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***** Woman's Diagnostic Cyber Newsletter *****
August 6, 2000
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
This week from Woman's Diagnostic Cyber
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Anatomy of a wrinkle
2. Osteoporosis vs arthritis - the differences
3. Reader submitted Q&A - Pain with PCOS
4. Abdominal exercises after surgery or delivery
5. The warning signs of appendicitis
6. Health tip to share - Lichen sclerosis Rx
7. Humor is healthy
Spread the word! Send a copy of this newsletter
to someone you know.
Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Anatomy of a wrinkle
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Not all skin wrinkles are alike. Some are very
fine lines due to the breakdown of underlying
collagen tissue mostly due to aging and sun damage
over time. They are present all of the time. Other
wrinkles are deep and due to the underlying
musculature deeper than the skin. You only see
them when a person smiles or frowns or tenses
those muscles. Dr. Audrey Kunin at Dermadoctor.com
explains the differences and how they are treated
differently.
Sunburns, especially in children or youth, are the
greatest cause of fine wrinkles later in life.
Prevention with sunblock and avoiding the sun is
effective long term medicine that we can give our
children.
To improve or rejuvenate the skin, several things
must be done. The thickened skin of aging needs to
be thinned with exfoliative agents. Underneath the
skin, moisture retention is important. Compounds
which help the connective tissue retain moisture
will make the skin look younger.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
2. Osteoporosis vs arthritis - the differences
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Bone diseases such as osteoporosis and the various
types of arthritis can sometimes be confusing.
They all produce pain, but osteoporosis is more of
a silent disease until so much calcium is lost
from bone that a woman has spontaneous fractures.
Bone pain occurs late in osteoporosis but earlier
in the arthritis conditions. Osteoporosis is
mostly preventable if we know it is taking place
whereas most of the arthritis conditions are not
really preventable with current knowledge.
The two major types of arthritis are
osteoarthritis and rheumatoid arthritis.
Osteoarthritis is a condition of degeneration of
the cartilage in joints that are chronically
overused and abused. The abuse of the joint may be
in one's work, a sport, exercise or just from
heavy weight. The degeneration of the joints often
involves knees, hips and smaller joints of the
hands, as well as the vertebrae of the neck and
lower spine. Most people who jog or run for
exercise on a regular basis over many years will
eventually develop osteoarthritis or the knees.
If osteoarthritis is from degeneration of joint
cartilage due to chronic trauma, rheumatoid
arthritis is an immune disease in which the body
produces enzymes that attack cartilage. The
enzymes also cause symptoms other than joint pain,
stiffness and deformity such as fatigue, fever
weight loss and anemia.
For a discussion of these bone problems, see the
article at the NIH Osteoporosis and Related Bone
Diseases National Resource Center:
Osteoporosis vs arthritis
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
3. Reader submitted Q&A - Pain with PCOS
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Last month I had a vaginal hysterectomy due to
PCOS (polycystic ovarian syndrome), but the Dr.
refused to take out the cysts in my ovaries and
didn't take out the ovaries either. The pain is
still present and feels like someone is squeezing
the ovary really hard. I can't stand it and it
affects both ovaries. Birth control pills didn't
work. Any suggestions as to what I can do? The Dr.
is no help. I'm 36 years old and in pretty good
health."
KE
This is a difficult question because traditional
polycystic ovarian syndrome (PCOS) is not
associated with ovarian pain for the most part. It
is not impossible for the pain to be due to PCOS,
but most likely the pain is due to multicystic
ovaries (a different condition of recurrent
ovarian cysts) or possibly due to other conditions
such as pelvic congestion, bowel dysfunction or
endometriosis.
After you recover more from the surgery (about 3
months at least) you and your doctor will need to
go back and try to see if the correct diagnosis is
PCOS, or whether it can be something else. You may
want to look at our article about cysts and pelvic
pain and PCOS.
Polycystic Ovarian Syndrome and Pelvic Pain
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
4. Abdominal exercises after surgery or delivery
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"When can I start abdominal exercises to get rid
of this bulge?" is a common question after surgery
or delivery. What is not asked or answered often
enough is what type of exercises are best to
restore a flat stomach.
At prevention.com there is a very good article "To
tighten your tummy in 21 days". They do an
excellent job of describing how to isolate the
rectus abdominus muscle by palpation while
standing and then performing correct abdominal
crunches that exercise the entire rectus muscle
(not just the upper part) and at the same time do
not harm the lower back muscles. If you have never
had expert instruction in abdominal muscle
exercises, this is a good place to start.
As far as performing these exercises after
delivery or surgery, they are definitely safe and
the best way to go. It might take more than 3
weeks to get up to maximum repeats and tone but
they allow for you to go at your own pace.
