10 Tips on Dietary Fiber

10 Tips on Dietary Fiber

1. Keep in mind that a high-fiber diet may tend to improve:
• Chronic constipation
• Coronary heart disease
• Hemorrhoids
• Diabetes mellitus
• Diverticular disease
• Elevated cholesterol
• Irritable bowel syndrome
• Colorectal cancer

2. Try to double your daily fiber intake.
• Average American intake: 10-15 grams per day
• Recommended intake: 20-35 grams per day

3. Understand what fiber is, where it comes from:
• Insoluble fiber
• Cereals
• Wheat/wheat bran
• Whole grains
• Soluble fiber
• Brans
• Fruit
• Oatmeal/oat bran
• Psyllium
• Vegetables

4. Substitute high-fiber foods for high-fat and low-fiber foods.

5. Keep your daily fiber intake stable. Consider a fiber supplement if you:
• Travel
• Eat away from home often
• Find it difficult to get enough fiber through food choices alone

6. Don't shock your system: Increase fiber levels in your diet gradually.

7. Always increase fluids (water, soup, broth, juices) when you increase fiber.

8. Add both soluble and insoluble fiber, from a variety of sources.

9. Compare fiber content of foods:

Grams of Fiber
1 cup of Rice Krispies® 1
1/3 cup of 100% Bran® 9
1 slice of white bread 0.5
1 slice of whole wheat bread 1.4
1/2 cup white rice 0.5
1/2cup brown rice 1.5
Bowl of chicken broth 0
Bowl of thick vegetable (minestrone) soup 1

1. Choose foods high in fiber content.
Fruits and Vegetables
Highest in Fiber Per Serving
Fruits
Artichokes
Apples, pears (with skin)
Berries (blackberries, blueberries, raspberries)
Dates
Figs
Prunes Vegetables
Beans (baked, black, lima, pinto)
Broccoli
Chick-peas
Lentils
Parsnips Peas
Pumpkin
Rutabaga
Squash (winter)
Other Good Fiber Choices
Barley
Bread, Muffins (whole wheat, bran)
Cereals (branflakes, bran, oatmeal, shredded wheat)
Coconut
Crackers (rye, whole wheat)
Nuts (almonds, Brazil, peanuts, pecans, walnuts)
Rice (brown)
Seeds (pumpkin, sunflower)

Eating high-fiber foods is a healthy choice for most people. If you have ever received medical treatment for a digestive problem, however, it is very important that you check with your doctor to find out if a high-fiber diet is the right choice for you.

Please remember, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

10 Tips on Constipation and Incontinence of Stool

1.Despite widespread belief, constipation is not necessarily a part of growing older.

2.Bowel habits are similar in both younger and older healthy people.

3.Constipation is defined as stools that are:
Too small
Too hard
Too difficult to pass
Infrequent (less than 3 per week)

4.Constipation is caused by:
Not enough dietary fiber or fluids
Medication side effects
Emotional or physical stress
Misconception about normal bowel habits
Lack of activity
Medical problems

5.How to manage mild-to-moderate constipation:
Gradually add dietary fiber from variou sources
Increase fluids (water, soup, broth, juices)
Eat meals on a regular schedule
Chew your food well
Gradually increase daily exercise
Respond to urges to move your bowels
Avoid straining
See your doctor if these measures don't work

6.Dietary therapy (increased fiber and fluids) and fiber supplements are the preferred treatment for chronic constipation.

7.In some cases, your doctor may recommend the use of stool softeners.

8.Use of mineral oil or stimulant laxatives regularly, consult your doctor to make sure what you are using is right for you.

9.Incontinence of stool or fecal soiling is most often due to leakage around a fecal impaction. Removing the impaction will usually restore continence.

10.Incontinence of stool in healthy older people deserves full education and treatment. Treatment options include:

Adjustment in dietary fiber to reduce amount of stool
Medications to decrease stool frequency
Prescribed use of enemas (not soap enemas)
Biofeedback training
Surgery to restore anal function

Please remember, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

Gastric distress-related ED visits may increase during the holidays

At hospitals, gastric distress is a part of the holiday tradition." Indeed, "in the early hours of Thanksgiving...emergency rooms are typically empty," but certain turkey-cooking practices "can easily strike a blow" to diners. Typically, a frozen turkey is left on a countertop for 12 hours, while a roasted bird may sit "for two or three hours before" reaching the table. "During that time, a virus or bacterium can land on the food and start growing," causing gastroenteritis. "Although bacteria will die" once the bird is reheated, "the toxins made by the bacteria that cause illness can survive even in a hot oven." Bones have also been known to trigger "trips to the hospital," and those "with heart conditions should avoid too much salt, which can trigger an accumulation of fluid in the lungs."

Please remember, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

10 Tips on Belching, Bloating, and Flatulence

1.Belching is caused by swallowed air from:
Eating or drinking too fast
Poorly fitting dentures; not chewing food completely
Carbonated beverages
Chewing gum or sucking on hard candies
Excessive swallowing due to nervous tension or postnasal drip
Forced belching to relieve abdominal discomfort

2.To prevent excessive belching, avoid:
Carbonated beverages
Chewing gum
Hard candies
Simethicone may be helpful

3.Abdominal bloating and discomfort may be due to intestinal sensitivity or symptoms of irritable bowel syndrome. To relieve symptoms, avoid:
Broccoli
Baked beans
Cabbage
Carbonated drinks
Cauliflower
Chewing gum
Hard candy

4.Abdominal distention resulting from weak abdominal muscles:
Is better in the morning
Gets worse as the day progresses
Is relieved by lying down

5.To prevent Abdominal distention:
Tighten abdominal muscles by pulling in your stomach several times during the day
So sit-up exercises if possible
Wear an abdominal support garment if exercise is too difficult

6.Flatulence is gas created through bacterial action in the bowel and passed rectally. Keep in mind that:
10-18 passages per day are normal
Primary gases are harmless and odorless
Noticeable smells are trace gases related to food intake

7.Foods that are likely to form gas include:
Milk, dairy products, and medications that contain lactose--If your body doesn't produce the enzyme (lactase) to break it down.
Certain vegetables--baked beans, cauliflower, broccoli, cabbage
Certain starches--wheat, oats, corn, potatoes. Rice is a good substitute.

