers and/or take substantial pay cuts, or else face extensive travel to other areas to retain their jobs. They often must take a back seat in their career plans. Regarding the family, the children are often placed in school systems that may be inadequate. Such is the case in Marlboro County schools where scores remain some of the lowest in the state based on Palmetto Achievement Tests. An alternative to the public school system is a private school; however, enrollment is currently very limited. Travel to the neighboring county of Chesterfield or Scotland County, North Carolina are other choices that some parents consider, due to higher ranking test scores. Ultimately, issues with the spouses and children significantly undermine the retention rate. Not everyone is cut out for the bucolic lifestyle, and many families of these physicians opt to live outside of the county. In fact, some of these families live as far away as Columbia, SC and their spouses commute over an hour and a half to get back into the county. (personal observation)

Of those physicians that opt to stay, studies have shown that many have backgrounds growing up in small town atmospheres. (Rabinowitz, 1999) They were looking for comfortable environments that offered a slower pace of life and the chance to get to know their patients. In short, they wanted to feel a community connection. Other factors that have a positive effect on their decision to stay, revolve around the types of rural care programs accessible in their medical school training. Some medical schools offer in their curriculum rotations through rural practices, rural health centers or health departments. (Hancock, 2009) Others believe that if medical schools encouraged students to follow in primary care studies, then more would be inclined to practice in rural areas. (Phillips, 1998) Their involvement with this type of curriculum tends to be a positive affirmation to pursue rural care. It has also been shown that when physicians buy practices they are more likely to be committed to their community and are more likely to stay. (Pathham, 2004)

A negative community perception of their hospital is directly affected by the inability to recruit and retain physicians. Citizens want to have a continuity of care and with a steady stream of changing physicians it is difficult to establish trust. This is especially true if the same physicians that work in the community do not live, nor do their children attend schools in the county. (O’Shaughnessy, 1997) The same citizens may feel that the rural hospital may not be as up to date as larger more urban hospitals and therefore will leave the county for their care. Interestingly, the Northeastern Rural Health Network keeps statistical information of those that use MPH emergency room and those that seek the same care outside of the county. Of the total number of cases seen by MPH and other ER facilities by the residents of Marlboro County, 57% of those cases remained in the county and sought care, while 43% went to other emergency rooms outside of the county. Of this 43%, most residents sought care in the neighboring county of Chesterfield, followed by Florence and Dillon counties. (South Carolina Budget and Control Board [SCBCB], 2009) These facts account for a tremendous amount of revenue lost by MPH. Studies have also shown that one-half of pregnant women in rural areas bypass their local practitioners and hospitals and opt for more urban centers. The same is true of those with private insurance, except the percentage is lower at 30%, and those seeking treatment for more complex illness. (Escarce, 2009) While hospitals may have these services, some people are just resistant to using these rural facilities. When informally questioning neighbors and asking them why they did not use the local hospital, the overwhelming response was that they felt services were lacking. The second most frequent response was that their primary care physician had moved and they were forced to see a physician in another county.

Lack of primary care physicians also account for frequent visits to the Emergency Department. Data attained from the Northeastern Rural Health Network show that MPH had 13,567 ER visits. They also listed the top fifty reasons for these visits. While they did not categorize these into what constituted simple primary care issues, we know that there is a 10% admission rate from the ER at MPH. (SCBCB, 2009) National averages of admission rates are 12.8%. MPH reports that ER visits have shown a yearly increase, while admissions have basically not changed. The same is reported by the Center for Disease Control (CDC) in their National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. From these reports, we can determine that most visits involved non-emergent issues, thus probably primary care issues. Under Emergency Medical Treatment and Active Labor Act, or EMTALA, these patients cannot be turned away, however, if they do not have a primary care practitioner, where are they to go? Those without resources or transportation are limited to their county emergency departments and unfortunately drive the cost of care up and play havoc with the revenue of the hospital. Again, the answer to this problem is the availability of primary care physicians and a community commitment to utilize what is available in the county.

The incentives given by federal, state, and the local hospital for physician recruitment are entirely monetary. The retention involves more than just a monetary fulfillment, but rather a family and personal commitment to a community. If that commitment cannot be attained, then the attrition rate will remain high for rural areas. Again, there is no simple solution to keeping physicians. The community must support their hospitals. MPH is convenient, there are services available, and there are doctors that are giving their time and dedication to serving the county. The more the community gives to the hospital, the more the hospital can give to the community. It falls on the lap of the human resource department at MPH to remain on the front line of physician recruitment and retention, not only relying on what the state and federal government provide, but becoming creative in developing solutions to overcome some of the counties short comings.


References:


Association of American Medical Colleges. Loan Repayment/Forgiveness and Scholarship Programs.


(2009). Retrieved from http://services.aamc.org/fed_loan_pub/index.cfm?fuseaction=public.


welcome&CFID=743225&CFTOKEN=86105576






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Programs Fact Sheet. (2009). Retrieved from http://services.aamc.org/fed_loan_pub/index.cfm


?fuseaction=public.program&program_i






Deprez, Ronald. (2004). Physician Specialty Practices strategic. Survival for Rural Hospitals. Healthcare


Financial Management, 58(1):76-80.






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Hospital Choice in Rural California. Journal of Health Care for the Poor and Underserved, 20,


625-644.






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modperl/achievement/sc/770#pact






Hancock, Christine, Steinbach, Alan, Nesbitt, Thomas S., Adler, Shelley R., Auerswald, Collette L.


(2009). Why doctors choose small towns: A developmental model of rural physician


recruitment and retention. Social Science and Medicine, 69, 1368-1376.






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http://www.jointcenter.org/hpi/pages/marlboro-county-sc-profile






Norbut, Mike. (2004). New Reasons for Hospitals to Buy Practices. American Medical News, 47.46


(Dec 13, 2004): 29.






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Factors For the Survival of Rural Hospitals. Best Practices & Benchmarking in Healthcare, 2(1).






Pathman, Donald E., Konrad, Thomas R., Dann, Rebekkah, Koch, Gary. (2004). Retention of Primary


Care Physicians in Rural Health Professional Shortage Areas. American Journal of Public Health, 94(10), 1723-1728.






Pennsylvania Department of Health. (2009). Primary Care Practice Opportunities. Benefits of HPSA and


MUA/P Designations. Retrieved from http://www.dsf.health.pa.us/health/ cwp/view.asp?a=169&Q=201491






Rabinowitz, Howard K., Diamond, James ., Hojat, Monammedreza, Hazelwood, Christina. (1999).


Demographic, Educational and Economic Factors Related to Recruitment and Retention of Physicians in Rural Pennsylvania. The Journal of Rural Health, 15(2), 212-218.






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from http://www.scahec.net/recruitment/recruitment.html






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Emergency Room Data. Retrieved from http://www.ors2.state.sc.us/er.php






South Carolina Department of Health and Environmental Control. Office of Primary Care. (2008).


Shortage Designations. Retrieved from http://www.scdhec.gov/health/opc/hpsa.htm






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Statistical Summary. Retrieved from http://www.dhhs.state.sc.us/Internet/


pdf/annual%20report%20final08.pdf






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Area Underserved Population (HPSA, MUA, and MUP). Retrieved from http://www.texmed.org/Template.aspx?id=2348






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http://www.census.gov/cgi-bin/saipe/saipe.cgi






U.S. Census Bureau. State and County Quickfacts. Data derived from Population Estimates, Census of


Population and Housing, Small Area Income and Poverty Estimates, State and County Housing Unit Estimates, County Business Patterns, Nonemployer Statistics, Economic Census, Survery of Business Owners, Building Permits, Consolidated Federal Funds Report. (2008). Last revised 17-Nov-2009. Retrieved from http://quickfacts.census.gov/qfd/states/45000.html






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Designations for HPSA, MUA. Retrieved from http://bhpr.hrsa.gov/shortage/muaguide.htm






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Payments. Do they Promote Access to Primary Care? Retrieved from http://www.oig.hhs.gov/oei/reports/oei-01-93-00050.pdf

Ex-Con preaching health misinformation for $$$

Do you really want to buy this guys books, and trust what he is telling you? Lots of people do and are duped into believing this ex-cons stories and mis-information. I urge folks to seek out healthcare advice from reputable and knowledgeable and credentialled professionals and not become a victim of snake-oil salesmen such as Trudeau.

-JP

The unstoppable Kevin Trudeau: Infamous infomercial king is at it again

by Mitch Lipka (WalletPop.com)
Dec 3rd 2009 at 6:00AM

Even if you don't know Kevin Trudeau by name, you'll likely recognize his face. You've probably seen him while channel surfing during a bout of insomnia; he's the perfectly coiffed guy who confidently explains to one or more women on his talk show style-infomercials about having the answers for all that worries you -- from illness to money.

Trudeau is a legendary figure in the world of infomercials, with a charismatic approach that has won him a legion of followers. Over the years, he's offered us advice on how to beat cancer, improve our memory, read faster, lose weight and straighten out our finances. Now he's onto the next life-altering topic. Trudeau is currently saturating the infomercial airwaves with 30-minute segments about his latest book: "Free Money 'They' Don't Want You to Know About."

Trudeau has sold millions of books that dole out his expansive range of advice. Yet, one thing his adoring fans might not realize is that the charming pitchman on the television is also a convicted felon who has been slammed with an extraordinary series of sanctions by the FTC for allegedly misleading consumers. Currently, there is a $40 million-plus fine looming over Trudeau's head in an ongoing court battle with the Federal Trade Commission.

A judge even gave him the distinction of being the only pitchman banned from doing infomercials.But that hasn't slowed Trudeau. In fact, you might have seen him last night on an infomercial. "I have free rein. I can sell whatever I want because I'm protected by the First Amendment," Trudeau told WalletPop. "I can sell a book that says the moon is made of cheese, and it should be protected by the First Amendment."

He has yet to write the moon-cheese book, but if he did, he most certainly would sell a lot of them. His critics -- including the government of the United States -- have portrayed him as a huckster who gets millions of people to pay for worthless advice based on impossible claims. His followers, on the other hand, believe him wholeheartedly."He's just playing right into what everyone wants. He's a master of looking for weaknesses," said marketing expert Tom Antion. "Those are the same characteristics as a con man."

Trudeau was definitely playing a con's game in the late 1980s, leading to criminal charges in 1990 for larceny (posing as someone else to cash $80,000 worth of worthless checks) and credit card fraud (for using a bunch of his customers' credit card numbers to ring up more than $120,000 in charges). He went to federal prison for two years and was released in August 1993. "If I did drugs it would be no problem. Because I bounced checks and couldn't cover them and applied for an Amex card with wrong information, I'm the devil incarnate," Trudeau said. "I made some really bad choices. I did wrong. I pled guilty. I didn't blame anyone but myself."

A few years after Trudeau was released from prison, he paid $185,000 to settle allegations with eight states that he was running a pyramid scheme selling the multilevel marketing program Nutrition for Life. The Federal Trade Commission, meanwhile, has been battling with Trudeau over his advertising claims for well over a decade. In 1998, the FTC and Trudeau negotiated a settlement over allegations his advertisements for "Hair Farming," "Mega Memory System," "Addiction Breaking System," "Action Reading," "Eden's Secret," and "Mega Reading" were deceptive. Trudeau and his colleagues paid $1.1 million in a settlement. The key word here is "settlement." That allows Trudeau to accurately claim he didn't pay a fine (it's not a fine; it's a settlement) and that the charges were dropped.

Then, in 2004, he was banned from infomercials -- except for selling books -- and settled his case with FTC by agreeing to pay $500,000 cash and by surrendering a "luxury vehicle" and a home in California.

A Master of Spin:
Trudeau has managed to turn the constant allegations by the government into a marketing tool. The more trouble he's in, the more he looks like a hero speaking out against a vast government conspiracy intended to silence his powerful messages. His messages, he claims, are ones that the government doesn't want you to know. In fact, the phrase "They don't want you to know about" is incorporated into his most recent book titles."

The government wants to stop the free flow of information. They think these people are too stupid to know they are being ripped off. It's insane," said Trudeau. "It's a testament to his sales ability and naivete of the consumer. This is a person who time and time again has been targeted by different government agencies due to unsavory business practices and continues to sell product," said Scott Testa, a marketing professor at Cabrini College outside Philadelphia. The FTC said in a statement that Trudeau "is free to hawk his books in infomercials, as long as he does not misrepresent the content of the book." "The FTC alleged, and both a federal district court and the 9th Circuit Court of Appeals found, that Mr. Trudeau had made just such a misrepresentation about his book 'The Weight Loss Cure "They" Don't Want You to Know About'," the agency's statement said. A $37 million judgment against Trudeau was vacated in August and sent back to a lower court to be heard again. Now, he faces an even stiffer fine. Yet, Trudeau professes not to care. "I'm never going to pay it," he said. "The FTC has filed briefs in the district court asking for relief consistent with the court of appeals' finding, which if adopted should protect consumers from any further infomercial misrepresentations by Mr. Trudeau," the FTC statement said. When asked if the agency has a particularly antagonistic relationship with Trudeau, the FTC replied: "The FTC's relationship with Mr. Trudeau is no more or less contentious than it is with any party that violates an order. When parties violate a federal court order obtained by the FTC, they can expect the Commission to act."

Policing the kinds of claims that Trudeau makes can be very difficult, said David Rudd, chairman of the Business Department at Lebanon Valley College in Annville, Pa."We have yet to develop an effective means of policing these schemes in an electronic world," Rudd said. "It would be hard to prove he was being fraudulent even if he has the reputation of knowing how to be fraudulent." he told WalletPop in an email.

Trudeau said he has important messages to tell and a lot of people counting on him to spread the word. Even though he said he doesn't need the money, he'll keep on cranking out the books, buying air time on TV to sell them and keep raking in the cash. "I think the people overwhelmingly like what I do or nobody would be buying my stuff," he said.

Source: http://www.walletpop.com/blog/2009/12/03/the-infamous-king-of-infomercials-kevin-trudeau-is-at-it-again

Ryan Haight Act affects Online Pharmacy Practices

What is the Ryan Haight Act?

by Rhiannon Coppin
Wednesday, 14 January 2009

The Ryan Haight Online Pharmacy Protection Act was signed into law by President Bush on October 15, 2008. It is a bill that gives the DEA a lot more power to enforce what had been fuzzy rules around who is and who isn't a legally-operating distributor of controlled substances -- drugs, medications.

It officially prohibits anyone from selling or shipping "controlled substances" over the Internet when the customer does not have a "valid prescription," which means a prescription that a doctor issued during a real in-person visit.

The Act makes some exemptions for telemedicine (doctors phoning in refills, I presume?), but doctors doing telemedicine have to register first with the Attorney General.

The Act requires an online pharmacy to:
(1) display on its Internet homepage a statement that it complies with the requirements of this Act;
(2) comply with state laws for the licensure of pharmacies in each state in which it operates or sells controlled substances;
(3) post on its Internet homepage specified information, including the name, address, and telephone number of the pharmacy, the qualifications of its pharmacist-in-charge, and a certification of its registration under this Act; and
(4) notify the Attorney General and applicable state boards of pharmacy at least 30 days prior to offering to sell, deliver, distribute, or dispense controlled substances over the Internet.

The Act also imposed criminal penalties for some of the violations, and allows states to sue civilly to stop an online pharmacy from endangering its residents.

Post & Courier Article on Thanksgiving Day

The Post & Courier (Charleston, SC) Article on Dr. Saleeby's practice:

Local doctor pays house calls

with mobile medical service

By Jessica Johnson

The Post and Courier

Thursday, November 26, 2009

Photo by Jessica Johnson

Dr. JP Saleeby and his wife, Sharon, provide mobile health care in the area via their new venture, Carolina Mobile MD. Saleeby will make house and business calls to patients in a two-hour radius of the Charleston area. Sharon Saleeby also works as a respiratory therapist at the Medical University of South Carolina Children's Hospital.