The biggest question that is not well answered
with scientific studies but is common experience
is when to to start these exercises. These are
personal rules-of-thumb for beginning abdominal
muscle tightening after you have been examined by
your doctor to make sure there has not been any
infection or impairment of wound healing:
after delivery an uncomplicated delivery
- 2nd day after
after a transverse incision without muscle cutting
(most C-Sections and hysterectomy incisions
- 6 weeks
after midline incision or transverse muscle
cutting incision (rarely used now)
- 8 weeks
add two weeks for every decade of age over 50
because of slower wound healing with age
add 6 weeks for any surgery involving repair of
hernia, pelvic organ prolapse or urinary
incontinence.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
5. The warning signs of appendicitis
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Appendicitis strikes most often between the ages
of 10-30. It can be quite confusing and difficult
to diagnose. Symptoms often include pain around
the navel which progresses to pain in the right
lower abdominal area after about 12 hours. Usually
there is tenderness to pressing on the abdomen,
loss of appetite, nausea and even vomitting.
Sometimes there is a fever but not always.
High resolution CT (computerized tomography) scans
are frequently used to diagnose appendicitis and
if it is suspected by a surgeon, laparoscopy is
often used to remove the appendix. Sometimes at
laparoscopy (20-30%) the appendix appears normal.
It is usually removed anyway because appearances
can be wrong and the recovery is not too much
different.
It is not known how to prevent appendicitis
although countries with high fiber diet have much
lower incidences.
Appendicitis warning signs
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
6. Health tip to share - Lichen sclerosis rx
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I have had lichen sclerosis for about a year. A
Dr. had me use a cortisone cream on it, but it
kept getting worse. I went to a dermatologist
and she said that medicine was too strong. She
put me on Aclovate ointment, 0.05% and in just 2
weeks it has cleared up a lot.
Audrey
[ed note - In the U.S. this is clobetasol which is
marketed under the name of Temovate(R) or
Cormax(R)]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
7. Humor is healthy
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Some say a computer is a woman --
if you do something wrong, it will remember every
bit of it.
Some say a computer is a man --
if you had just waited one more week, you could
have gotten a better model for less.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
That's it for this time.
Your BACKUPMD on the Net.
Rick
Frederick R. Jelovsek MD
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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****** Woman's Diagnostic Cyber Newsletter ******
August 13, 2000
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
This week from Woman's Diagnostic Cyber
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Low back pain - a major cause of disability
2. Test your contraceptive IQ
3. Reader submitted Q&A - Pregnancy test timing
4. Vaginal douche product effect on vaginal bacteria
5. Keeping weight loss with a walking program
6. Health tip to share - Severe bleeding
7. Humor is healthy
Spread the word! Send a copy of this newsletter
to someone you know.
Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Low back pain - a major cause of disability
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Many reproductive conditions in women can cause
low back pain because the same nerves feed the
pelvic organs that get compressed with spinal cord
or back muscle problems. A bladder infection,
prolapse of pelvic organs, uterine fibroids,
endometriosis and even just an enlarged or
"tipped" (back) uterus can cause low back pain.
The most common cause of low back pain, however,
is injury to the vertebral bodies of the spine,
the ligaments or muscles of the back. This pain
can become chronic and far removed from the injury
making it difficult to tell if your low back pain
is a musculoskeletal problem or a gynecologic
problem.
Usually the key differentiating symptom is pain
that worsens with movement of the lower back, the
lumbosacral spine. This points to a
musculoskeletal problem if the pain is aggravated
in going from standing to sitting, sitting to
standing, or any rotational (twisting) movement of
the upper body between the waist and shoulders.
Low back pain from a gynecological or urological
cause is much more constant, a worsens mainly with
pressure on the abdomen, vaginal intercourse and
vigorous exercise.
If you suspect your low back pain may not be
pelvic in origin but rather from the lower spine,
look at this low back pain tutorial from
R.C.Sechrest MD. It has great illustrations with
it that explain about causes of pain from the
lower back as well as how MRI is used in
diagnosing disk problems.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
2. Test your contraceptive IQ
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The Association of Reproductive Health
Professionals has developed a test-your-knowledge
section on various methods of contraception. It
asks about 6 general questions concerning
prevention of pregnancy and then 10 questions
about your specific type of contraception or tubal
ligation.
You may be contraceptively challenged if you are
not aware that:
tubal ligations are not 100% effective
birth control pills do not prevent STDs
it takes about 12-18 months on the average to
conceive after stopping DepoProvera injections
latex condoms should not be used with oil based
lubricants
Test your contraceptive IQ
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
3. Reader submitted Q&A - Pregnancy test timing
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"When is the best time to check a pregnancy test
if you have regular cycles and are trying to get
pregnant? Is it true the earlier the test turns
positive the less likely it is to have a
miscarriage?"
Anon
For many women, a regular menstrual cycle with
ovulation occurring on the same cycle day is a
exception rather than a rule. Ovulation can vary
by several days or even skip months. For women who
are fairly regular (every 26-32 days), however,
pregancy testing can start on the first day of a
"late" menses.