8.If flatulence is a concern, see your doctor to determine if you are lactose intolerant.

9.Identify offending foods. Reduce or eliminate these gas-forming foods from your diet.

10.Activated Charcoal may provide some benefit.

Please remember, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

5 Tips on Swallowing and Heartburn

1.Abnormal swallowing is commonly perceived as food "sticking on the way down." If this complaint persists, it is sometimes due to a serious condition and should always prompt medical attention.

2.Swallowing difficulty may be caused by a number of different problems including:
* Poor or incomplete chewing (possibly the result of dental problems, poorly fitted dentures, or eating too quickly)
* Abnormal muscle contraction
* Scar tissue from chronic inflammation
* Infection
* Cancer

3.Heartburn is a very common problem caused by regurgitation or reflux of gastric acid into the esophagus, which connects the mouth and the stomach.

4.Heartburn can often be eliminated by avoiding:
* Smoking
* Fatty food in the diet
* Caffeine
* Chocolate
* Peppermint
* Overeating
* Bed-time snacks
* Tight-fitting clothes that constrict the abdomen
* Certain medications
* Heavy lifting, straining

5.It is important to consider the possibility of heart disease before attributing any kind of chest pain to gastroesophageal reflux.

Please remember, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

MEDICATION EXPIRATION DATES

Is the expiration date a marketing ploy by drug manufacturers, to keep you restocking your medicine cabinet and their pockets regularly? You can look at it that way. Or you can also look at it this way: The expiration dates are very conservative to ensure you get everything you paid for. And, really, if a drug manufacturer had to do expiration-date testing for longer periods it would slow their ability to bring you new and improved formulations.

One of the largest studies ever conducted that supports the above points about "expired drug" labeling was done by the US military 15 years ago, according to a feature story in the Wall Street Journal (March 29, 2000), reported by Laurie P. Cohen. The military was sitting on a $1 billion stockpile of drugs and facing the daunting process of destroying and replacing its supply every 2 to 3 years, so it began a testing program to see if it could extend the life of its inventory. The testing, conducted by the US Food and Drug Administration (FDA), ultimately covered more than 100 drugs, prescription and over-the-counter. The results showed that about 90% of them were safe and effective as far as 15 years past their original expiration date.

In light of these results, a former director of the testing program, Francis Flaherty, said he concluded that expiration dates put on by manufacturers typically have no bearing on whether a drug is usable for longer. Mr. Flaherty noted that a drug maker is required to prove only that a drug is still good on whatever expiration date the company chooses to set. The expiration date doesn't mean, or even suggest, that the drug will stop being effective after that, nor that it will become harmful. "Manufacturers put expiration dates on for marketing, rather than scientific, reasons," said Mr. Flaherty, a pharmacist at the FDA until his retirement in 1999. "It's not profitable for them to have products on a shelf for 10 years. They want turnover."

If the expiration date passed a few years ago and it's important that your drug is absolutely 100% effective, you might want to consider buying a new bottle. And if you have any questions about the safety or effectiveness of any drug, ask your pharmacist. He or she is a great resource when it comes to getting more information about your medications.

First, the expiration date, required by law in the United States, beginning in 1979, specifies only the date the manufacturer guarantees the full potency and safety of the drug -- it does not mean how long the drug is actually "good" or safe to use. Second, medical authorities uniformly say it is safe to take drugs past their expiration date -- no matter how "expired" the drugs purportedly are. Except for possibly the rarest of exceptions, you won't get hurt and you certainly won't get killed.

Even 10 years after the "expiration date," most drugs have a good deal of their original potency. So wisdom dictates that if your life does depend on an expired drug, and you must have 100% or so of its original strength, you should probably toss it and get a refill, in accordance with the cliché, "better safe than sorry." If your life does not depend on an expired drug -- such as that for headache, hay fever, or menstrual cramps -- take it and see what happens.

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

A BETTER ANSWER FOR DOCTORS WORRIED ABOUT HIGH MALPRACTICE INSURANCE PREMIUMS ?

Tom Baker, a professor at the University of Pennsylvania Law School, is the author of “The Medical Malpractice Myth. Says that our medical liability system needs reform. But anyone who thinks that limiting liability would reduce health care costs is fooling himself. Preventable medical injuries, not patient compensation, are what ring up extra costs for additional treatment. This means taxpayers, employers and everyone else who buys health insurance — all of us — have a big stake in patient safety.

Eighty percent of malpractice claims involve significant disability or death, a 2006 analysis of medical malpractice claims conducted by the Harvard School of Public Health shows, and the amount of compensation patients receive strongly depends on the merits of their claims. Most people injured by medical malpractice do not bring legal claims, earlier studies by the same researchers have found.
On the other hand, risk managers, for example, and spurring anesthesiologists to improve their safety standards and practices. Even medical societies’ efforts to attack the liability system have helped, by inspiring the research that has documented the surprising extent of preventable injuries in hospitals. That research helped start the patient safety movement. When it comes to rising medical costs, liability is a symptom, not the disease. Getting rid of liability might save money for hospitals and some high-risk specialists, but it would cost society more by taking away one of the few hard-wired patient safety incentives.
Besides, there’s a better answer for doctors worried about high malpractice insurance premiums.