Dr. JP Saleeby wants to make a career change that eventually would take him out of the emergency room and into a patient's living room or office. Saleeby, an emergency room doctor for the past 16 years, and his wife, Sharon, a respiratory therapist at the Medical University of South Carolina Children's Hospital, launched Carolina Mobile MD in October. With it, the Saleebys will bring care to patients rather than having patients come to them.

JP Saleeby integrates traditional and alternative medicine but focuses on hormone management in his house-call practice. The Saleebys geared their fee-for-service practice to the busy professional who wants to save time by avoiding a waiting room and spend more of it with a doctor. They do not take insurance and plan to offer services to patients living within a two-hour drive of the Charleston area. Saleeby said he was inspired to make house calls because of what he's seen as the emergency room director at Marlboro Park Hospital in Bennettsville. There, Saleeby has treated a steady flow of patients who come to the E.R. with preventable problems, consequences of diabetes and hypertension, and avoidable heart attacks and strokes.

Nationally, hospital emergency rooms have reported an increase in patients, but a decline in the actual number of emergency cases, Saleeby said. More and more people come in with requests to refill prescriptions, complaining of chronic pain or with symptoms of minor illness, cases not meant for an E.R. As an emergency room doctor, Saleeby said, he has just a few moments to make a diagnosis. His mobile program would allow him to spend 60-90 minutes with a patient, longer than a typical doctor-patient interaction. Sharon Saleeby said medicine of today focuses on treating disease rather than preventing illness. The couple plan to take a different approach in their practice, offering patients a prescription for healthier living. Beyond the routine physical, JP Saleeby might also recommend an exercise regimen and vitamins, supplements and herbs for a patient to take.

Saleeby had a practice in Savannah but closed it in 2004 and later moved to the Florence area to make a home with his wife, a Mount Pleasant native. He's continued to see some of that practice's former patients via the Web and through house calls. Arguably, Saleeby could offer the same care in a brick-and-mortar practice. But a mobile practice allows him to avoid overhead costs: office equipment, staff and waiting room.

Visit www.carolinamobilemd.com.

Reach Jessica Johnson at jjohnson@postandcourier.com.

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Hyptis crenata (Brazilian Mint Tea) as pain reliever

Cup of mint tea is an effective painkiller

Graciela Rocha with one of her Brazilian mint plants

A cup of Brazilian mint tea has pain relieving qualities to match those of commercially available analgesics, a study suggests.

Hyptis crenata has been prescribed by Brazilian healers for millennia to treat ailments from headaches and stomach pain to fever and flu.

Working on mice, a Newcastle University team has proved scientifically that the ancient medicine men were right.

The study is published in the journal Acta Horticulturae.

In order to mimic the traditional treatment as closely as possible, the Newcastle team carried out a survey in Brazil to find out how the medicine is typically prepared and how much should be consumed.

The most common method was to produce a decoction. This involves boiling the dried leaves in water for 30 minutes and allowing the liquid to cool before drinking it as a tea.

The taste isn't what most people here in the UK would recognize as a mint Graciela Rocha Newcastle University

The team found that when the mint was given at a dose similar to that prescribed by traditional healers, the medicine was as effective at relieving pain as a synthetic aspirin-style drug called Indometacin.

They plan to launch clinical trials to find out how effective the mint is as a pain relief for people.

Lead researcher Graciela Rocha said: "Since humans first walked the Earth we have looked to plants to provide a cure for our ailments - in fact it is estimated more than 50,000 plants are used worldwide for medicinal purposes.

"Besides traditional use, more than half of all prescription drugs are based on a molecule that occurs naturally in a plant.

"What we have done is to take a plant that is widely used to safely treat pain and scientifically proven that it works as well as some synthetic drugs.

"Now the next step is to find out how and why the plant works."

Graciela is Brazilian and remembers being given the tea as a cure for every childhood illness.

'Interesting research'

She said: "The taste isn't what most people here in the UK would recognize as a mint.

"In fact it tastes more like sage which is another member of the mint family.

"Not that nice, really, but then medicine isn't supposed to be nice, is it?"

Dr Beverly Collett, chair of the Chronic Pain Policy Coalition, said: "Obviously further work needs to be done to identify the molecule involved, but this is interesting research into what may be a new analgesic for the future.

"The effects of aspirin-like substances have been known since the ancient Greeks recorded the use of the willow bark as a fever fighter.

"The leaves and bark of the willow tree contain a substance called salicin, a naturally occurring compound similar to acetylsalicylic acid, the chemical name for aspirin."

The research is being presented at the International Symposium on Medicinal and Nutraceutical Plants in New Delhi, India.

Source: BBC Health: http://news.bbc.co.uk/2/hi/health/8373791.stm

Carbon Monoxide Poisoning

This PowerPoint Presentation was created by Sharon K. Saleeby, RRT as part of a MUSC class project. It will be presented at the December 2009 IST for MCRS.

Ugly Numbers

Some Ugly Numbers

- JP Saleeby, MD

Examples of where a state implements a "Mandatory Health Insurance" policy are seeing some ominous signs. Massachusetts is a state that requires its citizens to carry health insurance and the outcome this year is that fewer (less than 44%) of Internists are accepting new patients, down from 58% in 2008. Only 60% of Family Practice physicians are accepting new patients, down from 65% in 2008 and 70% in 2007.

Another critical problem for Massachusetts is that there is a growing physician shortage and it is worsening. Poor reimbursements from government and private insurance companies will make "medicine" less attractive a career for those considering entering medical school thus compounding the problem. Doctors now are working harder than ever for less pay and the demands placed upon them by hospitals, insurance companies, CMS, and the public are becoming intolerable for many. This will be witnessed in other states should no action be taken to reform health care in a positive way, not only from a reimbursement end, but physician autonomy, freedom to practice with fewer restrictions and third party oversight.

Some Ugly numbers:

• According to recent reports from the US Census Bureau & the Am. Journal of Public Health we see that 46.3 million Americans are uninsured in 2008. This is a rise from the 45.6M in 2007.
• There has been a drop in the number of Americans with job-based health insurance in the last year from 177.4M to 176.3M.
• The most recent data (from 2005) of deaths attributed to lack of insurance was 44,840 and that number is expected to climb.

source: Medical Economics Journal 10/2009

- Dr. Saleeby is providing high quality, individualized health care to his patients via "house calls" in a step to reduce overhead and pass savings to his patients. He is currently taking steps that are impacting health care in American in a positive way with sliding-scale fees for those patients who are under-insured or without insurance. Dr. Saleeby advocates Health Insurance with low monthly premiums (higher annual deductible) that is affordable for catastrophic events, and a health savings account (HSA) / medical saving account (MSA) for routine medical and preventive care. For more information on the practice visit: http://www.CarolinaMobileMD.com

Ezetimibe (Zetia) shown INFERIOR to Niacin (B3)

Expensive Cholesterol Drug Loses Ground To Good Old Niacin (B3)

Zetia Tablets

The battle over expensive lipid lowering prescriptions versus inexpensive safe and effective vitamins took a major turn today. Cable news programs, Newspapers and Radio all broadcasted the latest clinical trial that gave the proverbial big two thumbs down to expensive medications and a grin to Vitamin B3.

One thing disturbs me however, and that is the fact that Vitamin B3 is reported as “Niacin” or “a prescription version of Niacin” or “Niaspan” and it appears that the press (possibly under the thumbscrews of Big Pharma) are trying to belittle the fact that a Vitamin beat out a million-dollar drug. Goliath here has been smitten by a young David. And I must admire the genitals of the researchers and the journal that reported these finding as I am sure the political pressure was enormous not to publish the findings.

Once again critics bash the finding stating that they don’t believe reduction in arterial plaques have an impact on cardiovascular death rates… hogwash! The researchers that don’t want to admit that this is just one of many studies that bash expensive, dangerous and ineffective drugs are just prostitutes for Big Pharma. My 8-year old child can deduce what this study has spelled out. Stay away from costly, often times harmful and in this case ineffective medication and stick with what nature has provided. Vitamin B3 or Niacin is a safe, rather inexpensive option that really makes an impact on cardiovascular health.

Vytorin ® which is a combination of ezetimibe (the drug found in this study to be ineffective) and simvastatin a statin drug will cost you $112 for a 30 day supply at a discount pharmacy. Zetia 10mg is ezetimibe alone and will set you back $111/month at the same pharmacy. Niacin 500mg for a 100 count bottle will only run you about $6. You do the math.

Ironically, as the news spreads today about this Merck drug, Merck stocks rise as Wall Street believes this study is too limited in scope. Are people crazy? Oh, yeah and ObamaCare is spot on for us to embrace as the cure-all and fix-all for our healthcare woes. Dream on. Come on folks, wake up and think for yourselves for a moment. This study was published on the online version of the New England Journal of Medicine and was presented at this year’s American Heart Association scientific meeting in Orlando, Florida, is called ARBITER-6. And even now alongside the studies posting is an editorial by some hired gun (on the Merck payroll) who despite the study’s facts is peddling the line that people should not abandon Zetia just yet… Oh, and what are we waiting for?

Please read my “Beyond Cholesterol” article (below) and power point presentation (link) on this blog.

------
Beyond Cholesterol

By JP Saleeby, MD (posted April 2005)

Cardiovascular disease the number one killer in America is at the forefront of the battle that steals years away from many Americans. Men are hardest hit, but women are not immune. Postmenopausal women will suffer death from cardiovascular causes at a rate of one in two. Cardiovascular disease kills more Americans than all cancers combined. This goes for women also; heart attacks (acute myocardial infarction or AMI for short) will take the lives of more women than all the lung and breast cancer deaths combined. Researchers are still searching for the right answer and the right medicine. Cholesterol has been in the sights for years and considered the major culprit. But there is more to this story, it does not end with just this one etiology, it is multi-factorial. Other risk factors may have more of an impact on the coronary artery than just cholesterol. For example Homocysteine, Lipoprotein (a), C-Reactive Protein, Fibrinogen and even Apoprotein A-1 and B impact cardiovascular health significantly and may even play a bigger role than "cholesterol." Tackling these other risk factors would go beyond the scope of this article, but I will take apart the Cholesterol issue.

In the past the focus was on reducing total cholesterol and low-density lipoproteins (LDL-C) a subtype of cholesterol. The National Cholesterol Education Program (NCEP) set up guidelines where they recommend Total Cholesterol remain under 200 mg/dL and LDL-C under 100 mg/dL (recently changed from a value of less than 130 mg/dL). Drugs were developed to lower total and LDL-C and thus save lives. Come to find out the true hero is the high-density cholesterol (HDL-C) subunit of cholesterol. This type of cholesterol scavenges the "bad" cholesterol and thus does not allow plaque formation to occur which narrows the coronary arteries and results in AMI. One can even measure the 5 subclasses of HDL-C where H1 & H2 may be harmful while the larger HDL subclasses of H3, H4 & H5 are considered good and reduce risk. The true predictor for cardiac risk is not the total cholesterol or even the LDL-C, but the total cholesterol to HDL-C ration (TC:HDL-C). If this ratio is above 4.8 you are at increased risk to suffer from heart disease. Once a low HDL-C and/or high Total Cholesterol level is diagnosed it is important to implement treatment. Diet alone often fails, since the liver will make up what cholesterol you don’t eat. Several therapies exist, and it is more a matter of how aggressive you need to be and how well tolerated they are as to which you choose.

In a recent case study at the SLI a 36 year old male patient with a total cholesterol of 241 mg/dL, and LDL-C of 159 mg/dL and an HDL-C of 44 mg/dL prior to any therapy was given several regiments in an attempt to control his dyslipidemia. This patient was taking and continued to take a potent multivitamin and mineral supplement and the antioxidant coenzyme Q10 (25 mg daily). First was the very well tolerated and safe Inositol Hexanicotenate (which converts to niacin in the liver) 2000 mg and Garlic 500 mg daily and after 3 months the Total cholesterol was measured at 251, LDL at 150, HDL-C at 43. Not much of an improvement. This is seen in about 50% of subjects started on Inositol Hexanicotenate. The second trial was with Zocor 20 mg at bedtime (again coQ10 was continued at 50 mg per day to offset deficiencies that can occur with this drug) and after 60 days the results were as follows: Total Cholesterol 197, LDL-C 117, and HDL-C of 40. It is interesting to note that a recent study of 153 randomized patients with CAD and low HDL were given low dose Statin and niacin combination with and without antioxidants. The subjects taking antioxidants did not have a rise in HDL-C as did those who did not take an antioxidant cocktail which saw an increase in HDL of 42%. This is of importance when a patient is not responding to statin therapy and on concomitant antioxidant therapy. These were the best results so far.

Finally, because of complaints of muscle pain and the fear of "untoward effects" from the statin drug, the patient was tried on a "new" highly touted lipid-lowering agent called Policosonal (oxycosonal, a derivative of the waxy coating of sugar cane and considered a natural alternative). After 60 days the lipid profile was as follows: Total Cholesterol of 220, LDL-C of 139 and HDL-C of 39. A slight drop in the LDL-C and total, but not good enough. Finally Niacin (in the form of sustained release Niaspan) was attempted, but discontinued after 8 weeks due to constant flushing and pruritis (itching).

While the Inositol Hexinecotinate/Garlic and Policosonal therapies are considered "natural" they certainly were not better at achieving results. Zocor a potent (HMG-CoA reductase inhibitor [Statin] drug (when taken correctly and monitored for liver toxicity and in combination with coQ10 supplementation) is a very aggressive way to lower LDL and raise HDL-C (minimally). There are now low dose statin drugs in combination with niacin (truly the one drug/supplement shown to raise HDL-C the best) that show promise. Factors that may interfere with this may be very high dose antioxidant therapy and one must follow on a case-by-case basis.

Another approach not yet explored with this patient is a combination of herbals and nutrients known to lower cholesterol. This "shot gun" approach may yield better results than any one agent used alone. As this patient is placed on a regiment of lower dose niacin, policosanol, plant sterols, tocotrienols, guggulipid, phosphatidylcholine, oat bran, garlic and antioxidants, time will tell and I will keep you posted. As an integrative physician I use the safest or least harmful therapeutics first, but should they fail, I apply more traditional synthetic drugs to reach an endpoint that is known to save or extend life. Not all that is synthetic is evil as this case study demonstrates; one has to always consider the risk benefit ratio.

-------------------

For the Beyond Cholesterol Slide Show: http://docsaleeby4.blogspot.com/2009/09/beyond-cholesterol-powerpoint.htmlfor PowerPoint Presentation

Hypothyroidism article

This is a very good article that echoes my same sentiments and beliefs
on this disease. Is an interesting read for those interested:

Hypothyroidism: The Silent Epidemic

Hypothyroidism can be loosely defined as a medical condition that results from
the under-secretion of Thyroid Hormone. The difficulty with this traditional
approach to diagnosis of hypothyroidism is that it relies on ‘normal values,’ or
reference ranges that are defined by the population itself. It has been
estimated that as many as 50 million American suffer from undiagnosed
hypothyroidism.

Fact #1: Thyroid hormone is necessary to maintain basal metabolic rate, or the
amount of fuel that is consumed to sustain health. The manifestation is that of
temperature.
a. When a person is generating too little thyroid hormone, or if the individual
has an imbalance that involves thyroid metabolism, body temperatures will fall.

b. These persons may be told that they ‘normally have low temperatures.’
c. This bit of nonsense is causing tremendous problems for society.
d. The result is weight gain, depression and elevations in cholesterol levels.