With today's sensitive home pregnancy tests, you
can have a positive result anywhere from 2-3 days
before a missed menses to 4-5 days after a missed
period. The pregnancy hormone HCG (human chorionic
gonadotropinn) enters the blood stream after
implantation occurs. Implantation most often
occurs on day 8 or 9 after ovulation. If it occurs
later than that, there is a higher early
miscarriage rate.
For a discussion of the timing of ovulation,
conception and implantation, see:
When to test for pregnancy
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
4. Vaginal douche product effect on vaginal bacteria
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Douching has been linked with actually causing
more bacterial vaginal infections than it cures so
it is not recommended on a regular basis. And yet
physicians are aware that it can be useful in
certain recurrent infection situations.
This study tested 7 commercially available douche
products against normal vaginal lactobacilli (the
bacteria you do not wish to kill off) and
bacterial strains causing bacterial vaginosis such
as Gardnerella, Mobiluncus, Mycoplasma,
Peptostreptococcus, and Ureaplasma, as well as
group B Streptococcus, and Candida yeast species.
They found that the 4 products containing
antiseptics had inhibitory effects against all
normal and abnormal bacteria and yeasts with only
a minute of contact time. On the other hand, the
vinegar containing douche products were effective
inhibitors of the "bad" bacteria and did not seem
to inhibit the "good" lactobacillus at all.
This data seems to imply that vinegar douches
may not be harmful and in fact may be beneficial
for treatment of the OCCASIONAL vaginal discharge.
Vaginal douche effects on vaginal bacteria
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
5. Keeping weight loss with a walking program
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Keeping weight off after a diet program is just as
tough as losing it in the first place. Most diet
programs show return to prediet weight (or more)
within 2 years in over 80% of people.
Exercise as part of a weight reduction program is
also questionable, believe it or not, as to
whether it helps to keep off the weight after the
intense diet phase is finished and maintenance
diet phase begun.
This study of over 200 women who underwent a 12
week diet program with an average loss of about 28
lbs and then were randomized to a maintenance
period of 40 weeks. One third had no exercise
program, one third had a walking program of 2-3
hours a week and one third had a walking program
of 4-6 hours. then all groups were observed with
no further intervention for 2 years.
During the maintenance period the women under
going exercise maintained their weight loss while
the control group gained 4.4 lbs (2.0 kg). During
the two year observation period, the control group
gained back 21 lbs (9.7 kg), the group who had
exercised 2-3 hours per week regained 13 lbs (5.9)
kg and the group exercising 4-6 hours a week
gained 20 lbs (9.2 kg) almost as much as the
control group.
The authors postulate that the higher duration of
exercise group was not able to maintain their
program as well as the 2-3 hour per week walking
group and thus "backslid" more. Thus exercise
helps keep off weight, but only if it becomes a
regular habit.
Walking program after diet program to keep it off
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
6. Health tip to share - Severe bleeding
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Due to months of severe bleeding I was faced with
the option of a hysterectomy or a lesser known
option called an 'endometrial ablation.' After
some research on the net and speaking with my
primary care physician, I opted for the ablation
procedure. It's been 2 months and knock on
wood...no bleeding, no period. I would highly
recommend exploring this option if a hysterectomy
is suggested. 1 week recovery at the very most!
:)"
CK
Editor Note - Last week's explanation about the
treatment of lichen sclerosis was unclear due to
my editor's note. The usual U.S. treatment is
clobetasol 0.05% a high potency steroid. The
point of the health tip was a better response from
a low potency steroid, Aclovate Ointment
(aclometasone), 0.05%. Different people have
different skin sensitivities to steroid ointments.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
7. Humor is healthy
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MID-LIFE REALITY
Mid-life is when you go to the doctor and you
realize you are now so old, you have to pay
someone to look at you naked.
The good news about mid-life is that the glass is
still half-full...of course, the bad news is that
it won't be long before your teeth are floating in
it.
Mid-life women no longer have upper arms, we have
wingspans...we are no longer women in sleeveless
shirts, we are flying squirrels in drag.
Mid-life has hit you when you stand naked in front
of a mirror and can see your rear end without
turning around.
Mid-life brings the wisdom that life throws you
curves...and that you're now sitting on your
biggest ones.
Mid-life is when you want to grab every firm young
lovely in a tube top and scream, "Listen, honey,
even the Roman Empire fell, and those things will
too!
Mid-life is when you start to repeat yourself...
and your chins follow suit.
You become more reflective in mid-life. You start
pondering the "big" questions -- what is life, why
am I here...how much Healthy Choice ice cream can
I eat before it's no longer a healthy choice?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
That's it for this time.
Your BACKUPMD on the Net.