Critics point to defensive medicine as the hidden burden that liability imposes on health care. Yet research shows that while the fear of liability changes doctors’ behavior, that isn’t necessarily a burden. Some defensive medicine is, like defensive driving, good practice. Too often, we can’t distinguish between treatments that are necessary and those that are wasteful. Better research on what works and what doesn’t — evidence-based medicine — will help. And it will address the more general challenge of avoiding costly but unnecessary care.
Just as we need evidence-based medicine, we also need evidence-based medical liability reform. The research shows, overwhelmingly, that the real problem is too much malpractice, not too many malpractice lawsuits. So medical providers should be required to disclose injuries, provide quicker compensation to deserving patients and — here’s the answer for doctors worried about their premiums — shift the responsibility for buying malpractice insurance to hospitals and other large medical institutions. Evidence-based liability reform would give these institutions the incentive they need to cut back on the most wasteful aspect of American health care: preventable medical injuries.

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

5 Tips on Inflammatory Bowel Disease

1. Inflammatory bowel disease (IBD) is an inflammation of the small or large intestine that may cause these symptoms:

• Diarrhea
• Rectal bleeding
• Sharp abdominal pain or cramping
• Intestinal obstruction
• Fever
See your doctor if you have any of these symptoms

2. There are two types of IBD:
• Ulcerative Colitis
• Starts in rectum and spreads upward
• Affects men more than women
• Crohn's Disease
• More patchy inflammation
• Can start anywhere in the digestive tract
• Affects women more than men

3. The cause of IBD is unknown. What is known about IBD includes the following:
• IBD is not Contagious.
• IBD is not caused by diet.
• IBD is not a form of cancer.
• IBD affects young and old alike.
• IBD can usually be treated with medicine but sometimes requires surgery.

4. Diagnosis of IBD is based on:
• Family history, travel history, current medications
• Stool sample to rule out infection
• Flexible sigmoidoscopy/colonoscopy and biopsy to rule out cancer and to identify
• IBD
• X-ray studies

5. Treatment of IBD may include:
• Medications to reduce or eliminate inflammation
• Special diet or elemental formula diet
• Surgery

Time is critical. If you suspect IBD, call your doctor

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

5 Tips on Gallstone Disease

5 Tips on Gallstone Disease
1. Gallstones typically develop over many years, although they can form in months. Gallstones are present in about 20% of women and 10% of men over the age of 55.

2. There are two basic types of gallstones: cholesterol and pigment. Cholesterol gallstones are the most common type in the United States.

3. About 75% of gallstones do not cause symptoms. The most common symptom caused by gallbladder stones is episodic upper abdominal pain.

4. For healthy patients who have no symptoms, no therapy or change in diet is needed. Patients with uncomplicated symptomatic gallbladder stones should reduce dietary fat and consider surgical removal of the gallbladder (cholecystectomy). An alternate approach is oral bile acid therapy. For complicated disease, gallbladder removal is warranted.

5. Patients who undergo rapid weight loss are at risk for the development of small cholesterol gallstones and may benefit from bile acid therapy. Gallstones can seldom be prevented, although a low-fat diet may provide some protective benefit.

CONTACT
Web: www.Hookman.com
Phone: 561.445.0486
E-Mail: hookman@hookman.com
Book Website: www.MedMalBook.com


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

For more health info and links visit the author's web site www.hookman.com

MORE PATIENTS WITH STROKES DIE ON WEEKEND HOSPITAL ADMISSION

R. Webster Crowley MD et al. reports that there is expanding literature to show that certain patients admitted during the weekend have worse outcomes than similar patients admitted during the week. Although many clinicians have hypothesized the presence of this "weekend effect" with patients with intracerebral hemorrhage, there is a paucity of studies validating this conjecture.

The authors performed a retrospective cohort study of patients with intracerebral hemorrhage (International Classification of Diseases, 9th Revision, Clinical Modification=431) extracted from the 2004 Nationwide Inpatient Sample. Multivariable logistic regression analyses and Cox proportional hazards regression were conducted to calculate the odds of death (within 7, 14, and 30 days) and the hazard ratio of death for patients with weekend intracerebral hemorrhage admissions compared with weekday intracerebral hemorrhage admissions. All analyses were adjusted for concurrent differences in length of stay, patient demographics, and comorbid disease.

The authors found that weekend hospital admissions accounted for 26.8% of the 13 821 patients with a diagnosis of intracerebral hemorrhage in the National Inpatient Sample. Admission during the weekend was a statistically significant independent predictor of death within 7 days (OR, 1.14; 95% CI, 1.05 to 1.25), within 14 days (OR, 1.15; 95% CI, 1.05 to 1.25), and within 30 days (OR, 1.15; 95% CI, 1.05 to 1.25).

The adjusted hazard of in-hospital death (hazard ratio, 1.12; CI, 1.05 to 1.20) indicates that the overall risk of in-hospital death with intracerebral hemorrhage is 12% higher with weekend admission, leading the authors to conclude that weekend admission for intracerebral hemorrhage was associated with increased risk-adjusted mortality when compared with admission during the remainder of the week.

COMMENT.
Is this one more instance of poor turnover problems with housestaff and nurses. We’ve seen a lot of problems with turnovers of patients with increasing frequency of shifts between hospitalists and nurses especially during a weekend. We’ve seen this same higher mortality with heart attacks admitted on weekends too. This study needs the highest priority to “fix the system.”


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for HOW DOES #TORT REFORM AND LIMITING #DEFENSIVE MEDICINE AFFECT TOTAL U.S. #HEALTHCARE EXPENDITURES?.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

Pressure Stockings 'Should Not Be Used' to Prevent DVT

Deep vein thrombosis (DVT) and pulmonary embolism are common after stroke. In small trials of patients undergoing surgery, graduated compression stockings (GCS) appear to reduce the risk of DVT.

National stroke guidelines in several countries extrapolating from these trials recommend their use in patients with stroke. Researchers assessed the effectiveness of thigh-length GCS to reduce DVT after stroke.

In an international trial, researchers randomized some 2500 immobile patients hospitalized within 1 week of an acute stroke to either use of, or avoidance of, thigh-length stockings. Ultrasound studies done at roughly 30 days found no significant difference between the groups with regard to the occurrence of DVT in the popliteal or femoral vessels.