Fact #2: The traditional approach to the diagnosis of hypothyroidism involves
measurement of a hormone released by the pituitary gland, TSH. If the central
nervous system senses that there is inadequate thyroid hormone in the blood
stream, TSH levels will increase. Increase in TSH should lead to increases in
the release of Thyroid Hormone from the Thyroid Gland. As levels of Thyroid
Hormone reach adequate levels, TSH release decreases.

Problem #1: Unfortunately, a lot can go wrong between the brain, pituitary
gland and the thyroid gland, itself. Inadequate levels of thyroid hormone can
persist, and the brain will ‘reset’ to new and lower levels of this hormone.
Factors that can cause this include:
1. chronic stress
2. pregnancy
3. trauma
4. chronic disease states.
5. autoimmune conditions
6. fasting or famine conditions.

As TSH levels drop back to normal, the diagnosis of hypothyroidism becomes more
difficult, if all the practitioner relies upon is the TSH level. Unfortunately,
this is the case more times than not.

Problem #2: Thyroid Hormone does not work alone. It requires adequate levels
of estradiol, estrone, progesterone, testosterone, cortisol, insulin, DHEA and a
host of other hormones, peptides, fatty acids and humoral elements. If any one
of these necessary pieces are missing, out of balance, or in excess, thyroid
hormone may not work properly, leading to a state of ‘functional
hypothyroidism.’

TSH levels, thyroid hormone levels are ‘normal,’ but the body does not function
properly and resembles the hypothyroid condition.

Problem #3: Thyroid Hormone replacement may be inadequate or improper for the
patient. That is, not all thyroid replacement works for all patients. There
are chemicals in some of the commercially available thyroid preparations that
cause all manners of problems. One such substance is ‘Acacia,’ which is a
family of shrubs and trees, and portions of this plant are used in some
medications to provide form and shape to tablets. Lactose is also used in the
most popular of the Thyroid Replacement Hormones. Not only is Lactose an
allergic trigger for people with lactose intolerance, but it may actually block
the absorption of the thyroid replacement, itself. Signs of lactose intolerance
include nausea, cramps, bloating, gas, and diarrhea.

It is very common to hear patients tell the doctor that the thyroid medicine
that they are receiving is ‘making me sicker.’ Unfortunately, the practitioner
does not often make the effort to figure out why this might be the case.

Problem #4: Certain foods make thyroid conditions worse. Patients with
auto-immune disorders may be more sensitive to soy-protein than other persons.
Soy contains two chemicals that inhibit an important enzyme that is necessary
for thyroid hormone replacement. If a person is already ‘on the edge,’ taking
soy protein can make the condition worse. To a lesser extent, peanuts, pinto
beans do this, as well.

Recommendations:
1. In order to sort through the diagnosis of thyroid related problems, it is
important to determine not only the levels of thyroid hormones and TSH, but it
is important to determine the presence of antibodies to the binding protein and
converting enzymes.
2. If you suspect that you have hypothyroidism, it is necessary to cease eating
anything that contains soy, soy lecithin, peanuts and pinto beans.
3. Replacement of thyroid hormone should be accomplished with products that do
not contain lactose, Acacia, and artificial colorations.
4. Thyroid hormone must be taken on an empty stomach.
5. Determination of hormone imbalances that affect thyroid metabolism must be
accomplished.

Source: e-newsletter from David S. Klein, MD

MSM and Performance Athletes

Came across this article by Dr. Klein.  Spells out some basic principles on
neural reflexes and pain and performance.  Added a few things to the piece in
"[  ]"

The Spinal Withdrawal Reflex and Athletic Performance

While the principal focus of athletic training has been placed, traditionally,
on improvement in strength and enhanced flexibility, measurable degradation in
actual performance results from involuntary, protective mechanisms ‘hard-wired’
into our nervous system.

The Spinal Withdrawal Reflex (SWR) is one such protective mechanism that robs
the athlete of what could be the winning difference or competitive edge.

Sometimes known as the nociceptive spinal reflex, the SWR protects the body from
self inflicted damage. Stretch, pressure, or pain receptors are triggered, and a
signal follows the sensory nervous system to the spinal cord. Processed in the
Dorsal Horn, a reflex signal is then sent back to the same limb or region of the
body accomplishing a ‘shut down’ of the offending muscle or muscle groups.

One example might be a tear in the rotator cuff of the shoulder. As the athlete
reaches with the arm, a pain signal from the damaged shoulder ligament travels
to the spinal cord causing a reflex ‘withdrawal’ of the shoulder muscles.
Because of the SWR, and due to the protective nature of the reflex, the shoulder
muscles are never allowed by this body to operate at full capacity,. The net
effect is decreased range of motion and a measurable decrease in strength. This
decrease is estimated to be between 1-4% of optimum performance.

Important to the athlete is that the decrease in range of motion, strength and
flexibility can be reduced or eliminated by decreasing the pain modulator in the
damaged tissue. That is, modulating the pain receptor can measurably and
significantly improve performance and recovery. This must be accomplished
without increasing the likelihood of re-injury. Medicines that ‘numb’ the pain
receptor increase the likelihood of re-injury by reducing the pain signals that
result from tissue damage. Local anesthetics and counter-stimulants fall into
this category.

While it is critical for full recovery, to insure that the injury has proper
time to heal, it is also vitally important that the rehabilitation process
allows for full extension and performance of the injured area. Too many times
the physical therapy recovery is inhibited by the discomfort of the person going
through their exercises. We must make certain that the individuals in recovery
are “pushed” to their safe limits in order to guarantee they return at optimum
effectiveness. Ironically, the more strenuous the safe management of the
recovery process, the quicker we can usually expect a return to activity. This
time factor can be critical regardless of whether you run a dojo or are
competing.

The pain receptor can, however, be safely modulated with resulting improvement
in strength and flexibility using anti-inflammatory and anti-oxidant topical
medications such as a high-concentration methylsulfonylmethane (MSM) containing
salve.


In summary, the performance-robbing qualities of the spinal withdrawal reflex
can be reduced, with high concentration transdermal MSM, thereby improving
flexibility, range of motion and muscular strength. Improvement by as little as
2-5% in strength, reach and range of motion could make the difference between
winning and losing. It has been said that at the professional level in most
sports the difference between winning and losing is usually around a 1%
difference in performance. Low concentration MSM containing salves, such as
Tiger Balm® are somewhat beneficial where newer products that contain high
concentrations of MSM, such as Kink Ease® provide much more rapid and dramatic
results.

[Taking MSM orally or topically is beneficial.  NSAIDs as well as SAMe, Vitamin C
and Zn for tissue repair, Boswellia serrata as an anti-inflammatory, Turmeric,
and L-Proline are all beneficial.  These are found in Joint Support
(http://www.vitasanus.com/vsn_products/jointsupport.htm).  Also MSM can be
compounded in a high potency topical cream by a compounding pharmacy under the
direction of an MD/DO.  Oral MSM (http://www.vitasanus.com/vsn_products/msm.htm)
can be ordered from sites such as this.]

Source:  David Stephen Klein, MD, FACA, FACPM
Pain Center of Orlando, Inc.

Vitamin D-3 & Viral Infections

Vitamin D-3 in the Prevention & Treatment of Viral Infections and Influenza

Supplemental cholecalciferol (vitamin D) significantly reduces all-cause
mortality emphasizes the medical, ethical, and legal implications of promptly
diagnosing and adequately treating vitamin D deficiency. Vitamin D deficiency is
common, and is implicated in most of the diseases of civilization.

Vitamin D-3 is a steroidal hormone that targets more than 200 human genes in
a wide variety of tissues. With genes as its target, vitamin D has been shown to
up-regulate the gene that is involved in the production of cathelicidin, a
naturally occurring broad-spectrum antibiotic.

Treatment of vitamin D deficiency, in otherwise healthy persons involves
dosages between 2,000-7,000 IU vitamin D-3, daily.  With serious systemic
illnesses, associated with vitamin D deficiency, such as cancer, heart disease,
multiple sclerosis, diabetes, autism, the doses should be somewhat higher to
maintain 25(OH)D levels between 55 -70 ng per mL.

Vitamin D-deficient patients with serious illness should not only be
supplemented more aggressively than the well, they should have more frequent
monitoring of serum 25(OH)D and serum calcium.

NOTE: Doses of vitamin D-3 (2,000 IU per kg per day for three days) may produce  
enough of the naturally occurring antibiotic cathelicidin to cure common viral  
respiratory infections, such as influenza and the common cold, but such a theory  
awaits further science. This is a very high dosage regimen.  For general use,  
Vitamin D-3 dosages of 2,000 to 5,000 IU are sufficient to enhance immune  function
and minimize flu symptoms, if exposed to the virus.

Vitamin D-3 is very inexpensive, about $4 per month.  Because Vitamin D-3 is
oil-soluble, it must be taken with an oil capsule, of almost any type.

Source: David S. Klein, MD, FACA, FACPM is the Medical Director of the Pain Center of  
Orlando, Inc.  A graduate of the University of Maryland School of Medicine, Dr.  Klein
received training in General Surgery at the University of North Carolina,  
and Anesthesiology at Duke University.

Policosanol vs Statin Drug

Policosanol is a wonderful alternative to prescription 'statin' drugs in the
treatment of elevated cholesterol.

The side effects of statin drugs [are]:

1.  Changes in liver function. Liver 'transaminases' can become elevated,
indicating liver damage with the use of prescription statin medications.  For
this reason, routine, periodic blood work must be performed to monitor for this
potential and fairly common problem.

2.  Muscle cramping and muscle aches. Muscle symptoms are common Lipitor side
effects, but occasionally something called “myopathy” occurs, involving actual
damage to muscle tissue.

3.  Altered Memory and Poor Concentration. Changes in memory, focus,and/or
concentration can occur in patients receiving statin medications. People may
develop difficulty finding the right word.  Lose items, and have memory issues
that can be disturbing. .

4.  Depression and Irritability. Depression and mood changes are common
side-effects associated with statin use.

5. Headaches, Joint and Abdominal Pain.

6.  Peripheral Neuropathy. Peripheral neuropathy, perhaps due to CO-Q10
depletion may occur in patients receiving statins.

7. Sexual function problems, fatigue, dizziness.


Dosage and Administration of Policosanol:


1.  Generally, starting dosages are 10 to 20 mg, by mouth daily.  Cholesterol
levels can be expected to drop 10 to 20% at the 20 mg dosage, and increasing it
to 20 mg twice daily may give additional although non-linear results.

2.  I [David Stephen Klein, MD] start my patients on 20 mg twice daily.  Policosanol is so inexpensive and
so devoid of side-effects that the higher dosage is the better place to start.

3.  To this, I add Folic Acid 5,000 mcg (5 mg) once daily.

[**editors note:  I will often time recommend Niacin (no-flush niacin) and extract of red rice yeast in addition to
policosanol.  Also coQ10 is added in smaller amounts then what is recommended to be taken with statins when using
red rice yeast extract because in fact it is a natural "statin" agent]

source:  www.suffernomore.com

** additions by JP Saleeby, MD

Dr. Saleeby's Medical Antique Collection up for grabs

Dr. Saleeby's Antique Medical Instruments& Books

Sample of Dr. Saleeby's Antique Medical Instrument Collection. Photo by Paul Nurenberg, featured in Savannah Magazine in 2005

Over 100 medical antiques and books from 100 AD Roman instruments to Civil War Era (amputation kit, field surgical kit, etc.) to 1940's -50's equipment.

Currently for Sale (e-mail for price and viewing)
Craigslist Posting ID: 1433637777

Quote of the day

"Words - so innocent and powerless as they are, as standing in a dictionary, how potent for good and evil they become, in the hands of one who knows how to combine them!" - Nathaniel Hawthorne (1804 - 1864)

Ovarian Cancer

Ovarian Cancer (Ab ovo)

By JP Saleeby, MD

Ovarian cancer is the 5^th most common cancer in women after lung, breast, colorectal and pancreatic cancers. It accounts for only three percent of cancer in women, and fortunately there has been a decline in incidence of this type of cancer by about 1% over the last twenty years. Unfortunately, diagnosis is usually late as there are very subtle and often protean symptoms and signs. Ovarian cancer is not just a cancer of old age, it can occur at any age, even infancy, however, the incidence of this cancer does rise significantly after the age of 50.

There are certain risk factors for ovarian cancer, chief amongst them is family history and some associated genetic syndromes. A blood relative with ovarian cancer raises the risk for their female relative by 5% for this cancer. There is a syndrome of hereditary breast and ovarian cancer which occurs in one out of every 500 women and being an autosomal dominant genetic disorder results in BRCA1 and/or BRCA2 gene mutation. The other is Lynch II syndrome a hereditary non-polyposis colorectal cancer syndrome, again autosomal dominant, which increases risk for ovarian cancer by 12%. However, the majority of women diagnosed with ovarian cancer have no family history and the etiology remains unknown. When ovarian cancer occurs and is not detected early when localized to one ovary, the cancer will usually spread to the unaffected ovary and uterus first, but can spread to the liver, lungs, adrenal glands, spleen and other intraperitoneal organs.

Some things that reduce risk are the protective effects of oral contraceptives, late menarche, early menopause, multipariety (having more than one child) and breastfeeding. Progesterone appears to be protective, but there is controversy as a 2009 Danish study suggests that all HRT results in increased risk (the study was performed with estrogen alone (unopposed) or estrogen & progestin (progestin is a synthetic progesterone compound). Further study in the use of natural bio-identical hormones for prevention will need to be performed to clear up this controversy as earlier studies showed HRT to be protective. There are modifiable factors such as reducing weight (avoiding obesity), smoke cessation, reducing a high starch and fat diet that can reduce risk of this cancer. It has been shown that a well balanced diet high in carotene, vitamin C and E and unsaturated fats with moderate physical activity all help reduce ovarian cancer risk.

There is much difficulty in making an early diagnosis due to the fact that signs and symptoms are very often subtle and non specific, and unless you go looking for this disease with specific diagnostic lab and radiology tests you are not likely to find it early on. Some symptoms include abdominal pain and fullness, back pain, nausea, constipation, diarrhea, fatigue, pelvic pain and urinary symptoms. Laboratory testing should be considered in women over 40-years of age if these symptoms persist as they are a higher risk population for ovarian cancer. Testing usually involves a CBC, metabolic panel and serum CA 125 levels. CA 125 is a cancer marker that is rather sensitive and specific for ovarian cancer, however there are some other conditions that can elevate this marker such as pelvic inflammatory disease (PID), endometriosis, ovarian cysts and pregnancy. CA 125 is a good test but not perfect since it is elevated in 90% of patients with advanced disease, but only upwards of 50% with stage I tumors. Additionally, there are other markers that make themselves useful, and they include the beta subunit of human chorionic gonadotropin (Beta-HCG), serum alpha-fetoprotein (AFP), neuron-specific enolase (NSE), and lactate dehydrogenase (LDH). Diagnosis is also made by diagnostic imaging, such as the Doppler transvaginal ultrasound (ultrasonography or US), often used as an initial evaluation for a pelvic mass. US is helpful in determining benign ovarian lesions such as simple cysts from those that appear more malignant such as complex solid tumors. Other modes of radiological imaging useful to the diagnostician are CT scan and gadolinium-enhanced MRI.

Treatment usually includes (after thorough diagnostic testing and staging) excision of the mass/tumor by surgery. Depending on the stage of the disease other organs may also be removed, for example the appendix is generally removed due to its potential target for metastasis. Following removal of the tumor, chemotherapy is typically initiated with a combination of platinum and taxane-based agents. Carboplatin and Taxol are two chemotherapeutic agents that are often used. For those women beyond their reproductive years, a total hysterectomy is often considered, while radiation therapy is reserved for palliative and persistent disease that reappears after a regiment of chemotherapy.