Rick
Frederick R. Jelovsek MD
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Back to top
***** Woman's Diagnostic Cyber Newsletter *****
August 20, 2000
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
This week from Woman's Diagnostic Cyber
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Heat Stroke, Dehydration and Prevention
2. Treatment of hemorrhoids
3. Reader submitted Q&A - Weight gain on OCPs
4. Reflex sympathetic dystrophy - chronic pain
5. G6PD genetic enzyme deficiency
6. Health tip to share - Dizziness and vertigo
7. Humor is healthy
Spread the word! Send a copy of this newsletter
to someone you know.
Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Heat Stroke, Dehydration and Prevention
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
It is very easy at this time of year to become
involved in a strenuous activity outdoors in a hot
sun. You might think you are in good shape for a
hike, yard work or even a game of tennis or golf.
You may even have a quart of water handy to
prevent dehydration from sweating. As the water is
finished and you get thirstier, you still push on.
Several hours after finishing a strenuous
activity, symptoms of fatigue, exhaustion, nausea,
lightheadedness and even heat cramps can signal a
condition of heat exhaustion. The fact that it
can come several hours after finishing the
activity and even happen after replacing some of
the fluids, may make it hard to recognize. Lack of
replacing the salts lost in sweating is the main
culprit in heat exhaustion.
Even worse than heat exhaustion is heat stroke.
Heat stroke is a more extreme condition and is a
life threatening condition. Symptoms include
disorientation, combativeness and hallucinations.
The body has lost its heat control mechanism and a
person with heat stroke needs hospitalization.
To learn about prevention of this serious and
unsuspected condition, see:
Heat stroke and dehydration prevention
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
2. Treatment of hemorrhoids
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Hemorrhoids are not a serious condition, but they
can really be a PAIN! They are enlarged, swollen
veins like a varicose vein of the rectum or anus.
They can be inside the anus (internal hemorrhoids)
or outside (external) and present as rectal pain,
bright red bleeding with bowel movements, and
sometimes as an itchy lump by the rectum if the
hemorrhoid is external.
Factors which contribute to hemorrhoids are:"poor
bowel habits", constipation, diarrhea, pregnancy,
obesity, and especially frequent straining when
having a bowel movement."
Treatment of hemorrhoids is at first conservative
including:
keep area clean and dry
avoid straining at stool
increased dietary fiber
hot sitz baths several times a day
When conservative measures have failed to clear up
the hemorrhoids, there are other surgical
treatments such as:
ligation (banding)
infrared photocoagulation
laser
surgical excision
For more information about treatment and
prevention of hemorrhoids, check see the site at Jackson
Gastroenterology.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
3. Reader submitted Q&A - Weight gain on OCPs
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"I have been taking birth control pills for about
six months now. I am thrilled at the idea of not
becoming pregnant, however, my problem is
tremendous weight gain as a result of water
retention. I have experienced no increased
appetite, however my breasts are a full cup size
larger and I feel that I have an added layer onto
my body that makes me very uncomfortable. Is there
anything that can be done about this problem?"
Anon
Weight gain from pills can be from fluid retention
or simply by eating more. It is surprising that
almost all recent studies show there is not a net
weight gain or weight loss with the pills. If 10%
of women gain weight when starting a pill, 10%
lose weight thus off setting the ones who gained.
When compared to placebos, as many women gain
weight on the placebos as do on the pills.
Because of this doctors will often tell you that
the pills do not cause weight gain. More likely,
the pills do cause weight gain and weight loss.
The estrogen level seems to be associated with
fluid retention and the progestin component may be
associated with insulin resistance in a smaller
subset of women and these women have the larger
weight gain.
For an explanation and to see what you may be able
to do, see our article at:
Weight gain and birth control pills
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
4. Reflex sympathetic dystrophy - chronic pain
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Reflex Sympathetic Dystrophy Syndrome (RSD) is
also known as Complex Regional Pain Syndrome
(CRPS). It is a mouthful and a poorly understood
dysfunction of the sympathetic nerves that can
cause chronic pain. Even a small injury to the
skin, muscles or bone of anywhere on the body can
trigger this abnormal nerve response with pain
that is out of proportion to the injury.
It is important to know about this entity because:
it is more common in women than men
if undiagnosed and untreated it can spread to
large regional areas of the body
Symptoms in addition to more pain than the injury
would suggest may include:
Abnormal nerve function, burning, tingling, deep
muscle pain
Swelling, edema often stopping at a line on the
skin.
Joint stiffness, muscle cramps or jerking.
Changes in skin (shiny, dry), hair growth or
wasting of muscles
For a discussion of this unusual condition and to
learn about reflex sympathetic dystrophy, see this
clinical practice guidelines paper at the Reflex
Sympathetic Dystrophy Syndrome Association Of
America web site:
Reflex sympathetic dystrophy
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
5. G6PD genetic enzyme deficiency
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The congenital absence of an essential enzyme,
glucose-6-phosphate-dehydrogenase (G6PD) is one of
the most common genetic enzymes deficiencies in
the world today. It makes the red blood cells very
sensitive to certain infections and especially
drugs. These can cause breaking up of the red
blood cells (hemolysis) and thus a major anemia
without any evidence of bleeding or losing blood.