However, the risk for adverse effects (skin breaks, ulcers, blisters, and necrosis) was much higher in stocking users than nonusers (5% vs. 1%).
Graduated compression stockings don't reduce the risk for deep venous thrombosis after stroke, according to this large trial. Commentators say flatly that the stockings "should not be used after stroke and current guidelines will need to be amended."

The Lancet, Online Publication, 2009 doi:10.1016/S0140-6736(09)60941-7

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for Don't spend your life trying to impress others.

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How to Find a Good Hospital

The reality is, says S.Balauf of US News, that not all hospitals—or doctors or nurses, for that matter—deliver high-quality care. The United States has a "very inconsistent, uneven quality of healthcare," says Anne Weiss, who leads the quality/equality healthcare team at the Robert Wood Johnson Foundation, a healthcare philanthropy based in Princeton, N.J. Even the type of treatment that similar patients get can vary from hospital to hospital and region to region. In some parts of the country, for example, heart patients are more likely to receive angioplasty than coronary bypass surgery, while in many places the opposite is true. (U.S. NEWS wrote about this phenomenon and the fact that some heart patients may get the less appropriate procedure because they may not be fully informed about their options.)

The time to find a good hospital is ling before you need one. By tapping a few readily available resources, however, patients can make informed decisions about a good local hospital for the treatment they need. According to the National Committee for Quality Assurance, a healthcare nonprofit based in Washington, D.C., patients who make informed choices and get engaged in their care early ultimately reap better health outcomes.

• Your primary-care physician. Consult this trusted source if a specialist ever tells you that surgery or treatment is necessary, and ask your primary-care doc where he recommends you have it done. Primary-care physicians have a good working knowledge of the hospitals in their area, including each institution's overall reputation and how it stacks up against its local peers for specific procedures and treatments. Ideally, their reasoning will be based on other patients' outcomes

• Your insurance company. Inquire about the quality data they've collected on each facility where they would cover your treatment. That info can typically be found on the plan's website or by phone. The data might be limited to the pool of patients your plan covers and the doctors and hospitals in the plan's network, but it's nevertheless a source of details that can inform your choice.

• That friend of a friend who is a nurse. Your extended social network may include more hospital employees than you realize. "Most people know someone in the local healthcare system. But realize they provide a narrow view, seeing perhaps only one slice of all the variables that make up a hospital's level of care.

• A trusted family member or friend. Bringing someone you trust to an important appointment, or simply going through the hospital-selection process with another person, can be quite powerful. "Never go alone" and "Never stay alone."If nothing else, your companion is likely to be more clear-headed than you are when you're faced with daunting new information about your health. He or she need not be a medical professional.

• I would not trust highway billboards touting a hospital's latest award. They're hard to miss—and plentiful in many regions of the country. But beware the source. The prize may or may not have any real bearing on the real quality of care a patient could expect at that hospital. As an example Hospital Compare, hosted by the federal Centers for Medicare and Medicaid Services, focuses on how often hospitals give heart attack patients aspirin within 30 minutes of their arrival at the ED, give surgery patients the correct antibiotic at the right time prior to the procedure, and otherwise do the right thing in 23 "process measures." Some-I believe most of these criteria-- are relative lightweights. Most hospitals show great success, for example, at giving smoking-cessation advice to heart patients who smoke. (Nurse: "I see you're a smoker, Mr. Smith. You know it doesn't help your heart condition, don't you?" Mr. Smith: "Yes, I do." Nurse marks box on discharge form.)

• Hospital Compare also indicates whether a hospital's death rates in heart attack, heart failure, and pneumonia patients is better, no different, or worse than the U.S. average. That might seem useful, but the average is so broadly defined that only about 2 percent of hospitals are "better" or "worse." Clicking on the graph or table view of the page will reveal the actual death rates, as well as average state and national rates. Last year, the site began offering patient satisfaction data gleaned from surveys, such as the percentages of patients who reported their nurses always communicated well and of those who said they would definitely recommend the hospital. Look, but take with a grain of salt. Studies show that individuals whose medical care was successful tend to be more satisfied with a hospital in other ways.

• Some websites [www.hookman.com] have links to other sites that also rank or rate good hospitals across the country, and such sites have potential value to people who are seeking a good hospital in their area.

Is there a correlation between hospitals’ “quality”scores?
Unfortunately no! A study reported in the JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION found no correlation between how well hospitals scored on a 13-item set of Leapfrog quality and safety measures and death rates, adjusted for severity, of patients admitted to the hospitals. The study didn't look at rates of complications.The Leapfrog Group is a nonprofit business coalition that allows consumers to compare hospital safety and quality ratings based on results of a voluntary survey. Hospitals are rated on their ability to satisfy two sets of safety standards. One set, such as appropriate ICU staffing and a program to reduce bedsores, applies to the entire hospital. The other set reflects quality of care and cost for 10 specific procedures and conditions, including repairing an abdominal aortic aneurism and treating pneumonia. Hospitals can be compared directly. You may not be able to find yours, however. Roughly 1,300 hospitals out of more than 5,000 in the nation—two out of 16 in Baltimore, for example—responded to the most recent Leapfrog survey.

COMMENT:
In the end after you do all your research it then really comes down to luck and faith. Faith that you have a fine doctors who will make good decisions for you. Trust—but verify.

African medical facilities always have relatives in with patients. That’s a good thing.
Always have someone with you in the hospital—a friend or loved one who will stay with you and watch out for you.


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for Avoidable Post Hospital Discharge Errors Are Common

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

WHICH ORAL ANTIBIOTICS ARE SAFE DURING PREGNANCY AND BREASTFEEDING?