Prognosis is a bit complicated as it is based on the staging of the disease as well as the histological grade (type of tumor etiology) that typically plays a role in recurrence rates. For example, an epithelial ovarian cancer (histologically) has a low malignant potential if diagnosed at stage I and has a 95 – 99% survival rate at 10-years.

Screening for ovarian cancer should include annual physical examination and directed exams by markers and imaging only when warranted. Routine screening with CA 125 yield too many false positives and misses too many tumors early on to be a good general screening test. BRCA analysis should be reserved for descendents of those with mutated BRCA1 & BRCA2 genes, it is not recommended as a general screening tool. The current recommendations for women meeting criteria for high risk or very high risk for ovarian cancer is to be screened with a transvaginal ultrasound and have a CA 125 measured every six months during days 1 through 10 of their menstrual cycle beginning at age 35.

The take home message here is that women need to be diligent with regard to their annual physical examinations and to not ignore persistent symptoms that may point a finger to an underlying more serious condition.

---

JP Saleeby, MD is director of Carolina Mobile MD, a “house call service” offering integrative general medical services to clients in the Carolinas. For more visit: www.CarolinaMobileMD.com

References:

Roett, M. Evans, P., “Ovarian Cancer: An Overview”, American Family Physician, Vol. 80, Num 6, September 15, 2009, p.609-616.

http://www.ncbi.nlm.nih.gov/pubmed/10933270 (Accessed 10/8/2009)

http://www.medicinenet.com/script/main/art.asp?articlekey=103822 (Accessed 10/8/2009)

© 2009

Dr. Casey Mann's last day at MPH

Dr. Casey Mann one of our fine and well loved FP docs at MPH is departing the fold to hang his shingle just outside Myrtle Beach, SC. Casey, was great working with you and you will be missed by patients and doctors alike in Marlboro Co. Pictured here is Dr. Moore, Casey, myself and one of our CNAs.

Quote of the day:

"Our moral progress may be measured by the degree in which we sympathize with individual suffering and individual joy." - George Eliot (1819-1880)

RH

September 30th (night shift) marked my last day in the Rutherford Hospital ED. My 6 months helping out the group (REM) ended with the usual busy shift work. My stint in the Mts of NC is over for the summer. Back to BVille and my new "house call" practice. No great fan fair aside from the wonderful going away "party" the nursing and clerical staff threw me that evening. Will miss everyone staffing the ER up there as they were a great group of nurses, clerks, CNAs and EMTs.

Dr. Saleeby awarded TOP Health Blogger HONORS

Dr. J P Saleeby, MD

General Medicine Community

FIBROMYALGIA - (A Power Point Presentation by Dr. Saleeby)

Royal Pains

The USANetwork TV series "Royal Pains" is an original series about a young doctor making house calls to the wealthy in the Hamptons. For the "real deal"... Saleeby takes his healing skills on the road in NC and SC. Probably not as glamorous but just as appreciated.

Beyond Cholesterol (PowerPoint Presentation)

Power Point Presentation on Anti-Aging and hGH

Mercury and Neuron Damage

Interesting video presentation from the University of Calgary on the effects of Mercury (Hg) on neuron and brain tissue.

http://www.youtube.com/watch?v=XU8nSn5Ezd8

Menopause & Natural (Bio-identical) Hormone Replacement Therapy

Bio-Identical HRT for Women

by JP Saleeby, MD

Hormones and Their Functions

Hormones are chemical messengers, produced by the endocrine system (produced by one organ), that circulate in your bloodstream giving instructions to your cells (another organ/system). For example, the thyroid gland's hormone, thyroxine (T4), governs and monitors your body's rate of metabolism and energy production.

The hormones that are most vulnerable to the aging female are called sex steroid hormones produced by a woman's ovaries.

Sex (Gonadal) Steroid Hormones

Estrone (E1), Estradiol (E2), and Estriol (E3): Categorized as 'the estrogens', each of these ovarian hormones has its particular functions. Estradiol, the most potent estrogen, primarily aids in the cyclic release of eggs from the ovaries for potential fertilization and preparation of the uterus for pregnancy. In addition to its role in cycling and pregnancy, estradiol also has powerful beneficial effects on heart, bone, brain and colon. It is the reduction in the level of estradiol that causes common menopausal symptoms such as hot flashes and night sweats. Estriol is produced in large quantities during pregnancy and is considered by some to be the 'gentle' estrogen providing some of the protection without exposure to the risks associated with stronger estrogens. Estrone, which can be converted to estradiol in some women, is the primary estrogen in postmenopausal women and is generated in fat cells.

Progesterone: Produced cyclically by the ovaries, progesterone maintains the uterine endometrium to nurture a fertilized egg and allows for fetal development throughout a pregnancy. Progesterone has been labeled the body's anti-estrogen, partnering with estradiol to maintain the delicate balance required between a woman's reproductive hormones. A woman's progesterone level diminishes, along with that of estradiol, as she approaches and enters menopause and, in most women, drops to low postmenopausal values.

As a woman ages (in her 40’s or 50’s)there is the slow decline of ovarian hormone production beginning with the irregular cycling of perimenopause which can last several years followed by menopause which is defined as not having cycled for twelve consecutive months. Though menopause brings with it a variety of desirable changes in a woman's life such as no more menstrual cycles, contraception or PMS, there can be many undesirable symptoms. These include:

1. Hot flashes, night sweats

2. Vaginal dryness

3. Dryness and thinning of skin, nails, hair

4. Bone loss

5. Mood swings

6. Decrease in libido (sex drive)

7. Memory problems

8. In addition to the decline in estradiol and progesterone levels, a woman's testosterone and DHEA levels continue to drop throughout her lifetime and are responsible for some menopausal symptoms.

Surgically Induced Menopause

Removal of a woman's ovaries will result in immediate menopause creating a series of rapid and intense symptoms that can be debilitating and can be addressed successfully with the appropriate form of hormonal intervention.

Diseases Associated with Hormones and the Aging Process

 Heart disease is the number one killer in America and the leading cause of death in women over age 65. As a woman's estradiol level decreases, her risk of heart disease increases. Older women are 10 times more likely to die from heart disease than breast cancer.

 Osteoporosis, a disease that occurs when bone is breaking down faster than it is being rebuilt, makes bones more fragile and susceptible to fracture. Testosterone has also been shown to help protect against osteoporosis.

 Alzheimer's Disease affects more than four million Americans a year with women at greater risk than men. Women taking estrogen therapy have a significantly lower risk of the dementia. In addition, recent animal studies indicate that testosterone may also have a protective effect against Alzheimer's Disease.

 Colon cancer is the second leading cause of cancer death in the United States with women at greater risk than men. Estradiol is now being studied as providing protection against this disease though the mechanism is still unclear.

What is Hormone Replacement Therapy?

HRT is the administration of steroid hormones (either natural, synthetic or animal-derived) to make up for the decline in those hormones (that drop naturally with age). Natural HRT or bio-identical HRT refers to a regimen of hormones that is bio-identical in structure and physiological activity to what the body produces. Importantly it also refers to the correct ratios of hormones. For example the correct ratio of E1:E2:E3 and E2:P. Natural progesterone is derived from Mexican Wild Yam, but must be manipulated in the lab. The wild yam is only active in humans once pharmaceutical conversion has taken place. Natural HRT brings with it the following benefits:

 Better tolerance (less unwanted side effects) such as blood clots, gallbladder disease.

 Better therapeutic profile, since the ratios are correct for humans.

 Improved long term patient acceptance.

Currently, more and more women and men are opting for natural HRT. Given both the short and long term health benefits, HRT is now considered by many healthcare providers as the preventive medicine of the 21st century for women and men in the second half of life. On the average, a female HRT user can expect to live up to 3 years longer than a non-user.

Replacing the body's declining hormones with natural, bio-identical hormone replacement is quite different from what might be considered 'natural' menopausal choices that can include:

 Maintenance of a healthy lifestyle such as frequent exercise, no smoking and minimal stress

 Dietary intervention with plant estrogens (such as those in soy products)

 Herbal intervention such as with dong quai, black cohosh or licorice (see below)

While there are scientific studies showing that some of these solutions do address short-term symptoms such as hot flashes, research is on going as to the long-term benefits of natural, non-hormonal solutions. This topic is evoking much interest especially with breast cancer patients and survivors who are experiencing severe menopausal symptoms and hesitate to intervene with hormones. While there is some concern about the estrogenic effects of these phytoestrogens they are weak at best and do not come close to the potency of E2. It is said that about 25% of postmenopausal women with breast cancer and 15% of postmenopausal women without breast cancer use these products. This is the conclusion by researchers at the Univ. of Pittsburgh studying the effects of Dong quai, vitex, Chinese ginseng, American ginseng, black cohosh, red raspberry leaf, licorice root, wild yam root.

Soy based compounds such as tofu, soy milk, roasted soy nuts, (and in one study 60 grams of soy protein daily caused a 33% decrease in not flashes after 4 weeks and 45% reduction after 12 weeks) are useful in reducing menopausal symptoms.

Vitamin E (800 IU per day) has been shown in studies as far back as the late 1940’s to alleviate menopausal symptoms. A trial period of no less than 3 months is recommended.

Vitamin C (1200 mg daily) was studied in the mid 1960’s and reports concluded that in combination with the bioflavonoid hesperidin ameliorate menopausal symptoms.

Herbals with weak estrogen-like actions have similar effects they include Licorice, Alfalfa, Red clover, Black cohosh, Vitex, Dong quai, Ginseng and Sage (useful in profuse sweating) have been tested by Germany’s Commission E. It is recommended that before starting any herbal patients should consult with their physician especially a nutritionally minded physician. While herbal preparations are somewhat effected the compounded NHRT creams and prescriptions are the most potent form of replacing low hormone levels.

Women who lead sedentary lifestyles are more likely to have menopausal symptoms. In one trial menopausal symptoms were reduced immediately after aerobic exercise. Aerobic exercise is certainly recommended for other health benefits as well.

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Dr. Saleeby offers mico-management of Natural Bio-identical Hormones for men and women via home visitation/house calls. For more information visit: www.CarolinaMobileMD.com

(c) 2009

Dr. Saleeby NOW accepting NEW patients

Dr. Saleeby making House Calls

Coming soon..... Dr. Saleeby will be making house calls in limited areas in the Charleston, SC area and Research Triangle Area (Raleigh, Durham, NC) area. Keep a watch out for these convenient and cost saving services.

Questions?

Call (800) 965-8482.

Dr. Saleeby writes about EM Physician Burnout - a personal experience

Physician Burnout

In February 2009 the Annals of Emergency Medicine, a peer reviewed journal put out by the American College of Emergency Physicians, published an article entitled: "Tolerance for Uncertainty, Burnout and Satisfaction with the Career of Emergency Medicine", it was a paper reporting results of a study that surveyed many ACEP members. The study wanted to realize the impact of physician “burnout” in this field of medicine. The importance in this group of physicians is that several years ago it was noted that the number of doctors retiring from this field is equivalent to those entering this field of medicine. And with healthcare reform inevitable, emergency rooms will be even more crowded and utilized as we have seen massive surges in recent years. This fact coupled with a rather high incidence of Emergency Room closures due to the economy places amazing strains and stress on the physician providers.

I have been practicing medicine since 1991 and for the past 16 years Emergency Medicine in one capacity or another. It is claimed that the “burnout rate” of a typical EM physician is some 8 or so years. So maybe I have superseded this statistic. However, as of late I have felt the “hurt”. I have decided that my family, my sanity and overall well being take priority over my primary calling in medicine. Luckily, I wear many hats and can diversify into other areas of medicine such as urgent care, occupational medicine and natural and integrative medicine or even a small private general practice. That is my immediate plan. After September of this year I will reduce my hours in the ED. Unfortunately, I am not the only one with these thoughts or plans. As the medical schools in America cannot keep up with the demand for primary care physicians and the EM training programs are not putting out enough trained to meet the need, and those taking early retirement are high it leaves a vacuum. This is something the Obama administration better address as they look into healthcare reform. Keeping physicians happy and making this field attractive to those thinking of a career in medicine is paramount to the success of any healthcare system. An exodus of physicians seeking early retirement or another career would result in an implosion of our healthcare system.

Physician burnout is not just a symptom of Emergency Medicine; it has affects in many other fields. It is multi-factorial and encompasses aspects of what American’s envision as the pursuit of life, liberty and happiness, it also deals with family dynamics, the insurance industry with reimbursements, pay scale, time off. Additionally it deals with pressures to perform by exceedingly higher patient standards and perceptions, pressures from hospital administrators, medical malpractice claims and insurance premiums.

Early on the physician susceptible to burnout exhibits an eagerness to work overtime and in so doing can disrupt his own life. He also has a feeling of delivering an unrealistic standard of care given the system. And there is the belief in the novice EM physician that he, unlike his predecessor is immune from burnout.

When burnout starts to show, there are signs of irritability, restlessness and fatigue. Also some experience boredom in the mundane and repetitiveness of what they do and see. For example, seeing the 10^th geriatric nursing home patient that presents with generalized weakness in one shift can drive anyone past their limits. Anxiety and depression may follow and there are those with somatic symptoms such as backache and headache that develop. Insomnia is often a symptom as one worries about their next shift. Skipping breaks and not taking lunch or dinner routinely can hasten the burnout process. Other symptoms and signs noticed by others can be the constant rumination and conversations about work and the job. The use of drugs and alcohol to self treat the symptoms of burnout are an ominous sign.

Late in the burnout stage a physician can often be perceived as cynical, apathetic and having lost interest in his work. Some with burnout will arrive late to work or even call in sick. There is an overtone of loss of empathy, callousness and even the reference of patients in a dehumanizing way. The use of terms such as gomer, trolls, dirt bags are signs of such. There are those who have feelings of loneliness, despair, isolation and hopelessness. This can all lead to the development of a negative attitude towards oneself, family and co-workers. Some with burnout are unable to find joy in any aspect of life; they can lose control and become verbally and physically abusive to others. Often times they will argue with staff and nurses over minor and trivial issues. Panic attacks, severe clinical depression, guilt, rumination and suicidal thoughts are common psychological manifestations of burnout.

Les I become victim or victimize my family and friends; I have taken a step toward reducing those things that are beyond my control to avoid the late stages of burnout. This should be lesson for others.

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JP Saleeby, MD is an Emergency Room physician of over sixteen years. He also has interests in nutritional and preventive medicine and has authored a book on Adaptogen Herbs.

References:
http://www.medicalnewstoday.com/articles/4563.php

http://www.acep.org/pressroom.aspx?id=44050

Schumacher Group Online CME

©2009

Power Point Presentation on EFA

The AMA Speaks Out on Healthcare

The American Medical Association has weighed in on Obama's new health care package. The Allergists were in favor of scratching it, but the Dermatologists advised not to make any rash moves. The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the Administration had a lot of nerve. Meanwhile, Obstetricians felt certain everyone was laboring under a misconception, while the Ophthalmologists considered the idea shortsighted. Pathologists yelled, "Over my dead body!", while the Pediatricians said, "Oh, grow up!" The Psychiatrists thought the whole idea was madness, while the Radiologists could see right through it. Surgeons decided to wash their hands of the whole thing and the Internists claimed it would indeed be a bitter pill to swallow. The Plastic Surgeons opined that this proposal would "put a whole new face on the matter".
The Podiatrists thought it was a step forward, but the Urologists were pissed off at the whole idea. Anesthesiologists thought the whole idea was a gas, and those softy Cardiologists didn't have the heart to say no. In the end, the Proctologists won out, leaving the entire decision up to the assholes in Washington.