The only genetic advantage of having this enzyme
deficiency is that is makes a person more
resistant to malaria, so it is more commonly found
among people living near the equator. An allergy
to fava beans is almost diagnostic of this
condition.
As far as inheritance goes, it is what is called
an X-linked recessive. In other words a man who
inherits the gene from his parents will always
have the disease because he only has one X
chromosome. A woman has to inherit the enzyme
deficiency from both parents and if she is
positive then it is likely her brothers and
sisters are all positive. Any of her sons will be
positive although her daughters will not be
positive unless her husband also has the disease.
If her daughter is not affected but is a carrier
of the gene (one X chromosome affected, half of
the daughter's sons will have the condition.
It is very important to know about this condtion
because many medicines we routinely use can cause
a severe anemia and even heart failure due to the
anemia. Drugs and medications that will cause
hemolysis in a G6PD deficient individual include
among others:
aspirin
sulfa antibiotics
several antihypertensives
certain antimalarial drugs
Macrodantin
Pyridium
vitamin C
vitamin K
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
6. Health tip to share - dizziness and vertigo
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
For vertigo when standing, and when walking, not
seated or lying down, and not that which some have
when first standing up from a seated or lying
position, get an x-ray of your neck from the side
to see whether or not your cervical spine is
positioned in the natural curve that it's supposed
to be. If C-4, 5 and 6 are not curved properly
[i.e., too straight], they could be pinching the
nerves to your inner ear and be the cause of your
problem. It was for me. Changing to a new
chiropractor who found and corrected it after 20
months of trying about everything in the book was
what did it! Have at least neurological and ENT
causes ruled out first, tho'. There was
absolutely no nausea ever with this form of
vertigo.
Jli
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
7. Humor is healthy
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
An elderly woman went into the doctor's office.
When the doctor asked why she was there, she
replied, "I'd like to have some birth control
pills."
Taken aback, the doctor thought for a minute and
then said, "Excuse me, Mrs. Smith, but you're 75
years old. What possible use could you have for
birth control pills?"
The woman responded, "They help me sleep better."
The doctor thought some more and continued, "How
in the world do birth control pills help you to
sleep?"
The woman said, "I put them in my granddaughter's
orange juice and I sleep much better!
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
That's it for this time.
Your BACKUPMD on the Net.
Rick
Frederick R. Jelovsek MD
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Back to top
****** Woman's Diagnostic Cyber Newsletter ******
August 27, 2000
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
This week from Woman's Diagnostic Cyber
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Never too old for a mammogram
2. Irritable bowel syndrome diagnosis
3. Reader submitted Q&A - Premenstrual symptoms
4. Ovarian cancer tutorial
5. Men's health resources and links
6. Health tip to share - Bleeding from fibroids
7. Humor is healthy
Spread the word! Send a copy of this newsletter
to someone you know.
Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Never too old for a mammogram
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Did you know that a woman's chance of having a
breast cancer is:
by age 30. . . 1 out of 2,212
by age 40. . . 1 out of 235
by age 50. . . 1 out of 54
by age 60. . . 1 out of 23
by age 70. . . 1 out of 14
by age 80. . . 1 out of 10
Can you see why it would be a mistake for an older
woman to skip her annual mammogram? Women worry
about breast cancer in their forties but it gets
you in the 60's-80's.
The Breast Cancer Resource Center at the American
Cancer Society has an excellent section on
mammography. They provide a good description of
the standard mammogram procedure and what it looks
for. Current recommendations include a yearly
mammogram over the age of 40 for all women.
They also give you tips for when you have your
mammogram such as to avoid scheduling the study in
the week before your menses, to avoid using
deodorants or creams immediately before the study,
and to bring a list of the dates and results of
other studies and procedures you have had done.
Another helpful section is the description of
additional studies that might be suggested to you
such as ultrasound, ductogram, or image-guided
biopsy which may need to be performed if the
screening mammogram has any suspicious or
uncertain areas.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
2. Irritable bowel syndrome diagnosis
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Irritable bowel syndrome (IBS) can masquerade as
primarily pelvic pain in the ovary region,
especially on the left side, but most of the time
there is an obvious relationship of the pain to
eating meals or having bowel movements. Pain may
worsen or get better with bowel movements but the
relationship is clear.
Pain is not always present with IBS. It can be
just mild symptoms of abdominal bloating or pelvic
fullness. Sometimes the major symptoms are just a
change in bowel habits with alternating diarrhea
and constipation. If women take laxatives for the
constipation and antispasmodics for the diarrhea,
it can really become a confusing symptom picture.