Many are okay...and LESS risky than an untreated infection. But some have special precautions...and several should be avoided.
Penicillins and cephalosporins are usually safe.
Consider using a higher or more frequent dose during the 2nd and 3rd trimesters...to compensate for the increased volume of distribution and clearance.
Erythromycin and azithromycin are also generally safe in pregnancy. Don't use clarithromycin...due to concerns about birth defects in animal studies.
Nitrofurantoin is usually okay during pregnancy and breastfeeding. Don't use it close to delivery due to a small chance of hemolytic anemia in the newborn.
TMP/SMX should usually be avoided. Trimethoprim may cause birth defects during the 1st trimester...and sulfonamides may cause high bilirubin and jaundice in the baby if given near term.

Metronidazole is sometimes avoided in the 1st trimester due to concerns about possible malformations. But it can be used during pregnancy if there are no good alternatives.
For a single dose while breastfeeding, suggest stopping breastfeeding for 12 to 24 hours to allow the drug to be eliminated.
Clindamycin is an alternative to metronidazole for anaerobic coverage and is considered safe in pregnancy and lactation.
Fluoroquinolones (ciprofloxacin, etc) are associated with cartilage damage in animals. Even though this isn't confirmed in humans, try to avoid fluoroquinolones during pregnancy.
Tetracyclines should be avoided in pregnancy...especially in the 2nd and 3rd trimesters. They're associated with adverse effects on fetal teeth and bones, other defects, and maternal liver toxicity.
Tell moms that tetracycline can be used during breastfeeding...it only shows up in very low concentrations in breast milk.

On-line resources:
Motherisk. http://www.motherisk.org/index.jsp. Offers consumers answers to questions about morning sickness and the risk or safety of medications, disease, chemical exposure, and more. Provides teratogen information for healthcare professionals and updates on Motherisk's continuing reproductive research.
Perinatology.com. http://www.perinatology.com/. Provides teratogen information for healthcare professionals and links to clinical guidelines and more.
Organization of Teratology Information Specialists (OTIS). http://www.otispregnancy.org/. Provides medical consultation on prenatal exposures for consumers and healthcare professionals.
OBfocus. http://www.obfocus.com/. Provides information for healthcare professionals and consumers on pregnancy related issues, including drug exposure. Provides a list of resources on high risk pregnancy



Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for Women Still Drinking During Pregnancy

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WHAT KIND OF SPF SUNSCREENS TO USE

SPF is often misunderstood says the Prescriber’s Newsletter.

SPF applies only to UVB...not UVA. UVB causes the familiar sunburn. SPF is an estimate of how long a person can stay in the sun without obvious sunburn.

For example, if a person would burn in 10 minutes with NO protection, then an SPF 15 sunscreen will protect 15 times longer or 150 minutes...and an SPF 30 would protect 30 times longer or 300 minutes.There's no proof that an SPF over 50 gives any measurable added benefit.

UVB ratings get the most attention, but are only part of the story.
UVA ratings will appear on some sunscreens. You'll see 1, 2, 3, or 4 stars indicating low, medium, high, or highest protection.
UVA causes skin aging and skin cancer...not visual sunburn.

Recommend sunscreens labeled broad-spectrum. These contain UVA blockers such as avobenzone, zinc oxide, and/or titanium.

You'll now see Mexoryl SX (ecamsule) in some Anthelios sunscreens. Mexoryl SX covers some of the shorter UVA rays that are not covered by avobenzone...and it's more stable in sunlight.

But when avobenzone is combined with octocrylene, oxybenzone, or other ingredients it's more stable and has a broader spectrum.

Recommend zinc oxide or titanium dioxide for sensitive skin. They block UVA and UVB by sitting on top of the skin...not binding to it.

Water resistance ratings refer to how long the product is effective during swimming, heavy sweating, etc.

Explain to patients that a product labeled "water-resistant" lasts about 40 mins in water...and a "very water-resistant" product lasts about 80 mins.

Proper application is key. Instruct people to apply sunscreen 20 minutes before sun exposure...and reapply at least every 2 hours.

Emphasize applying enough...about 1/2 to one teaspoon per body part (leg, arm, back, face, etc)...or about 1 ounce for the full body. Applying only half the amount will give only half the protection.

Advise avoiding sunscreen/insect repellent combos. Suggest using separate products because the sunscreen needs to be applied more often than the repellent. Advise patients to apply the sunscreen first, then the repellent.

SUMMARY-COMMENT:
There are new ways to help you prevent the kind of damage to your skin that can cause not only wrinkles, but also skin cancer, which is the second most common form of cancer in the United States.

• Use skin care products with UVA/UVB and broad spectrum protection. Before going outside, apply sun-resistant skin care products such as body wash, makeup, and lip balm. Use sunscreen (SPF 30 or greater) that contains a broad spectrum protection ingredient such as oxybenzone, sulisobenzone, avobenzone, ecamsule, titanium dioxide or zinc oxide.

• Buy clothing with UVA/UVB protection. Everyone knows that the more you cover up, the less chance you have of damaging your skin. But did you know that you can get additional protection by choosing clothes made from fabrics that reflect ultraviolet light? These fashions, from bathing suits to sweatsuits, come with a label that states the UPF (ultraviolet protection factor) of the clothes. The higher the UPF, the more protection you receive.

• Add UPF to your own clothes. Special laundry additives are available that apply sun protection to your clothes for up to 20 washings. You can find more information about additives and purchase them online.

• Choose sun-resistant accessories. While you are outside, wear sunglasses that block at least 99 percent of UVB rays and at least 95 percent of UVA rays. Select a sun hat made with UPF fabric. Take an umbrella with you, even when it’s not raining.


* Tune in tomorrow for Sun Allergies!

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America's other drug problem

The National Council on Patient Information and Education has termed medication nonadherence "America's other drug problem.”

Approaches to improve adherence can be complex and labor intensive. The problem of medication nonadherence poses an even greater risk among elderly patients in the United States, among whom poor medication adherence is common, morbid, costly, and difficult to treat. And it is among the elderly, that polypharmacy, which is the use of multiple medications resulting in complicated drug regimens, is an important barrier to medication adherence. Of 4053 patients aged 65 years or older prescribed medications for hypertension and hyperlipidemia, the adherence to both classes of medication decreased rapidly to 40.5% at the 3-month interval, and then to 32.7% at 6 months.