-Author Unknown

Cola and osteoporosis

Cola and osteoporosis

This is important clinical research. With focus on administration of Vitamin

D-3, Vitamin K-2, Strontium, Calcium and Boron, we often pay too little

attention to the dietary factors that may worsen osteoporosis. This is one very

easy step, one very important step in the treatment of osteoporosis.



This is an exerpt from the National Library of Medicine abstract, for your

reading pleasure.





Tucker KL, Morita K, Quiao N, et al: Colas, but not other carbonated beverages,

are associated with low bone mineral density in older women: The Framingham

Osteoporosis Study. Am J Clin Nutr. 2006 Oct;84(4):936-42.



From Tufts University, Boston, MA 02111, USA. katherine.tucker@tufts.edu

Soft drink consumption may have adverse effects on bone mineral density (BMD),

but studies have shown mixed results. In addition to displacing healthier

beverages, colas contain caffeine and phosphoric acid (H3PO4), which may

adversely affect bone.

DESIGN: BMD was measured at the spine and 3 hip sites in 1413 women and 1125 men

in the Framingham Osteoporosis Study by using dual-energy X-ray absorptiometry.

Dietary intake was assessed by food-frequency questionnaire. We regressed each

BMD measure on the frequency of soft drink consumption for men and women after

adjustment for body mass index, height, age, energy intake, physical activity

score, smoking, alcohol use, total calcium intake, total vitamin D intake,

caffeine from noncola sources, season of measurement, and, for women, menopausal

status and estrogen use.

RESULTS: Cola intake was associated with significantly lower (P < 0.001-0.05)

BMD at each hip site, but not the spine, in women but not in men. The mean BMD

of those with daily cola intake was 3.7% lower at the femoral neck and 5.4%

lower at Ward's area than of those who consumed <1 serving cola/mo. Similar

results were seen for diet cola and, although weaker, for decaffeinated cola. No

significant relations between noncola carbonated beverage consumption and BMD

were observed. Total phosphorus intake was not significantly higher in daily

cola consumers than in nonconsumers; however, the calcium-to-phosphorus ratios

were lower.

CONCLUSIONS: Intake of cola, but not of other carbonated soft drinks, is

associated with low BMD in women. Additional research is needed to confirm these

findings.

Source: Newsletter from Dr. David S. Klein

Nutrition 101 - by Dr. Saleeby

Nutritional Intervention in the Middle-Aged Male Patient

While it is both natural and desirable to grow older, it is neither natural nor
desirable to feel or perform ‘older.’ Only a few short years ago, discussions
of erectile difficulties were unlikely topics for the average middle-aged male
patient. Frankly, few men were at all likely to admit to difficulties, at all.
Only after the introduction of Viagra® did the topic of erectile dysfunction
(ED) become regular or routine. Now, not only are these discussions routine,
but the topic is advertised on the side of a popular NASCAR race car.

Before we had Viagra®, impotence in the younger male was generally
considered to be a psychosomatic dysfunction. It is an interesting commentary
that only after a pharmacological intervention is introduced do many disease
states change from psychosomatic to physiologic in nature. While we now have
several good choices in medications with which to help reduce the symptoms of
ED, little is done to deal with the underlying conditions that lead to ED.
After elimination of the many common causes of iatrogenic and neurovascular
causes of ED, the typical patient is given the option of which pill to take.
This is indeed unfortunate because there are many interventions that the
physician can entertain that deal with the ED on a functional basis.

Male Hormonal Changes with Age
As men age past the age of 25, or so, testosterone levels can be expected
to drop, approximately 2% per year. Men at the age of 25 do not consider that
getting older, on a personal level. By the age of 50, testosterone levels have
dropped by 50%, and many men wonder where their youth and vitality went. This
is a well understood phenomenon, and many well-meaning physicians consider
testosterone replacement in this context. Testosterone will be metabolized into
estradiol. Treatment with testosterone without inhibiting this degradation will
result in elevations in serum estrogen.

What is less well recognized is the elevation in estrogen levels that
result during this same aging time-line. By the age of 40, many men will
demonstrate estrogen levels that exceed those of their spouses. The factor that
results in ED results more from the ratio of testosterone to estrogen than from
either hormone level, alone. That is, without addressing the elevation in
estrogen that is a normal, anticipated result from aging, the treatment of ED
with testosterone is likely to result in temporary, if any positive results. In
order to restore a healthy testosterone to estrogen ratio, the clinician must
inhibit the pathways that involve degradation of testosterone to estrogen. When
combined with enhancement of estrogen elimination, cholesterol levels can be
reduced, and weight loss can be anticipated.

The main metabolic pathways of testosterone to estrogen conversion involve
the enzymes 5-alpha reductase and aromatase. Both of these enzymes can be
effectively inhibited with inexpensive, available nutriceuticals. The
thoughtful balance of enzymatic inihibition with hormonal supplementation
results in restoration of healthy testosterone to estrogen ratios, and the
result is improvement or abatement of the symtoms of ED, reduction or
elimination of the problems seen with prostatic hypertrophy, and reduction in
serum cholesterol.

As with most other areas of interventional medicine, it is best to know
baseline hormonal levels before entertaining empiric intervention. Elevations
in estrogen can be treated with di-indol methane and indole-3 carbinol. When
combined with agents that stimulate biliary excretion, estrogen levels can be
lowered in a matter of a few weeks. The addition of saw palmetto and nettle
extract increases testosterone levels, relative to estradiol through the
inhibition of the 5 alpha reductase and aromatase enzymes. The reduction of
serum (total) estrogens can result in weight loss, and results in reduction in
depressive symptoms.

None of this is particularly difficult, and it is affordable to the vast
majority of the patient population. Sadly, the patient population has seen need
for these sensible approaches to health, but these same patients turn to lay
magazines, catalogues and self-serving marketers to provide the guidance that
they need. The general medical community has not taken the necessary steps to
educate ourselves in this vital area of preventive medicine. Until such time as
we collectively arm ourselves with the necessary understanding of functional &
nutritional medicine, the public will turn, in large numbers, to the clerk at
the vitamin store, the pharmacy technician and well-meaning neighbor for vital
(mis)information on the value of nutritional & nutraceutical maintenance of
health.

Source: newsletter@suffernomore.com

For male Natural Hormone Replacement Therapies contact Dr. Saleeby via www.saleeby.net

"And that's the way it is..."

Walter Cronkite (1916 - 2009)

A Plan Comes Together: The Sheep Obey

On May 1, 2009, the LA Times reported some amazing occurrences:

• Hospitals on New York’s Long Island were scrambling to bring extra workers in to handle a 50% surge in visitors to emergency rooms.
• In Galveston, Texas, the local hospital ran out of flu testing kits after being overwhelmed with patients worried about having contracted swine flu
• At Loma Linda University Medical Center near San Bernardino, California, emergency room workers set up tents in the parking lot to handle a crush of similar patients.
  In Chicago, ER visits at the city’s biggest children’s hospital are double normal levels, setting records at the 121-year-old institution.

So far, few of the anxious patients have had more than runny noses. The most disturbing revelations about these scenarios? They knew this was the way we would respond. What was published in 2006 has become fact in 2009.

A study conducted by the Harvard School of Public Health confirmed that public health officials could easily convince most people to alter their daily lives to stem the spread of influenza. “The Pandemic Influenza Survey” documented our willingness to do what we are told after only a little hyping that a deadly global pandemic was eminent. The 2006 survey included 1,700 Americans. More than 90 percent said they would [willingly] comply with government orders to postpone air travel, avoid public places such as movie theaters and shopping malls, and would keep their children home from school in the event of a flu pandemic. A full 94 percent said they would stay home from work for up to 10 days to help authorities control disease spread

How Soon We Forget

The word pandemic simply means a certain type of virus seems to be infecting persons over a wide area, in this case, several states and a few countries. The word “pandemic” is not synonymous with “massive death,” although the media would have us believe that the two are equal. In fact, most persons over 50 years of age experienced the last two documented pandemics and the pandemic scare of 1976. And according to a 2008 report by the CDC, “even those who experienced [the 1957 and the 1968] pandemics do not recall them as particularly memorable events.”

Most persons at least 43 years of age will no doubt recall the Swine flu hype of 1976. Starting from a single, infected military recruit, the threat of a pandemic and global death turned into a full-scale media and government circus. For many, the “Pandemic that Never Was” created havoc, death and long term disability. But the mayhem was not the work of a microscopic particle of replicating RNA. The carnage was created by the misguided steps our government and the overzealous drive from CDC officials to vaccinate.

The absolute belief in the effectiveness of vaccines resulted in the disability of 532 people who contracted Guillain-Barre Syndrome, a life-threatening form of paralysis. While many recovered in the ensuing months, at least 33 died and up to 10 percent remained paralyzed to varying degrees for the rest of their lives. While vaccine manufacturers reaped the rewards of government handouts to make vaccines, and secured legislation to protect them from liability (the Swine Flu Act of 1976), more than $1.3 billion of tax payer dollars were released to compensate those who had been injured by the swine flu vaccine.

For those X-Gens and Y-Gens under-40, ask your parents, grandparents and other senior relatives and friends what they recall about these Public Health panics. Surely they can shed some light about those moments in American history and their stories will help abate your fears of a “coming pandemic.” After all, they are alive to talk about it.

More Vaccines On The Way

Lessons about bad vaccines are rarely learned and the race to make more experimental doses has never been hotter. In 2005, Congress allocated $3.8 billion to developers with the stated goal of being able to “distribute a vaccine to every American within six months of the onset of a pandemic.” In 2006, our elected representatives went even further to ensure we are vaccinated: They created incentives for manufacturers by funding the Biodefense and Pandemic Vaccine and Drug Development Act of 2005, nicknamed BioShield II. (see previous article: Swine flu: The New Bird flu)

Along with BioShield II, legislation was passed to amend the Public Health Service Act and establish a division called Biomedical Advanced Research and Development Agency, or BARDA. The BARDA is responsible for coordinating and overseeing activities that support and accelerate research and development of countermeasures [i.e.vaccines] and other products that qualify as pandemic or epidemic products. The BARDA has budgetary authority to award contracts, grants, and cooperative agreements that will advance the research and development of drugs and vaccines. The creation of vaccines is big, serious business. To see the list of all agencies and federal legislation involved with creating pandemic vaccines and drugs as a countermeasure, spend some time website for the Center for Biosecurity.

On March 18, 2009, the BARDA requested $1.7 billion for FY 2010 to fund research and development of additional vaccines and drugs. Interestingly, just this week, President Obama released $1.5 billion of appropriations for pandemic planning. Although the funds were not specifically earmarked, it is probable that a portion of your tax dollars will go to fund BARDA. On May 1, 2009, the Working Group of the Infectious Disease Society of America chimed in and requested more funding for the current swine flu outbreak. Commending the President for releasing emergency appropriations for H1N1, the Working Group appealed to Congress for an additional $1.9 billion to fund the following:

• $870 million requested to expand cell and egg-based vaccine capacity. This money was requested from the previous Administration, but not funded in FY 2008. The money will also be used to purchase antivirals for the federal stockpile and to accelerate the R&D of rapid diagnostic tests;
• $350 million for States and localities to purchase equipment; funding staff and maintain 24-hour disease-reporting hotlines; increase public and clinician education about vaccines; distribute medical countermeasures [vaccines and antivirals], and refill staff positions lost to budget cuts;
• $122 million for State antiviral stockpiles for the treatment of people who become ill; and
• $563 million for States and localities to purchase personal protective equipment and antivirals for prophylaxis of healthcare and critical infrastructure workers.

This is amazing. A billion here, a billion there. A close look at these requests and it is apparent where the money flows: Directly into the pockets of the drug companies who make antivirals like Tamiflu and Relenza. The research and development funds will go toward new, novel flu vaccines, shots that much of the public has confirmed it would refuse.

On October 5, 2006 a survey reported by Reuters News service posted an article called, “Americans doubt need for flu vaccine: survey,” by Maggie Fox. The survey documented that fewer than half of Americans planned to get the flu vaccine that year, mostly because they do not worry about flu. The survey of 1,000 adults found that just 48 percent planned to get immunized that year. Of those who did not plan to get the vaccine, 43 percent said they did not think influenza was serious enough to warrant vaccination and 38 percent felt they were not at risk. Flu experts called the findings “disappointing,” and from that point forward, a full-court press has been on to increase the uptake of annual flu shots. No doubt the fear generated by the potential swine flu pandemic is part of the Play Book to make the flu seem serious enough for everyone to get vaccinated. However, it appears the latest Swine flu buzz is fading away as fast as it materialized. Scientists are coming to the conclusion that the new swine flu strain may actually be less dangerous than garden-variety, seasonal influenza. Even though there are positive cultures from 331 people in 11 countries, and 10 have died, even the WHO admits the numbers are “extremely small.” It is estimated that globally between 3 and 5 million people experience some level of the flu each year. One has to wonder why this has even made the news.

Something Bigger?

In January, 2009, the out-going Secretary of HHS, Michael Leavitt, released a report called “Pandemic Planning VI,” a summary of all the steps that have been completed to date in preparation for the next global pandemic. That document has become a suggested a check list for Janet Napolitano, President Obama’s Secretary of HHS, to complete. If you haven’t seen it, it is worth reading, even though it may keep you up at night, knowing what is coming in the form of vaccines, vaccine types and new vaccine adjuvants.

We have had three warm-up rounds: SARS, H5N1 bird flu and now, a “novel swine flu” from Mexico. Is there something bigger in store? There is no way to know for sure, but it is highly suspect. What we can say for sure is that another pandemic test round has passed muster. The media machine did its job, the government handed over billions for more vaccines and vaccine technologies, and, of course, many of the sheep obediently put on masks and fearfully ran off to doctors to be tested. When this has run its course, bureaucratic agencies will be slapping themselves on the back, affirming that all the systems worked ‘as planned.’ They turned the crank; the world danced to their tune.

For those who hope that one day, an informed citizenry will undertake a serious blow back against the continually escalating government propaganda and media manipulation, I hope most of you find the reports of runs on emergency rooms and the optional mask- and glove-wearing to be somewhere between amusing and annoying. Fear runs this country and when the great “What If” boogey man shouts, a large number seem to listen. As I write this, I am on a completely full, 737 airplane about to complete a three-hour flight from Houston to San Diego. Not one person came on the plane with a mask and I have not heard a single sneeze or a sniffle. I’m glad to see that many are going about their lives, business as usual.

The information in my book, FOWL!, is as timely now as when it was written. In 2006, I reported that the Director General of the WHO had said in 2005, “It is only a matter of time before an avian flu virus—most likely H5N1— acquires the ability to be transmitted from human-to-human, sparking the outbreak of human pandemic influenza. We don’t know when this will happen. But we do know it will happen.” (He didn’t say “might” or “maybe” – he said a pandemic “will” occur).

And if he is right and we do see another sizable pandemic –whether the virus is man-made or created by some natural, random reassortment of viral genes – my hope is that everyone will take a deep breath, exercise normal health precautions, increase their Vitamin D, A and E intake, get lots of extra sleep and remember the lessons from history so we do not repeat them.

source: http://drtenpenny.com/a_plan_comes_together.aspx / http://blogs.healthfreedomalliance.org/blog/2009/07/16/a-plan-comes-together-the-sheep-obey

Osteoporosis in our Seniors

Nutritional Factors in Osteoporosis

The incidence of osteoporosis increases with age, and is develops at an earlier
age in woman than in men. About 55 % of Americans, women more so than men, are
at risk of developing osteoporosis. This disease is characterized by a
demineralization of the bones, which become porous and fragile, this causing a
higher susceptibility to fractures.