While symptoms of abdominal pain, bloating, and
altered bowel habits are common to many
gastrointestinal conditions, there are some
important ones which strongly suggest IBS:
A long history of symptoms but not worsening over time
The absence of diarrhea at night
The absence of general findings such as fever,
weight loss, appetite loss, or anemia
Bowel movements primarily in the morning
Increased symptoms during periods of increased stress
A feeling of incomplete evacuation
Relief of discomfort with evacuation
The absence of blood in the stool
For more on IBS, see this clinical guideline at
familypractice.com
Irritable bowel syndrome
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
3. Reader submitted Q&A - Premenstrual symptoms
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Is it common after the birth of a baby (first
year not right after) to experience severe
moodiness, depression, and anger during or right
before a period?"
"I am 30 and have no previous medical problems."
Anon
It is not common but it can happen. As far as we
can tell, neither pregnancy nor labor and delivery
causes the onset of these symptoms. While many
women believe that abnormal hormone fluctuations
cause premenstrual syndrome, there is no evidence
that either estrogen, progesterone or gonadotropin
(LH and FSH) levels are different in women with
and without PMS.
For a discussion of causes and various treatments,
see our article at:
Onset and Cause of Premenstrual Syndrome
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
4. Ovarian cancer tutorial
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Ovarian cancer is always a frightful topic. There
are no symptoms with early cancers (stage 1 and 2)
when treatment is likely to produce a very good
survival. It is a silent disease and tumors grow
from the ovaries along the surface of
intraabdominal organs like the bowel.
Since tumor growth is on the outside surface of
the bowel, it will not be detected by xrays of the
upper GI series, barium enemas or even the scope
procedures such as sigmoidoscopy or colonoscopy
because all of those studies examine the inside of
the bowel, not the outside.
Until the fluid that gets secreted from extensive
tumor builds up (ascites) or the tumor actually
causes bowel obstruction, a woman may be unaware
she has the disease.
Borderline tumors are another strange category of
ovarian cancer. These are very slow growing
cancers that are treated surgically and if they
recur, they do so after 10-15 years rather than
within two years like most ovarian malignancies.
To learn more about ovarian cancer, see the
listing at the web site of William M. Rich, M.D.,
a gynecologic oncologist in Fresno, California.
Ovarian cancer tutorial
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
5. Men's health resources and links
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Men are not often known to be the guardians of
health for their families. In recognition of that,
we need to periodically look at some of those
health and medical conditions more commonly
affecting men so that you are aware of resources
to turn to.
Beyond just impotence, balding and AIDs, there are
numerous resources on the net for topics that men
may want to read. The Healthfinder gateway to
reliable consumer health and human services
information developed by the U.S. Department of
Health and Human Services has a section devoted to
men's health.
You can find content and links to topics like:
alcohol
heart disease
hypertension
prostrate problems
urology resources
occupational health
low back pain
dancing the work and family tightrope
depression in men before and after the birth of a child
fathering skills and issues
developing your fitness program
exercising proper care while working out
breast cancer links for men
conditions men get too
hair replacement - what works, what doesn't
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
6. Health tip to share - Bleeding from fibroids
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Severe bleeding from fibroids kept me sidelined
for weeks at a time. My doctor recommended a
hysterectomy. After research, I asked about a
uterine arterial embolization. My first period
after the procedure was normal as was the second.
I finally feel normal again. Women should
definitely explore this option!!!! I felt fine
one day after this non invasive procedure. I don't
know why ANY woman would chose a hysterectomy if
she had this as an option."
Chiqui
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
7. Humor is healthy
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Stress Reduction Technique"
Sit quietly and inhale deeply and slowly through
your nose.
Exhale slowly.
Picture yourself near a stream.
Birds are softly chirping in the crisp cool
mountain air.
Nothing can bother you here.
No one knows this secret place.
The soothing sound of a gentle waterfall fills the
air with a cascade of serenity.
The water is clear.
You breathe deeply.
You can easily make out the face of the person
whose head you're holding under the water.
Look.
It's the person who caused you all this stress in
the first place.
What a pleasant surprise.
You let them up ... just for a quick breath ...
then ploop! ...
Back under they go.
You allow yourself to take as many deep breaths as
you want.
There now ... feeling better?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
That's it for this time.
Your BACKUPMD on the Net.
Rick
Frederick R. Jelovsek MD
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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****** Woman's Diagnostic Cyber Newsletter ******
September 3, 2000
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
This week from Woman's Diagnostic Cyber
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Headache - what causes the pain?
2. Should teens be vaccinated for hepatitis A?
3. Reader submitted Q&A - Fibroids and HRT
4. Gynecologic cancer risk
5. Birth control pills and carbohydrate metabolism
6. Health tip to share - Recurrent yeast vaginitis
7. Humor is healthy
Spread the word! Send a copy of this newsletter
to someone you know.
Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Headache - what causes the pain?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Headache pain can come from the skin, muscles and
blood vessels of the head and scalp, but it does
not come from the skull bone or even the brain
inside. The brain and skull do not have many nerve
fibers. For the most part, headaches represent
muscle pain or blood vessel pain.