• The adherence rate for medical treatments [ or non-compliance rate] averages in some studies about 50%, with a range that extends from 0% to 100% .
• A Physicians' estimates of their own patients' adherence have no better than “chance accuracy”.
• Thus the problem of low adherence can be almost invisible to the individual practitioner dealing with a specific patient. This is true even for patients whom physicians feel they know well.
• Thus, part of the problem of detecting low adherence is that clinicians often think they know a poor or good complier when they see one, perhaps cueing on such characteristics as age, gender, education, and intelligence—none of which have been shown to have any consistent relationship to adherence.
• Adherence to chronic pharmacological therapies is poor.
• This often leads to worsening disease severity and increased costs associated with higher hospital admission rates.
• Barriers to medication adherence are numerous,and are particularly prevalent among the elderly population, placing them at increased risk for medication nonadherence.
  

J. K. Lee et al noted that poor medication adherence diminishes the health benefits of pharmacotherapies, especially in elderly patients with coronary risk factors who frequently require treatment with multiple medications, placing them at increased risk for nonadherence.

Of a total of 200 elderly patients, a pharmacy care program led to increases in medication adherence, medication persistence, and clinically meaningful reductions in BP, whereas discontinuation of the program was associated with decreased medication adherence and persistence.

“Effect of a Pharmacy Care Program on Medication Adherence and Persistence, Blood Pressure, and Low-Density Lipoprotein Cholesterol A Randomized Controlled Trial” published in JAMA. 2006;296: (doi:10.1001/jama.296.21.joc60162)
Chapman RH, Benner JS, Petrilla AA, et al. Predictors of adherence with antihypertensive and lipid-lowering therapy. Arch Intern Med. 2005;165:1147-1152.



* Tune in tomorrow for the latest Food Scare

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CAN WE BELIEVE HOSPITAL STATISTICS?

Reporting of Mistakes by Hospitals Is Faulted

A.Hatocollis reports that at least in one city--New York City-- hospitals are the least reliable in the state at reporting preventable mistakes and adverse incidents for patients like heart attacks, blood clots, hospital infections and medication errors, according to a new report by the office of City Comptroller.

The comptroller also expressed concern that the New York City data on medication errors appear to run counter to the national trend, citing estimates by the Institute of Medicine of the National Academies that at least 400,000 hospital patients are harmed and 7,000 killed by medication errors annually. In contrast, the report said, from 2004 through 2007, city hospitals rarely reported medication errors: 37 that resulted in death, near death or permanent harm to patients, with 22 hospitals, including four very large ones, reporting none.

The lack of accurate reporting makes it virtually impossible for consumers to judge accurately the quality of a hospital or for the hospital to compare itself with its peers and make improvements, the comptroller’s office argues, saying the consequences include longer hospital stays and higher health-care costs. “Without the fullest possible reporting, hospitals cannot identify areas where systematic improvement may be needed,” reads the report. “Weak enforcement and flagging commitment to a broad-based effort has compromised the whole program.”

NewYork-Presbyterian/Weill Cornell Medical Center one of New York City’s major academic medical centers, reported only about 20 adverse incidents per 10,000 patient discharges, while a comparable institution outside the city, which was not named, reported about 166 incidents per 10,000, a rate more than eight times higher.

Within New York City’s 60-plus hospitals, there was great range: 17 reported no heart attacks unrelated to a cardiac procedure while one had more than 40; six hospitals reported 2 blood clots or acute pulmonary embolisms per 10,000 patient discharges while two others had more than 60 per 10,000; one major academic medical center reported 3.6 post-operative infections per 10,000 discharges and a similar hospital had 32 per 10,000. None of these hospitals were named in the report.

The report, which looks at data from 2004 through 2006, with some additional data from 2007, echoes a state Health Department study in 2001 that similarly concluded that New York City underreported adverse incidents, with 6 of the 11 city-run public hospitals among the 25 lowest reporters. The new analysis faulted the state for not being more aggressive in enforcing penalties such as fines against hospitals with lax reporting, and cited “enormous and inexplicable disparities among individual hospitals.”

A hospital’s size and the type of procedures it performs do not seem to explain the differences in reporting rates.

The report does not name individual hospitals, but the comptroller’s office separately released a list of the 12 lowest reporters in the city based on 2006 data. The top three — St. Vincent’s Midtown and Cabrini Medical Center in Manhattan, and Mary Immaculate in Jamaica, Queens — have all since closed.

The others include some of New York’s biggest and most prestigious hospitals: Lenox Hill, on the Upper East Side (No. 7); Bellevue, the flagship hospital of the city’s Health and Hospitals Corporation (10); Weill-Cornell (11); and Mount Sinai (12).

COMMENT:
It’s not difficult to believe that NYC is not an isolated city. I believe that hospital statistics reported from other cities will have to also be investigated—with severe sanctions applied to violaters.

BOOKS TO READ ON THE BEACH

BOOKS TO READ ON THE BEACH SO YOU CAN SMARTLY CONVERSE AT LIBERAL DOCTOR HATING COCKTAIL PARTIES THIS FALL – OR READ THIS AND SAY YOU DID

Guy Clifton, a neurosurgery professor at the University of Texas Health Science Center in Houston, argues in his book Flatlined: Resuscitating American Medicine that there are two ways to control healthcare costs: price controls with rationing (used by most industrialized nations and abhorred in the U.S.) or increased efficiency. Clifton points out that the cost of healthcare is so high that it is affordable only if someone else is paying for it, such as government or employers. The "haves" consume the healthcare of the "have nots," to the detriment of both. An estimated 30,000 patients die each year from overtreatment. He estimates that 50 percent of healthcare is a waste, if you factor in excessive medical care and patient health behavior.