Bone is largely calcium in nature, but it is only now becoming more obvious that
calcium intake is but one of many nutritional concerns that must be addressed in
order to effectively treat osteoporosis.

FACT #1: The human adult requires approximately 200 mg of elemental calcium per
day, requiring a nutritional allowance is approximately 1,000 mg per day. Too
much calcium causes malabsorption of other nutrients. With calcium intake, more
may be less.

FACT #2: Taking a properly balanced mineral supplement minimizes the danger of
taking too much calcium.

FACT #3: Most commercially available vitamin/mineral supplements are worthless
because they present the minerals in a poorly absorbed, inorganic form. It is
better that you should keep your money in your pocket than to purchase this
junk.


Dietary Phosphoric Acid Accelerates Osteoporosis

Diet influences development of osteoporosis. Intake of phosphoric acid can
dramatically accelerate the development of osteoporosis. Cola beverages are the
greatest dietary/environmental risk in this regard. Phosphoric acid is present
in high concentration in cola beverages, and consuming phosphoric acid will
worsen calcium deficiency and weaken bone.

FACT #4: Phosphoric acid intake, in the form of carbonated soft-drinks can
hasten the development of osteoporosis.

Vitamin K-2

Vitamin K-2 is member of a lesser known vitamin group. Vitamin K-2 stimulates
bone formation by way of hormone-regulation, and Vitamin K-2 reduces the
incidence of vertebral fractures, despite having only modest direct effects on
the bone mineral density. Vitamins K-1 and K-3 are inactive in this regard.

Vitamin K-2 is found in certain vegetables, but it is absorbed best if injested
simultaneously with butter. Further, the production of Vitamin K-2 is
accomplished through ‘normal’ gastro-intestinal bacteria.

NOTE WELL: Supplementation of vitamin K-2 can prevent the development of
osteoporosis and reduce the risk of lumbar compression fractures from
osteoporosis.



FACT #5: GI bacteria are important to the production of Vitamin K-2.
Anti-biotics kill off the ‘good bacteria’ right along with the pathogenic
bacteria. Loose use of antibiotics alter GI flora, crippling our ability to get
VitaminK-2.

FACT #6: Taking the wrong form or formulation of Vitamin K, or Vitamin K-2 is
worthless in therapeutic benefit.

Vitamin D-3

Cholecalciferol (Vitamin D-3) is necessary for the absorption of calcium from
the gut as well as for deposition of calcium in the bone. Vitamin D-3 deficiency
leads to Osteoporosis. [editors note: Vitamin D is actually not a vitamin in the pure
sense by definition as our bodies make this compound when exposed to sunlight, however by
convention it is still referred to as a "vitamin". (Saleeby)]

Vitamin D-3 is really is not a vitamin, at all, but it is a hormone. Its
metabolic product, calcitrol has genetic receptors in over 200 genes in the
human body, and vitamin D deficiency is a major factor in the pathology of at
least 17 varieties of cancer as well as heart disease, stroke, hypertension,
autoimmune diseases, diabetes, depression, chronic pain, osteoarthritis,
osteoporosis, muscle weakness, muscle wasting, birth defects, and periodontal
disease.

FACT #7: Vitamin D-3 supplementation reduces the risk of breast cancer,
prostate and colon cancers by as much as 50%, and reduces the risk of developing
multiple sclerosis (MS) by as much as 40%.

Strontium

Strontium is an element necessary for the maintenance of calcium matrix.
Strontium supplementation decreases the risk of vertebral fractures, by 49%
within the first year of treatment. Further, this risk of non-vertebral
fractures is decreased by 16% and, in patients at high risk for such a fracture,
the risk of hip fracture is decreased by 36% over 3 yrs.

Other Important Nutrients



However, there are other vitamins and minerals needed for metabolic processes
related to bone, including manganese, copper, boron, iron, zinc, vitamin A,
vitamin C, and the B vitamins. The diet must be sufficient in balanced protein
as well as balanced with the appropriate fats and oils.

Deficiencies in zinc, magnesium, manganese, strontium, vanadium and chromium,
result in many disease states ranging from obesity and diabetes to Alzheimer’s
Disease and cancer.

To this end, I find it easiest to start my patients on a balanced mineral
supplement, separate and distinct from the vitamin and hormonal supplement
requirements. This permits adjustment for age, gender, and disease state. If
these products were presented in one capsule or packet formulation,
customization would be difficult if not impossible.



Summary

Bone is a dynamic organ system. Physiologic forces promote bone deposition and
production, while others promote resorption and destruction. Nutritional
influences are extremely important, both in positive and negative terms. It
takes a wide variety of essential substances, mineral, vitamin, protein, and
hormonal to maintain the health and integrity of each and every organ system,
including the musculoskeletal system.



Source: David S. Klein, MD e-mail newsletter

PE a commonly missed fatal disease

CTPA of patient with PE

Pulmonary Embolism

The patient's diagnosis was made based on the CT pulmonary angiogram (CTPA) of the chest, which revealed multiple thrombi extending into the lobar and segmental/ subsegmental branches of the right and left pulmonary arteries. Venous Doppler ultrasonography of both lower extremities was negative for deep vein thrombosis. A CT scan of the abdomen and pelvis with contrast did not reveal any thrombi in the pelvic veins. Venous Doppler ultrasonography of the upper extremities was not performed, as upper extremity thrombi are less common than lower extremity deep venous thrombi.

Pulmonary embolism is a serious and potentially fatal complication of thrombus formation within the deep venous circulation. Pulmonary embolism is the third leading cause of death in the United States, with approximately 650,000 patients developing pulmonary embolism each year. Most cases are not recognized antemortem; up to 80% of cases are diagnosed at autopsy.

The pathophysiology of pulmonary embolus is thought to result from obstructed pulmonary blood flow. Air, amniotic fluid, foreign bodies, parasite eggs, septic emboli, and tumor cells can all embolize in the pulmonary vasculature. The most common embolus is a thrombus, which can form anywhere in the venous system. The most common site for thrombus formation is in the deep veins of the lower extremities. The risk factors for thrombus formation are venous stasis, hypercoagulable state, and vessel wall (endothelial) damage (known as the Virchow triad). Several factors predispose individuals to an increased risk of pulmonary embolism, including an age of over 40 years, obesity, congenital thrombophilia, smoking, cancer, and pregnancy. The risk is also increased by use of oral contraceptives.

Although the presentation of pulmonary embolus can be extremely variable, the typical presentation includes dyspnea, cough, fever, leg pain and swelling, and chest pain. As the thrombus progresses, patients may develop apprehension, diaphoresis, palpitations, nausea, vomiting, chills, and syncope. If patients remain untreated, they may develop syncope, cyanosis, diaphoresis, tachycardia, hypotension, and shock. Less common signs include hemoptysis, atelectasis, wheezing, pleural friction rub, rales, accentuated S2 or S3, tricuspid regurgitation, jugular venous distension, and acute right ventricular strain. Signs of acute right ventricular strain that may be seen on an electrocardiogram include an S-wave in lead I, a Q-wave in lead III, and a T-wave in lead III. Right axis deviation and partial or complete right bundle branch block may also be noted.

The differential diagnosis of pulmonary embolism includes dissecting aortic aneurysm, pneumonia, acute bronchitis, bronchial carcinoma, pericardial or pleural disease, heart failure, costochondritis, pleurisy, pneumothorax, mucus plug, and myocardial ischemia.

Routine laboratory tests have limited value in the diagnosis of pulmonary embolism. Arterial blood gas may reveal hypoxemia, hypocapnia, and respiratory alkalosis with an elevated A-a gradient. A positive D-dimer is not specific for pulmonary embolism, but a negative D-dimer has a 95% negative predictive value; therefore, it is useful in ruling out pulmonary embolism in those with a low pretest probability of disease. Coagulation studies and coagulopathy workup are not useful in the diagnosis of pulmonary embolism, but they may be necessary once the diagnosis has been established to rule out an underlying hypercoagulable condition.
The gold standard for diagnosing pulmonary embolism has been pulmonary angiography; however, CTPA is rapidly gaining in popularity for diagnosing pulmonary embolism, with a sensitivity of 85-94%, and it is likely to become the new gold standard. Spiral CT scanning is less invasive and more available than pulmonary angiography. A ventilation-perfusion scan can be useful in ruling out pulmonary embolism, but it may be less useful in diagnosing pulmonary embolism because many clinical conditions can lead to defects in the perfusion scan as a result of decreased blood flow. A ventilation-perfusion scan is now generally done only when CT angiography is contraindicated. Chest radiography is usually performed, but it is rarely diagnostic and is often completely normal. An ECG is typically obtained to rule out alternative causes of chest pain/dyspnea, but it is also not of much diagnostic value in pulmonary embolism itself. The most common ECG abnormalities in pulmonary embolus include sinus tachycardia and nonspecific T-wave changes. Although the classic S1Q3T3 pattern was noted in hindsight in this patient, especially with return visits, it is not frequently seen.

The treatment for pulmonary embolism falls into 2 categories. The first category includes patients who are hemodynamically stable. For these patients, anticoagulation and prevention of recurrent pulmonary embolism are vital. Anticoagulation is initially obtained with the use of heparin, fondaparinux, or low molecular weight heparin (LMWH). After initial anticoagulation is started, warfarin may be commenced. Bridging with heparin or LMWH for the first 5 days of warfarin therapy, until a therapeutic international normalized ratio (INR; therapeutic range, 2-3) is achieved is necessary. To prevent recurrent pulmonary embolisms, inferior vena cava or other intravenous filters can be placed.

The second category of treatment addresses hemodynamically unstable patients. For these patients, there are 2 major treatment options. The first is direct removal of the clot, through surgical embolectomy or catheter-based extraction by an interventional radiologist. Surgical embolectomy should only be used in patients with contraindications to thrombolytics or failed thrombolytics, or in whom surgery may be the only chance for survival. The second form of treatment is thrombolysis. Although thrombolysis has not been shown to improve mortality, it is often readily available in EDs. Indications for thrombolytic therapy include patients with shock, right heart failure, underlying cardiopulmonary disease, recent pulmonary emboli, or severe pulmonary hypertension. Thrombolytics may cause significant bleeding, including central nervous system bleeding, and they should only be used in appropriate circumstances where the risk/benefit ratio is favorable.

Contraindications of thrombolysis include recent or suspected cerebrovascular accident, intracranial trauma or surgery within the past 2 months, active intracranial disease, major internal bleeding within the past 6 months, uncontrolled hypertension, bleeding diathesis/coagulopathy, recent major surgery within 10 days, recent trauma, infective endocarditis/pericarditis, pregnancy, aortic aneurysm or hemorrhagic retinopathy.

The patient (CT above) was admitted to the intensive care unit and started on LMWH and warfarin. Given the subacute nature of his symptoms and his apparent stability, thrombolytics were not initially administered. The patient's oxygen saturation and symptoms continued to improve during his hospitalization and further laboratory studies, including antinuclear antibody (ANA) , protein C and S, prothrombin mutation, factor V Leiden, lupus anticoagulant, and phosphatidyl antibody, were initiated. He was discharged once his INR was therapeutic at a range of 2-3 and followed up in an anticoagulation clinic to maintain a therapeutic INR. All coagulation panel labs were negative, and he has not had a recurrence of the pulmonary embolism. A CT scan of his chest, abdomen, and pelvis done 1 month after initiation of therapy revealed an approximate 95% decrease in the size of the emboli seen in the left pulmonary artery and an almost 80% decrease in the pulmonary emboli seen in the right pulmonary artery. The embolic source was never identified.

source: http://cme.medscape.com/viewarticle/704438?src=emed_case_nl_0

Takotsubo cardiomyopathy - Stress induced

Watch your stress... you may find yourself suffering from an unusual type of cardiomyopathy (enlargement of the apical aspect of the heart).

(A: Takotsubo Cardiomyopahty scheme with ballooning of the apical aspect of the heart. B: Normal heart cross section)

Takotsubo cardiomyopathy, also known as transient apical ballooning, apical ballooning cardiomyopathy, stress-induced cardiomyopathy, broken-heart-syndrome and simply stress cardiomyopathy, is a type of non-ischemic cardiomyopathy in which there is a sudden temporary weakening of the myocardium (the muscle of the heart). Because this weakening can be triggered by emotional stress, such as the death of a loved one, the condition is also known as broken heart syndrome.

The typical presentation of someone with takotsubo cardiomyopathy is a sudden onset of congestive heart failure or chest pain associated with EKG changes suggestive of an anterior wall heart attack. During the course of evaluation of the patient, a bulging out of the left ventricular apex with a hypercontractile base of the left ventricle is often noted. It is the hallmark bulging out of the apex of the heart with preserved function of the base that earned the syndrome its name "tako tsubo", or octopus trap (bowl) in Japan, where it was first described.

The cause appears to involve high circulating levels of catecholamines (mainly adrenaline/epinephrine). Evaluation of individuals with takotsubo cardiomyopathy typically include a coronary angiogram, which will not reveal any significant blockages that would cause the left ventricular dysfunction. Provided that the individual survives their initial presentation, the left ventricular function improves within 2 months. Takotsubo cardiomyopathy is more commonly seen in post-menopausal women. Often there is a history of a recent severe emotional or physical stress.

source: http://en.wikipedia.org/wiki/Takotsubo_cardiomyopathy

Ankylosing spondylitis

Ankylosing spondylitis is a chronic inflammatory disorder of multiple articular and para-articular structures that principally involves the axial skeleton. It usually affects the sacroiliac joints and the spinal facet joints of the vertebrae. It sometimes involves the appendicular skeleton as well, such as the joints of the greater trochanter, patella, and calcaneum. Other extraspinal manifestations include iritis/uveitis and pulmonary involvement. The basic pathologic lesion of ankylosing spondylitis occurs at the entheses, which are sites at which ligaments, tendons, and joint capsules attach to bone. In the outer layers of the annulus fibrosis of the intervertebral disks, the condition manifests as a formation of new bone. The name of the disease is derived from Greek; "ankylos" means stiffening of a joint, and "spondylos" means vertebra. The disease is classified as a chronic and progressive form of seronegative arthritis. Ankylosing spondylitis affects men 4-10 times more frequently than women, and the symptoms generally appear in those aged 15-35 years. More than 90% of whites with ankylosing spondylitis have the HLA-B27 gene, but 6-8% of those with this gene do not develop the disease.

Symptoms of ankylosing spondylitis include back pain and stiffness, peripheral joint and chest pain, sciatica, anorexia, weight loss, and low-grade fever. The back pain associated with this condition is typically transient at first, but it eventually becomes persistent. It is usually worse in the mornings and resolves with exercise. A typical patient may also complain of waking up with back pain at night. The pain is usually centered over the sacrum, but it may radiate to the groin, buttocks, and down the legs. With time, the back pain usually progresses up the spine and affects the rib cage, resulting in a restriction of chest expansion and diaphragmatic breathing (observed as ballooning of the abdomen during inspiration) as the costovertebral joints become affected. The cervical spine is ankylosed late in the course of the disease, leading to restriction in neck movement and head rotation. Without treatment, the spine eventually becomes completely rigid, with loss of the normal curvatures and movement.

On physical examination, the loss of lateral flexion of the lumbar spine is the earliest objective sign of spinal involvement. The sacroiliitis may be detected by eliciting a tenderness response during percussion over the sacroiliac joints. Objective tests to quantify spinal restriction include touching the toes, the Schober test, and measurement of chest expansion. Additional physical findings include restriction of motion in the peripheral joints and tenderness over the enthuses. The physical exam should also include evaluation for signs of potentially serious cardiovascular and pulmonary complications, such as aortic incompetence secondary to aortitis, conduction defects of the heart, cardiomyopathy, pericarditis, apical fibrosis of the lungs, bronchiectasis, cavitation of the chest, and development of a restrictive ventilatory pattern. Other associated conditions include the development of inflammatory bowel disease, uveitis (in up to 20% of patients), radiculitis secondary to inflamed nerves, and, rarely, amyloidosis.