When you get a very severe headache, much worse
than you have had before, you may wonder when it
is time to see a doctor. At PersonalMD.com there
is a list of headaches that require prompt medical
attention:
headache associated with fever
severe sudden headache
headache associated with convulsions
headache accompanied by confusion or loss of
consciousness
headache associated with pain in the eye or ear
headache following a blow on the head
recurring headache in children
persistent headache in someone who was previously
headache free
headache, which interferes with normal living
MRI studies or CAT scans are used to diagnose
unusual anatomic causes of headaches such as
tumors, abscesses or areas of the brain damaged.
Most of the time these studies are negative and
the cause is just blood vessels that are
hypersensitive to many conditions or head muscles
that chronically contract due to stress.
For a good review of headaches, see:
Headache - where does the pain come from?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
2. Should teens be vaccinated for hepatitis A?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Hepatitis is caused by viral infections of various
virus types A-G. Most of the types are contagious
by blood contact such as abrasions during sex,
contaminated needles or blood transfusions.
Hepatitis A, however can be passed by contaminated
produce, water or other foods, kissing, eating
utensils etc. In other words, it is much easier to
catch and epidemic outbreaks have been reported.
Western states tend to have a higher incidence and
it has been suggested that adolescents in those
states be vaccinated against hepatitis A. The
following article in the Archives of Pediatrics
and Adolescent Medicine does a cost effectiveness
analysis and concludes that Hepatitis A
vaccination is worthwhile for adolescents in those
states.
If you have a teen going off to school this fall,
you may want to consider going to your local
health department where the teen can get an
inexpensive vaccination. They will also vaccinate
against hepatitis B.
Adolescent Hepatitis A Vaccination
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
3. Reader submitted Q&A - Fibroids and HRT
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"If you have been on ERT and have a fibroid, what
will happen if you stop the ERT? Will you begin
to bleed, will the fibroid shrink?"
ANON
Fibroids are known to be hormonally sensitive.
they go away after menopause and do not grow until
after menses starts in adolescence. Birth control
pills can make fibroids grow rapidly.
Hormonal replacement therapy during menopause or
even in the perimenopause may cause fibroids to
resume growing. It appears that the progesterone
or progestin component makes the fibroids grow the
most. Some estrogens, ethinyl estradiol and
natural estradiol make fibroids grow more than
weaker estrogens such as conjugated estrogen or
estriol.
It is possible that raloxifene may cause fibroids
to shrink even in the presence of added estrogen.
For a discussion of these relationships, see our
article at:
Fibroids and estrogen replacement therapy
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
4. Gynecologic cancer risk
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The Woman's Cancer Network has developed a risk
assessment questionnaire for how likely it is that
a woman might develop cancer of the breast,
ovary, uterus and cervix. The questionnaire takes
about 5- 10 minutes to complete and they do not
ask your name.
The printout tells if you are at low, average or
high risk of developing a female genital cancer
and gives suggestions as to what you can do to
lower that risk, if anything.
This risk assessment tool is very good to put your
cancer risk into perspective so you worry (or not
worry) about the correct risk.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
5. Birth control pills and carbohydrate metabolism
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
When oral contraceptives first came out, it was
said that they altered carbohydrate metabolism,
i.e., they made a diabetic have higher blood
sugars and a normal woman have glucose tolerance
test values more like a pre diabetic. As pills
became lower and lower in dose and the progestins
in pills became more "progesterone-like" and less
androgenic (male hormone-like), glucose tolerance
became less and less abnormal.
There still has been some controversy, however, as
to whether pill hormones make some women more
insulin resistant and therefore more prone to
gaining weight due to abnormal glucose metabolism.
This epidemiological study looked at different
measures of abnormal glucose metabolism such as
fasting glucose, hemoglobin A1c, fasting insulin,
and found that women taking the current lower dose
birth control pills (mostly 35 mcgm of estrogen)
did not have significantly different values for
these carbohydrate measurements.
This study in the American Journal of Obstetrics
and Gynecology of over 4000 women thus supports
that, on the average, birth control pills do not
aggravate a tendency toward diabetes nor do they
seem to cause a pre diabetic state.
Oral contraceptive use and glucose metabolism
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
6. Health tip to share - Recurrent yeast vulvitis
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"I suffered from frequent yeast infections for
years and used every prescription and non
prescription treatment that my doctor or I could
find. They were mostly successful in treating each
infection, but did nothing to prevent the next one
from happening. A chance conversation with a gyne
nurse ended yeast infections for me, 100%. She
asked me if I used "Dove" soap. I did. She asked
me if I used 'Always' pads. I did. I stopped using
both and the infections have stopped entirely."
LKW
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
7. Humor is healthy
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
With Great Deliberation
-=-=-=-=-=-=-=-=-=-=-=-=-=-
Mrs. Smith was called to serve for jury duty, but
asked to be excused because she didn't believe in
capital punishment and didn't want her personal
thoughts to prevent the trial from running its
proper course.