In The Great American Heart Hoax: Lifesaving Advice Your Doctor Should Tell You About Heart Disease Prevention (But Probably Never Will), cardiologist Michael Ozner claims that the annual 1.5 million U.S. angioplasties and coronary bypass surgeries, for which the price tag is $60 billion, neither save lives nor prevent heart attacks. He cites Harvard research that 70 to 90 percent of those procedures are unnecessary.

The U.S. is the only industrialized nation not to guarantee healthcare to its citizens. We spend more than twice as much per capita as any other country, yet if longevity is the criteria comparatively we do not live longer lives. Medical professor Nortin Hadler, author of Worried Sick: A Prescription for Health in an Overtreated America, says healthcare interventions rarely, if ever, improve longevity. He defines two types of medical malpractice. Type I malpractice: Doing something medically necessary unacceptably poorly. Type II malpractice: Doing something unnecessary very well.

Journalist Shannon Brownlee, author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, gives partial credit of overtreatment to Americans’ blind faith in technology and science. About 34 percent agreed with the statement in a Harvard survey that modern medicine can cure almost any illness with the right technology. However, Brownlee points out that 25 to 40 percent of autopsies show that patients were being treated for the wrong diagnosis, which is virtually unchanged from 1910.

Physician Dennis Gottfried, who wrote Too Much Medicine: A Doctor’s Prescription for Better and More Affordable Health Care, wants to ban direct-to-consumer advertising for medications and aggressive promotion of pharmaceuticals to physicians because both result in prescription of more expensive, less effective drugs. About 31 percent of patients who see these advertisements ask about the drug, and a significant portion of them want it even though they are clueless to its effects. Unfortunately, he says,a significant percentage of doctors comply because they do not want to lose a fully insured patient.

POOR COMMUNICATION IN HOSPITAL READMISSIONS

Discharging and readmitting physicians communicated on only about half the patients who returned within 2 weeks.

When patients who are discharged from a hospital are readmitted, do the discharging and readmitting medical teams communicate with each other? To examine this issue, researchers at two Boston teaching hospitals surveyed residents and attending physicians about patients who required short-term readmission after being discharged from general medicine services.

Of 432 consecutive patients who were discharged and readmitted within the next 14 days, 123 had common providers on both teams, and 84 had planned readmissions; thus, 225 cases were analyzed. Discharging teams were aware that their patients had been readmitted in only 49% of cases, and communication occurred between teams in only 44% of cases. When communication did not occur, 61% of respondents believed that communication would have been beneficial.

Comment by Allan S. Brett, MD: These results won’t surprise physicians who work in systems in which hospitalist or resident-attending teams rotate every few weeks.
Better communication likely would enhance quality of care: In caring for hospitalized patients, we learn valuable medical and psychosocial information that doesn’t always appear in discharge summaries. Failure to communicate also results in lost learning opportunities: We surely learn valuable lessons when we see what happens to our patients shortly after hospital discharge. Creating systems to ensure communication between discharging physicians and readmitting physicians simply makes good sense.

Other articles on Hospital readmissions: physician awareness and communication practices.

Roy CL et al J Gen Intern Med. 2009 Mar;24(3):374-80. Epub 2008 Nov 4.Physicians are frequently unaware of patient readmissions and often do not communicate when readmissions occur. This communication is often desired and frequently results in the exchange of important patient information. Further work is needed to design systems to address this potential discontinuity of care.

Inform Prim Care. 2008;16(2):147-55.Design and implementation of a web-based patient portal linked to an electronic health record designed to improve medication safety: the Patient Gateway medications module.

Schnipper JL et al. This module allows patients to view and modify the list of medications and allergies from the EHR, report non-adherence, side effects and other medication-related problems and easily communicate this information to providers, who can verify the information and update the EHR as needed. Usage and satisfaction data indicate that patients found the module easy to use, felt that it led to their providers having more accurate information about them and enabled them to feel more prepared for their forthcoming visits.

J Gen Intern Med. 2008 Sep;23(9):1414-22. Epub 2008 Jun 19.Classifying and predicting errors of inpatient medication reconciliation.
Pippins JR et al.

Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.

J Am Med Inform Assoc. 2008 Jul-Aug;15(4):424-9. Epub 2008 Apr 24 A randomized trial of electronic clinical reminders to improve medication laboratory monitoring.
Matheny ME They identified high rates of inappropriate laboratory monitoring. Electronic reminders did not significantly improve these monitoring rates. Future studies should focus on settings with lower baseline adherence rates and alternate drug-laboratory combinations.

DOES ALCOHOL MAKE YOU FLUSH?

The Flushing Questionnaire
The flushing questionnaire consists of two questions:
(A) Do you have a tendency to develop facial flushing immediately after drinking a glass (about 180 ml) of beer?

(B) Did you have a tendency to develop facial flushing immediately after drinking a glass of beer in the first one or two years after you started drinking? For both questions, the choice of answers are: yes, no, or unknown.

If an individual answers yes to either question A or B, they are considered to be ALDH-2 deficient. The addition of question B is important because some individuals can become tolerant to the facial flushing effect.

The alcohol flushing response is a biomarker for ALDH2 deficiency. ALDH2-deficient patients have an increased risk for esophageal cancer if they drink even moderate amounts of alcohol. Because of the intensity of the symptoms, most people who have the alcohol flushing response are aware of it. Therefore clinicians can determine ALDH2 deficiency simply by asking about previous episodes of alcohol-induced flushing.

ALDH2-deficient patients can then be counseled to reduce alcohol consumption, and high-risk patients can be assessed for endoscopic cancer screening. The authors estimate that there are at least 540 million ALDH2-deficient individuals in the world, representing approximately 8% of the population. In a population of this size, even a small reduction in the incidence of esophageal cancer could result in a substantial reduction in esophageal cancer deaths worldwide.