Specific criteria for the diagnosis of ankylosing spondylitis include the Rome criteria (developed in 1963) and the New York criteria (developed in 1968). Although these criteria have been generally accepted as useful, limitations are recognized and overlaps exist among the clinical and radiologic features of various seronegative spondyloarthropathies. Sacroiliitis is the hallmark of ankylosing spondylitis and is a requisite for the diagnosis under both sets of criteria. Other conditions, such as psoriasis, Reiter disease, enteropathic arthropathy, hyperparathyroidism, and osteitis condensans ilii, may also result in bilateral symmetric sacroiliac joint disease and should be considered in the differential diagnosis. Ankylosing spondylitis may also present with asymmetric sacroiliitis, which may be more characteristic of other conditions, such as psoriasis, Reiter disease, rheumatoid arthritis, and gouty arthritis. Radiographically, diffuse idiopathic skeletal hyperostosis (DISH) has a similar appearance to ankylosing spondylitis; however, DISH typically occurs at a later age and does not involve the sacroiliac joint.

The radiographic changes usually first appear in the sacroiliac joints, followed by the thoracolumbar and lumbosacral spine; this is in line with the natural progression of the disease. The disease then proceeds cephalad up the spine; however, the cervical spine may also be affected without involvement of the thoracic or lumbar spine. Radiographically evident peripheral-joint abnormalities are seen in more than 50% of patients. Abnormalities can also be seen in the symphysis pubis and in the manubriosternal, sternoclavicular, and temporomandibular joints. Spinal findings include osteitis, syndesmophytosis, diskovertebral erosions and destruction (Romanus lesions), and disk calcification. Radiographically, joint involvement appears as joint-space narrowing, periostitis, osseous erosion, and minimal periarticular osteoporosis (less than that seen with rheumatoid arthritis). Sacroiliac joint involvement is usually bilateral and symmetric.

Common laboratory findings are an elevated erythrocyte sedimentation rate (during the acute phase), a positive HLA-B27 histocompatibility antigen, mild leukocytosis, normochromic normocytic anemia (anemia of chronic disease), and negative results for rheumatoid factor.

The general principles of managing chronic arthritis also apply to ankylosing spondylitis. Among the various nonsteroidal anti-inflammatory drugs (NSAIDs) available to treat the disease, indomethacin may be the most effective. The lowest dose that provides pain relief should be used in order to avoid potentially serious complications, such as gastritis, peptic ulcer disease, and renal insufficiency. Sulfasalazine can be useful if peripheral arthritis is substantial, but it may be less effective when spinal and sacroiliac pain are the most prominent symptoms. In the majority of patients, the symptoms persist for life, although in some cases remission does occur.

Physical therapy and exercise can help prevent axial immobility. Specifically, spinal extension and deep-breathing exercises maintain spinal mobility, encourage erect posture, and promote chest expansion. Maintaining an erect posture and sleeping on a firm mattress with a thin pillow can help reduce thoracic kyphosis. Severe hip or spinal involvement may require surgical repair. Antitumor necrosis factor (anti-TNF) agents, such as infliximab and etanercept, are relatively new but often very effective therapeutic agents that may be considered for patients with pain refractory to other interventions.

source: http://cme.medscape.com/viewarticle/703652_2

More on Hypothyroidism

Hypothyroidism:  The Silent Epidemic

Hypothyroidism can be loosely defined as a medical condition that results from
the under-secretion of Thyroid Hormone.  The difficulty with this traditional
approach to diagnosis of hypothyroidism is that it relies on ‘normal values,’ or
reference ranges that are defined by the population itself.  It has been
estimated that as many as 50 million American suffer from undiagnosed
hypothyroidism.

Fact #1:  Thyroid hormone is necessary to maintain basal metabolic rate, or the
amount of fuel that is consumed to sustain health.  The manifestation is that of
temperature. 
a.  When a person is generating too little thyroid hormone, or if the individual
has an imbalance that involves thyroid metabolism, body temperatures will fall. 

b.  These persons may be told that they ‘normally have low temperatures.’ 
c.  This bit of nonsense is causing tremendous problems for society.
d.  The result is weight gain, depression and elevations in cholesterol levels.

Fact #2:  The traditional approach to the diagnosis of hypothyroidism involves
measurement of a hormone released by the pituitary gland, TSH.   If the central
nervous system senses that there is inadequate thyroid hormone in the blood
stream, TSH levels will increase.  Increase in TSH should lead to increases in
the release of Thyroid Hormone from the Thyroid Gland.  As levels of Thyroid
Hormone reach adequate levels, TSH release decreases.

Problem #1:  Unfortunately, a lot can go wrong between the brain, pituitary
gland and the thyroid gland, itself.  Inadequate levels of thyroid hormone can
persist, and the brain will ‘reset’ to new and lower levels of this hormone. 
Factors that can cause this include: 
1.  chronic stress
2.  pregnancy
3.  trauma
4.  chronic disease states.
5.  autoimmune conditions
6.  fasting or famine conditions.

As TSH levels drop back to normal, the diagnosis of hypothyroidism becomes more
difficult, if all the practitioner relies upon is the TSH level.  Unfortunately,
this is the case more times than not.

Problem #2:  Thyroid Hormone does not work alone.  It requires adequate levels
of estradiol, estrone, progesterone, testosterone, cortisol, insulin, DHEA and a
host of other hormones, peptides, fatty acids and humoral elements.  If any one
of these necessary pieces are missing, out of balance, or in excess, thyroid
hormone may not work properly, leading to a state of ‘functional
hypothyroidism.’ 

TSH levels, thyroid hormone levels are ‘normal,’ but the body does not function
properly and resembles the hypothyroid condition.

Problem #3:  Thyroid Hormone replacement may be inadequate or improper for the
patient.  That is, not all thyroid replacement works for all patients.  There
are chemicals in some of the commercially available thyroid preparations that
cause all manners of problems.  One such substance is ‘Acacia,’ which is a
family of shrubs and trees, and portions of this plant are used in some
medications to provide form and shape to tablets.  Lactose is also used in the
most popular of the Thyroid Replacement Hormones.  Not only is Lactose an
allergic trigger for people with lactose intolerance, but it may actually block
the absorption of the thyroid replacement, itself. Signs of lactose intolerance
include nausea, cramps, bloating, gas, and diarrhea.

It is very common to hear patients tell the doctor that the thyroid medicine
that they are receiving is ‘making me sicker.’  Unfortunately, the practitioner
does not often make the effort to figure out why this might be the case.

Problem #4:  Certain foods make thyroid conditions worse.  Patients with
auto-immune disorders may be more sensitive to soy-protein than other persons. 
Soy contains two chemicals that inhibit an important enzyme that is necessary
for thyroid hormone replacement.  If a person is already ‘on the edge,’ taking
soy protein can make the condition worse.  To a lesser extent, peanuts, pinto
beans do this, as well.

Recommendations: 
1.  In order to sort through the diagnosis of thyroid related problems, it is
important to determine not only the levels of thyroid hormones and TSH, but it
is important to determine the presence of antibodies to the binding protein and
converting enzymes.
2.  If you suspect that you have hypothyroidism, it is necessary to cease eating
anything that contains soy, soy lecithin, peanuts and pinto beans.
3.  Replacement of thyroid hormone should be accomplished with products that do
not contain lactose, Acacia, and artificial colorations.
4.  Thyroid hormone must be taken on an empty stomach.
5.  Determination of hormone imbalances that affect thyroid metabolism must be
accomplished.

email from David S. Klein, MD, FACA

Thyrotoxicosis & Thyroid Storm

Thyrotoxicosis refers to an elevated concentration of thyroid hormone as well as the related clinical manifestations. This is differentiated from thyroid storm, a life-threatening manifestation of thyrotoxicosis in which a markedly hypermetabolic state is present. Hyperthyroidism most commonly results from uncontrolled Graves disease, in which autoantibodies to the TSH receptor are produced. This leads to excessive thyroid hormone production from the thyroid gland and a reflexive inhibition of TSH release from the pituitary gland. Other etiologies can include a solitary thyroid adenoma, toxic multinodular goiter, hypersecretory thyroid carcinoma, thyrotropin-secreting pituitary adenoma, struma ovarii, and iodine or amiodarone administration. A precipitating event, such as surgery, trauma, myocardial infarction, pulmonary embolism, diabetic ketoacidosis, childbirth, severe infection, discontinuation of antithyroid medication, or thyroid surgery on a patient with uncontrolled hyperthyroidism, is often needed to push a patient with hyperthyroidism into thyroid storm.

The incidence of hyperthyroidism in the United States is 0.05% to 1.3%, most of which remains undiagnosed. Approximately 1-2% of these patients will progress to thyroid storm at some point. The prevalence is slightly higher in women compared with men and in white and Hispanic populations compared with black populations. Thyroid storm is most common in the third to sixth decades of life, although it can occur at any age.

Thyroid storm is a clinical diagnosis and, considering the acuity of this life-threatening condition, patients with thyrotoxicosis should be treated empirically when the diagnosis is suspected. Symptoms of thyrotoxicosis include weight loss, palpitations, hair loss, diplopia, chest pain, oligomenorrhea, or confusion. The physical examination reveals a hypermetabolic state, with abnormalities involving multiple organ systems. These findings commonly include hyperpyrexia, tachycardia, tachypnea, and hypertension. Other findings may include fine tremor, exophthalmos, ophthalmoplegia, pretibial edema, congestive heart failure, thyromegaly, thyroid bruit, and hyperreflexia. Laboratory studies show a low TSH level and elevated T3 and T4 concentrations. TSH is the most precise indicator of thyroid function because of the very high sensitivity of the thyroid-pituitary feedback loop, and current assays are able to detect levels of 0.02 mIU/L or less. As such, a normal TSH level largely excludes significant thyroid disease. Other laboratory findings seen in thyrotoxicosis may include hyperglycemia, hypercalcemia, leukocytosis, and elevated liver enzymes. Further testing may be indicated as part of a search for the precipitating cause of clinical decompensation, such as infection, myocardial infarction, or diabetic ketoacidosis. Electrocardiography most often reveals sinus tachycardia or atrial fibrillation. Although thyroid storm requires more rapid and aggressive therapy than thyrotoxicosis, differentiating between the two can sometimes be difficult, as it was in this patient. Burch and Wartofsky developed a scoring system to assist in making this distinction that takes into account thermoregulatory dysfunction, central nervous system effects, gastrointestinal dysfunction, the degree of tachycardia, the extent of congestive heart failure, the presence of atrial fibrillation, and the presence or absence of a precipitating event.

Cardiac complications from thyrotoxicosis include arrhythmias, congestive heart failure, and pulmonary hypertension. The most common arrhythmia in thyrotoxicosis is sinus tachycardia; however, atrial fibrillation occurs in 10-20% of patients with thyrotoxicosis, most often in patients who are older than 60 years. Risk factors for atrial fibrillation in these patients include male sex, increasing age, coronary heart disease, heart failure, and structural heart or valvular disease. Congestive heart failure in thyrotoxicosis is predominantly caused by either persistent tachyarrhythmias (tachycardia-induced cardiomyopathy) or uncontrolled hypertension as a consequence of thyrotoxicosis. Systolic dysfunction can occur as a consequence of the persistent cardiac arrhythmias, but it usually resolves once the hyperthyroid state is treated. Pulmonary hypertension can also occur in thyrotoxicosis, either as a result of a primary effect of thyroid hormone on pulmonary arteriolar resistance vessels, decompensated left heart failure, or via increased pulmonary arterial blood flow (high-output).

The differential diagnosis for thyrotoxicosis and thyroid storm may include anxiety, congestive heart failure, heat exhaustion or heatstroke, factitious disorder, neuroleptic malignant syndrome, panic disorder, septic shock, serotonin syndrome, anticholinergic or sympathomimetic toxicity, and alcohol or benzodiazepine withdrawal syndromes. Because infection is a common trigger for thyroid storm, an initial misdiagnosis of sepsis is not uncommon because of similar characteristics, such as tachycardia, fever, and altered mental status.

Management of thyrotoxicosis consists of a 5-pronged, ordered approach, targeting each step in the biosynthetic pathway of thyroid hormone and its activity on target tissues. Treatment begins with administration of propylthiouracil (PTU) or methimazole, both of which act by inhibiting new hormone synthesis. PTU has the added effect of decreasing peripheral T4 to T3 conversion. Beta-blockers are then employed to inhibit target activity of thyroid hormone. Propranolol is the preferred agent because it also blocks peripheral conversion of T4. When cardioselective agents are preferred, atenolol or metoprolol may be used. At least 1 hour after administration of PTU or methimazole, the patient may be given iodide to inhibit further thyroid hormone release. It is imperative that iodine be given only after synthesis of new hormone is blocked because iodide administration can have the undesired effect of increasing new hormone synthesis. Potassium iodide or Lugol solution of iodine is recommended. Peripheral conversion of T4 to T3 is blocked, as noted above, and dexamethasone may be used as well. Further treatment is supportive and may include acetaminophen for fever and hydrocortisone if the patient is hypotensive as a result of adrenal insufficiency. Salicylates are contraindicated because they displace bound thyroid hormone in the blood.

With regard to the management of cardiac symptoms related to thyrotoxicosis, treatment is focused on reducing adrenergic drive to the heart and restoring normal cardiac rhythm. As mentioned above, beta-blockers are very effective for rapid hemodynamic improvement. Either propranolol or metoprolol given intravenously can be used to improve heart rate control either in sinus tachycardia or atrial fibrillation. In severe cases, a continuous infusion of esmolol may be required for rate control. Amiodarone should be avoided when treating atrial fibrillation from thyrotoxicosis because of its high iodine content, which may induce or exacerbate thyroid storm. If a patient is hemodynamically unstable from atrial fibrillation, direct current cardioversion should be employed. If symptoms of pulmonary congestion appear, diuretics may be used. Other drugs for heart failure (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/or aldosterone receptor antagonists) are reasonable agents in patients who have depressed left ventricular systolic function. Anticoagulation is recommended for patients in atrial fibrillation secondary to thyrotoxicosis. The 2006 American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) guidelines recommend anticoagulation with warfarin to an international normalized ratio of 2.0-3.0 until the patient is euthyroid, after which recommendations and risk stratification are the same for atrial fibrillation without thyrotoxicosis. Of note, PTU, methimazole, and iodide solutions are all classified as pregnancy class D and, as such, should not be used in pregnancy.

Source: Medscape CME Online

Population Clock for the USA

http://www.census.gov/population/www/popclockus.html

Really this is ONLY A JOKE

I love this Doctor

Q: Doctor, I've heard that cardiovascular exercise can prolong life. Is this true?
A: Your heart is only good for so many beats, and that's it.... don't waste them on exercise. Everything wears out eventually. Speeding up your heart will not make you live longer; that's like saying you can extend the life of your car by driving it faster. Want to live longer? Take a nap.

Q: Should I cut down on meat and eat more fruits and vegetables?
A: You must grasp logistical efficiencies. What does a cow eat? Hay and corn. And what are these? Vegetables. So a steak is nothing more than an efficient mechanism of delivering vegetables to your system. Need grain? Eat chicken. Beef is also a good source of field grass (green leafy vegetable). And a pork chop can give you 100% of your recommended daily allowance of vegetable products.