Philip J. Brooks e al has documented that approximately 36% of East Asians (Japanese, Chinese, and Koreans) show a characteristic physiological response to drinking alcohol that includes facial flushing nausea, and tachycardia,

This so-called alcohol flushing response is predominantly due to an inherited deficiency in the enzyme aldehyde dehydrogenase 2 (ALDH2) found mostly in Asia but also present in the West.

Few are aware of the accumulating evidence that ALDH2-deficient individuals are at much higher risk of esophageal cancer (specifically squamous cell carcinoma) from alcohol consumption than individuals with fully active ALDH2.

Esophageal cancer is one of the deadliest cancers worldwide, with five-year survival rates of 15.6% in the United States, 12.3% in Europe, and 31.6% in Japan.
When detected early, esophageal cancer can be treated by endoscopic mucosectomy, a standard and relatively non-invasive procedure. However, once the cancer has grown large enough to penetrate the submucosal layer, the likelihood of lymph node metastasis increases significantly. Only about 20% of esophageal cancer patients survive three years after diagnosis, emphasizing the importance of disease prevention.

In view of the approximately 540 million ALDH2-deficient individuals in the world, many of whom now live in Western societies, even a small percent reduction in esophageal cancers due to a reduction in alcohol drinking would save many lives. Increasing evidence also points to the metabolism of ethanol by microorganisms in the oral cavity as an important source of acetaldehyde in saliva and, by extension, in the esophagus. Acetaldehyde levels in saliva are 10–20 times higher than in blood, due to the local formation of acetaldehyde by oral microorganisms. Importantly, ALDH2 heterozygotes have two to three times the acetaldehyde levels in their saliva compared to fully active ALDH2 individuals after a moderate dose of oral ethanol.

For patients at high risk of esophageal cancer, doctors should also consider endoscopy for early cancer detection.
Using a version of the health risk assessment that includes the flushing questionnaire as a major component, it has been estimated that approximately 58% of esophageal cancers in the population could be detected by screening.

Philip J. Brooks et al. The Alcohol Flushing Response: An Unrecognized Risk Factor for Esophageal Cancer from Alcohol Consumption. PLoS Med 6(3): e1000050. doi:10.1371/journal.pmed.1000050

Part II of II: GERD- Heartburn of Pregnancy

Part II of II.

Gastro-esophageal reflux is the phrase used to describe the backward flow or regurgitation of stomach contents passing up into the esophagus. The typical symptom of GERD is a burning discomfort behind the breast bone. Some describe heartburn as indigestion, a "sour" stomach, pain in the upper abdomen or chest, regurgitation of food or bitter liquid into the mouth or excessive production of saliva. GERD is a common condition and symptoms of heartburn are experienced at least once a month by more than 60 million Americans.

For women, the first experience with heartburn is often during pregnancy. Studies suggest that over 50% of pregnant women will experience heartburn during pregnancy. This is due to hormones of pregnancy and pressure from the growing fetus. Symptoms of heartburn resolve in most of these women after delivery of the baby.

What causes GERD?
Acid is produced in the stomach every day. Normally, a small amount of acid passes into the esophagus through a valve between the esophagus and stomach called the lower esophageal sphincter. When the frequency or amount of acid in contact with your esophagus increases, symptoms and damage to your esophagus can occur.

What are the stimuli of heartburn?
Pregnancy
Eating a large, especially fatty meal
Tomato sauces (spaghetti & pizza)
Lying down after a meal
Chocolate, peppermint
Coffee and tea
Smoking
Alcohol and carbonated beverages
Some muscle relaxers and blood pressure medicines
Excess weight
Eat more frequent, but smaller meals

What to avoid?
fatty food, coffee & tea, chocolate, peppermint, alcohol, smoking, carbonated beverages.

What to do?
Maintain a normal weight
Avoid eating 2-3 hrs before bedtime
Elevate the head of the bed 4-6 inches
Don’t lie down after eating

What medications are effective in relieving symptoms?
Antacids
(liquid or tablets):
Tums®, Rolaids®, Mylanta®, Maalox®, Gaviscon®, and many others.

OTC Acid Blockers:
Pepcid AC® , Tagamet HB® , Zantac AC® ., Prilosec OTC®
*Important Note: If you are pregnant or nursing a baby, seek the advice of a doctor before using OTC acid blockers.

Proton Pump Inhibitors:
esomeprazole, Nexium®; or
lansoprazole, Prevacid®; or
pentaprazole, Protonix®; or
rabeprazole, Aciphex®;

Pro-motility Drugs:
cisapride, Propulsid®

Prescription Strength Antacids:
sucralfate, Carafate®

Prescription Strength H2 Blockers:
cimetidine, Tagamet® , ranitidine, Zantac® , famotidine, Pepcid® , nizatadine, Axid®

When should you see a doctor about symptoms of heartburn?

If you have any of the following:
Symptoms of heartburn two or more times a week
Don’t get lasting relief on medication you are taking
Difficulty swallowing, especially solids
Choking, wheezing, hoarseness caused by regurgitation of acid into the throat
Signs of bleeding (vomiting dark coffee ground-like material or passage of tarry black bowel movements)
Unexplained weight loss
Reflux symptoms over more than one year

What treatments for heartburn are safe during pregnancy?
During pregnancy, the medical treatment of reflux should be balanced to alleviate the mother’s symptoms of heartburn, while protecting the developing fetus.

Step 1: Modification of diet & lifestyle

Step 2: Antacids are probably safe.

Sodium bicarbonate can cause a condition known as metabolic acidosis and should be avoided during pregnancy. Magnesium containing antacids may interfere with uterine contractions during labor and should be avoided during the last trimester of pregnancy.

Step 3: sucralfate (Carafate®) has a good record for safety and results with pregnant patients. Acid blockers can probably be administered safely, but require a doctor’s supervision.

Step 4: Other medical therapy should only be used when the benefit of the medicine for the mother outweighs the risk of the medicine to the developing fetus.


Please remember, as with all our articles we provide information, not medical advice.

For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.