Q: Should I reduce my alcohol intake?
A: No, not at all. Wine is made from fruit. Brandy is distilled wine, that means they take the water out of the fruity bit so you get even more of the goodness that way. Beer is also made out of grain. Bottoms up!

Q: How can I calculate my body/fat ratio?
A: Well, if you have a body and you have fat, your ratio is one to one. If you have two bodies, your ratio is two to one, etc.

Q: What are some of the advantages of participating in a regular exercise program?
A: Can't think of a single one, sorry. My philosophy is: No Pain...Good!

Q: Aren't fried foods bad for you?
A: YOU'RE NOT LISTENING!!! ..... Foods are fried these days in vegetable oil. In fact, they're permeated in it. How could getting more vegetables be bad for you?

Q: Will sit-ups help prevent me from getting a little soft around the middle?
A: Definitely not! When you exercise a muscle, it gets bigger. You should only be doing sit-ups if you want a bigger stomach.

Q: Is chocolate bad for me?
A: Are you crazy? HELLO Cocoa beans ! Another vegetable!!! It's the best feel-good food around!

Q: Is swimming good for your figure?
A: If swimming is good for your figure, explain whales to me.

Q: Is getting in-shape important for my lifestyle?
A: Hey! 'Round' is a shape!

Well, I hope this has cleared up any misconceptions you may have had about food and diets.
AND.....
For those of you who watch what you eat, here's the final word on nutrition and health. It's a relief to know the truth after all those conflicting nutritional studies.

1. The Japanese eat very little fat
and suffer fewer heart attacks than Americans.

2. The Mexicans eat a lot of fat
and suffer fewer heart attacks than Americans.

3. The Chinese drink very little red wine
and suffer fewer heart attacks than Americans.

4. The Italians drink a lot of red wine
and suffer fewer heart attacks than Americans.

5. The Germans drink a lot of beers and eat lots of sausages and fats and suffer fewer heart attacks than Americans.

CONCLUSION

Eat and drink what you like.
Speaking English is apparently what kills you.

AND REMEMBER:
'Life should NOT be a journey to the grave with the intention of arriving safely in an attractive and well preserved body, but rather to skid in sideways - Chardonnay in one hand - chocolate in the other - body thoroughly used up, totally worn out and screaming 'WOO HOO, What a Ride'

Warning: This is only a joke. Anyone who takes this advice seriously needs a mental health evaluation. It is funny because it truly goes against common sense and scientific studies.

Mediterranean Diet Pyramid

Source: Oldways

Metabolic Syndrome, Chromium & Vanadium

Weight Gain, Insulin Resistance and Metabolic Syndrome “X”

Insulin Resistance Syndrome (IRS), sometimes referred to as Metabolic Syndrome
“X” is a medical condition affecting as many as one in four Americans.
Considered to be a ‘pre-diabetic’ state, IRS precedes the development of
diabetes by as much as 10 years.

Insulin is a hormone, secreted by the pancreas.  Insulin has two principal
functions: (1) control of blood sugar, and (2) deposition of free fatty acids
into the fat cells.  If the insulin receptor becomes dysfunctional, it takes
more and more insulin to maintain normal blood sugars.  Unfortunately, the
increase in the Insulin level results in fat deposition, mostly in the abdomen.

As more and more insulin is needed to maintain blood sugar levels, the fat cells
respond to the situation by becoming ‘fatter.’  This in turn results in even
higher insulin levels.  Eventually, blood sugar levels cannot be maintained,
even with the very high insulin levels, and ‘diabetes’ is diagnosed.  Clearly,
the animals were well out of the barn by the time ‘diabetes’ was finally
diagnosed.

The key to diabetes prevention is detecting ‘insulin resistance’ before things
get totally out of control.  In order to do this, serum insulin levels should be
determined simultaneously with blood glucose.

NOTE:  Healthy blood sugar to insulin ratio should be greater than 10 to 1.

The first step to restore more normal, lower insulin levels is to treat with a
combination of trace minerals.  The key here is balance.  Chromium and vanadium
are associated with insulin receptor dysfunction, but these should not be taken
without adequate intake of zinc and selenium. Many patients will
experience some weight loss. Typically, patients will
lose 4-8 pounds over the course of 6 to 8 weeks.

After 1-2 weeks of mineral use, blood sugar levels can be expected to drop.
When weight loss ends, additional chromium is administered.  Typically chromium
200 mcg, taken twice daily is added to the a typical regiment of chromium and vanadium.
Alpha Lipoic Acid(ALA) 500 mg taken twice daily will further sensitize the cells to insulin.

Source:  Email from David Stephen Klein, MD, FACA, FACPM, FACMIMS

Letter from President Obama

May 13, 2009

Good afternoon,

You are receiving this email because you signed up at WhiteHouse.gov. My staff and I plan to use these messages as a way to directly communicate about important issues and opportunities, and today I have some encouraging updates about health care reform. The Vice President and I just met with leaders from the House of Representatives and received their commitment to pass a comprehensive health care reform bill by July 31. We also have an unprecedented commitment from health care industry leaders, many of whom opposed health reform in the past.

Monday, I met with some of these health care stakeholders, and they pledged to do their part to reduce the health care spending growth rate, saving more than two trillion dollars over the next ten years -- around $2,500 for each American family. Then on Tuesday, leaders from some of America's top companies came to the White House to showcase innovative ways to reduce health care costs by improving the health of their workers.

Now the House and Senate are beginning a critical debate that will determine the health of our nation's economy and its families. This process should be transparent and inclusive and its product must drive down costs, assure quality and affordable health care for everyone, and guarantee all of us a choice of doctors and plans.

Reforming health care should also involve you. Think of other people who may want to stay up to date on health care reform and other national issues and tell them to join us here: http://www.whitehouse.gov/EmailUpdates Health care reform can't come soon enough. We spend more on health care than any country, but families continue to struggle with skyrocketing premiums and nearly 46 million are without insurance entirely.

It is a priority for the American people and a pillar of the new foundation we are seeking to build for our economy. We'll continue to keep you posted about this and other important issues.

Thank you,

Barack Obama

P.S. If you'd like to get more in-depth information about health reform and how you can participate, be sure to visit http://www.healthreform.gov/.

This email was sent to jpsaleeby@aol.com Privacy Policy

The White House · 1600 Pennsylvania Ave NW · Washington, DC 20500 · 202-456-1111

Zinc (Zn)

Zinc: An Essential Element for Health

by JP Saleeby, MD

Zinc is an important element for human metabolism and health. After Iron (Fe) it is the second most abundant element in our body. The importance of this element covers many body processes from the regulation of gene expression to protein synthesis and structure. Zinc is the co-factor in as many as 100 enzymatic reactions in the human body. If we have a well rounded diet we acquire Zn naturally from beef, poultry, seafood and grains. In a 2002 survey some 2.5 percent of those adults surveyed stated they took Zn as a dietary supplement daily. Also noted in epidemiological studies is that zinc deficiency accounts for a global death rate of 1.8-million individuals each year. This is mostly seen in the severely malnourished. Other symptoms of Zn deficiency are growth retardation, delayed puberty, erectile dysfunction, loss of hair, nail dystrophy and hypogonadism in males.

Zinc has been used to treat childhood diarrhea, age related macular degeneration, prevention of upper respiratory infections and in wound care. Zinc with the co-factor of Vitamin C is intricately involved in the process of development of collagen and connective tissue repair. Additionally, it has been associated with reduction of rapid progression of HIV disease in those who are Zn deficient and in treating those with Wilson disease (a Copper (Cu) metabolism disorder) as it competes for protein binding sites with Cu. Zinc is important to T-cell maturation (a component of our immune system) as it is a co-factor in the production of thymulin a thymic hormone essential for T-cell production and function. There is some controversy as to whether Zn lozenges help treat upper respiratory infections (URI) already acquired versus preventing them, but more research is needed.

There are issues with taking too much Zn. A safe dose is around 20 to 30 mg per day. The upper limit being 40mg/d for most people for long term use. Too much zinc can inhibit the absorption of copper as it competes for its absorption in the body, it can suppress the immune system, decrease HDL-C (good cholesterol) and cause a hypochromic microcytic anemia. It can also result in nausea, vomiting and abdominal cramping. Zn absorption is inhibited by concomitant administration of iron (Fe) and large intakes of phytates found in grains and legumes. So these should be taken separately when Zn supplements are taken.

Not all Zn supplements are equal. For example Zinc acetate has only 30% of the elemental zinc by volume where Zinc sulfate has 23% and Zinc oxide has 80%. So of you take 25 mg of Zinc acetate you are only getting 7.5 mg of elemental Zn, but if you take 25 mg of Zinc oxide you receive 20mg of Zn. So read labels carefully on your selection of zinc supplements.

To slow the progression of Age Related Macular Degeneration (ARMD) a study show effectiveness in people over 55-years of age with the combination of 80mg of Zn, 2mg of copper and in combination of Vitamin C (500mg), Vitamin E (400IU), and Beta-carotene (15mg) acting as antioxidants. Incidentially, zinc holds antioxidant properties in and of itself.

Zinc containing foods

There are studies to show the importance of Zn in human reproduction. Zn in important in females for fertility as well as males. Zinc can aid in the production of testosterone, increase sperm cell counts and help in the uncoupling of testosterone from binding proteins. Additionally Zn can act to prevent the aromatization of testosterone to estrogens and conversion of testosterone to DHT (undesirable in men).

(c) 2009

References:

Saper, RB, et, al. Zinc: An Essential Micronutrient, Am Fam Physician. 2009;79(9):768-772

http://cat.inist.fr/?aModele=afficheN&cpsidt=3046105

1918 Children's Rhyme

I had a little bird
Its name was Enza
I opened up the window
And in-flu-enza


A human "bird house"
Little House Society

A Call for Calm

Lets Reflect Calmly on the Flu Outbreak

-JP Saleeby, MD

Swine Flu vaccine being administered in 1976

Lets put things in perspective. We need a call for calm and rational thinking. Today is not the day for irrational fears, panic and alarmism. Today's report from the CDC on this years "Swine Flu" in this country amount to cases in 41 state with 642 confirmed cases and only 2 deaths so far. The impact on the health care system far exceeds the true threat this illness is having on our population. We must remain calm and rational.

Of course with the memories of the devastating effects of the post WWI flu pandemic of 1918 with the worldwide death rate somewhere between 30 and 40 million people (only 0.5 million deaths in America) we have a right to be concerned and implement effective action. We don't have the right however to become alarmists and panic mongers. This serves neither our patients or our health care system. We can take concerted efforts to control the spread and handle cases that present to our EDs, but we don't have to strike panic in the hearts of the public. Lets take lessons from the 1976 Swine Flu debacle as well as those pearls of wisdom learned from 1918. Lets also put into perspective the death rates of more "mundane" or less sexy health / medical issues our nation / world faces each day.

The Spanish Flu pandemic of 1918 cost the world some estimated 40-million people. Those at the CDC in 1976 estimated some one-million deaths from that years epidemic. In reality there were only 200 cases confirmed with only one death. There was actually more death and destruction that occurred in the process of containment. With the vaccination program in 1976 some 500 cases were reported of the devastating consequence of viral immunizations called Guillain-Barre syndrome which resulted in 25 deaths. So here we have a clear example of where the American public was herded down the wrong path due to irrational panic and the "treatment" was actually worse than the disease. It was also reported in Pittsburgh that three elderly people standing on the long lines for their flu vaccines died of acute heart attacks succumbing to the stress of it all. Again panic claimed three-times the lives of the virus itself. Lets not repeat that in 2009.

There are other things to consider as caution must be taken when reporting and discussing this years flu epidemic. Economic impacts on the travel industry, aviation, travel agencies, hotels, and restaurants for example are feeling the heat quite possibly unnecessarily. Even the lowly pig farmer is suffering mostly due to the misunderstanding of the disease process. The debacle of the Swine Flu epidemic of 1976 which just didn't pan out embarrassed our federal government and cost the job of the director of the CDC. So let us proceed cautiously.

Putting things in greater perspective lets look at other issues that are maybe less glamorous today but still impact our health care system. Possibly this will give us reason to become more interested in conquering these great threats. Lets take world-wide malaria. Malaria kills almost 3000 people a day in sub-Saharan Africa (mostly children) that amounts to almost 1.1-million deaths a year. Those are numbers we should be ashamed of and they just don't make the headlines today. Lets look at the impact of auto accidents on our highways. Some 115 deaths occur each day as a consequence of motor vehicle accidents and that come to 42,000 deaths a year. Many of those deaths are caused by drunk drivers. Alcohol impaired drivers make up some 32% of deaths on the highway (13,500 motorists per year die at the hands of the drunk driver).


So before we get crazy over a "flu pandemic" that may not even pan out, lets take some quiet time to reflect on the facts and reality and realize what we are truly facing and handle it with poise and rational behavior.

-JP Saleeby, MD is medical director of the ED at MPH in Bennettsville, SC.

Letter to Representative John Spratt (US House for SC)

Representative Spratt,

Now that over $12 trillion have been pledged towards our financial crisis, more people than ever are concerned about where their money is going, and if it's accomplishing anything.

But in the face of an ever-worsening recession, the Federal Reserve refuses to furnish Congress and the American people with records of how the Bank is allotting and spending trillions of bailout dollars. Shrouded in secrecy, the Federal Reserve is a danger to our political process: No one knows where our money is going or what it is doing, and Chairman Bernanke has said that efforts to disclose such information are "counterproductive."

But that's my money they're using, Representative Spratt! $12 trillion! And without any record of how the Federal Reserve is managing and distributing these trillions of taxpayer dollars, there is no way to know if our present course is sustainable or not.

We must know what is happening with our money, and the Federal Reserve must come clean with the American people.

Please co-sponsor HR 1207, The Federal Reserve Transparency Act of 2009, and do everything in your power to see this bill through to a passing vote.

Respectfully,

JP Saleeby, MD

Herbal treatment for Pancreatic Cancer

Thymoquinone, the major constituent of the oil extract from a Middle Eastern
herbal seed called Nigella sativa, exhibited anti-inflammatory properties that
reduced the release of inflammatory mediators in pancreatic cancer cells.

Nigella sativa seeds and oil are used in traditional medicine by many Middle
Eastern and Asian countries. Previous studies have also shown it to have
anti-cancer effects on prostate and colon cancers.

Hwyda Arafat, M.D., Ph.D., associate professor of Surgery at Jefferson Medical College of Thomas Jefferson University, nigella sativa helps treat a broad array of diseases, including some immune and inflammatory disorders.

Based upon their previously published findings that thymoquinone inhibits
histone deacetylases (HDACs), Dr. Arafat and her colleagues compared the
anti-inflammatory properties of thymoquinone and trichostatin A, an HDAC
inhibitor that has previously shown to ameliorate inflammation-associated
cancers.

The herb also inhibited the activation and synthesis of NF-kappaB, a
transcription factor that has been implicated in inflammation-associated cancer.
Activation of NF-kappaB has been observed in pancreatic cancer and may be a
factor in pancreatic cancer's resistance to chemotherapeutic agents. When animal
models of pancreatic cancer were treated with thymoquinone, 67 percent of the
tumors were significantly shrunken, and the levels of proinflammatory cytokines
in the tumors were significantly reduced.

Inflammation has been implicated in the development of several solid tumor
malignancies. Chronic pancreatitis, both hereditary and sporadic, is associated
with the risk of developing pancreatic cancer.

Pancreatic cancer is the fourth leading cause of cancer death in the United
States, with approximately 32,000 deaths a year. Only five percent of
individuals with pancreatic cancer live for at least one year after diagnosis.

source: newsletter@suffernomore.com e-mail newsletter
http://www.sciencedaily.com/releases/2008/05/080519092215.htm