But the public defender liked her thoughtfulness
and quiet calm, and tried to convince her that she
was appropriate to serve on the jury.
"Madam," he explained, "this is not a murder
trial! It's a simple civil lawsuit. A wife is
bringing this case against her husband because he
gambled away the $12,000 he had promised to use to
remodel the kitchen for her birthday."
"Well, okay," agreed Mrs. Smith, "I'll serve.
I guess I could be wrong about capital punishment
after all."
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
That's it for this time.
Your BACKUPMD on the Net.
Rick
Frederick R. Jelovsek MD
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Back to top
***** Woman's Diagnostic Cyber Newsletter *****
September 10, 2000
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
This week from Woman's Diagnostic Cyber
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Pain and its effect on sexual response
2. Fallopian tube cancer and cancer support
3. Reader submitted Q&A - Breast cyst on mammogram
4. Self-injury -- A quick basic guide
5. Diet information links
6. Health tip to share - Yogurt for vulvar pain
7. Humor is healthy
Spread the word! Send a copy of this newsletter
to someone you know.
Note: Some of the long URLs may not wrap as a
hyperlink and you may need to cut and paste.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Pain and its effect on sexual response
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Any type of pelvic pain, but especially vulvar
pain at the entrance to the vagina, alters a
woman's desire, arousal, and response for sexual
intercourse. Sometimes the pain cannot be cured or
even lessened. How then does a woman cope with the
pain and its effect on sex?
This paper at the University of Michigan entitled
"Helpful strategies to deal with pain and sex" is
a valuable resource for any woman experiencing
this problem. It gives hints on dealing with the
medical establishment to communicate about the
problem and get help. In addition to reminding you
to avoid any sex that hurts (yes, some women need
to be told that), it gives suggestions about
expanding your sexual repertoire to include that
which does not hurt, to experiment with sexually
stimulating activity that does not involve
penetration, and to change away from outcome
(orgasm) oriented sex.
Pain and sexual response
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
2. Fallopian tube cancer and cancer support
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Cancer of the fallopian tube is quite rare. While
found in only about 1% of gynecologic cancers,
even 90% of that time a malignancy of the tube is
from another site (metastatic); it does not
originate in the tube.
Symptoms of fallopian tube cancer are very similar
to uterine cancer. Vaginal bleeding is the
hallmark sign. Sometimes there is discharge,
abdominal pain and pelvic pressure. The only
symptomatic difference from endometrial cancer is
that it sometimes give a very colicky abdominal
pain followed by a thin, very watery discharge.
Further diagnosis is by surgery, as is treatment
depending upon the extension and cell type.
Eyeontheprize.org is more than an information
source for women with gynecologic cancer. It
functions as a support resource for women who have
cancer. It includes sections on:
What to expect from the different cancer treatments
What to expect for cancer follow-up
Working with the medical system
Follow-up tests
Life after cancer
Surgical menopause
Sexuality
Loss of fertility
Emotional impact
Talking with family and friends
Fallopian tube cancer
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
3. Reader submitted Q&A - Breast cyst on mammogram
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"I just had a mammo, and had to go back for
another one and an ultrasound, they found a 1/2
inch cyst with a smaller one next to it. My Gyno
is leaving it up to me to see a surgeon, What are
your thoughts on this?"
"I am 42 white female, I also have cysts on my
ovaries, fibroid on my uterus and just had the
Leep procedure done to get rid of bad cells on my
cervix. My periods are regular, but I do clot a
lot and bleed heavily."
Cathy
The quick answer is to go ahead and have the cyst
aspirated. That is the easiest way to confirm that
the mass is a benign process and that you do not
need surgery to excise the cyst.
Cysts in the breast and fibrocystic breast disease
are different but related entities. To see a
discussion of breast cysts, see our article at:
Breast cyst on mammogram
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
4. Self-injury -- A quick basic guide
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Yes, there are people, more often women, who
intentionally harm their own bodies. They may cut
their skin with knives, razor blades, pins, glass
or any sharp object. It may include biting
yourself, scratching your skin until it bleeds,
hitting your body, burning yourself or even head
banging.
This condition doesn't refer to the once every 5
years of scratching yourself raw while being
anxious. This is a repetitive self-inflicted
violence. It is not part of the self-harm
condition if a woman is doing it for:
sexual pleasure
body decoration
spiritual enlightenment via ritual
fitting in or being cool
See this primer about self-injury at Palace.net if
you know anyone who might have this problem.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
5. Diet information links
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Web sites that are primarily link collections and
without original material can be frustrating
especially if the links are out of date. On the
other hand, there is so much diet and nutrition
web material that you can get lost quickly without
ever coming across the type of information you
wanted. You may want facts about fat or calorie
content of food or just some tools to tell how
much fat or calories are appropriate for someone
of your size. What about diet pills. fad diets,
cancer fighting foods?
Thedietchannel.com has coordinated over 600 links
about all you ever wanted to know about dieting.
You will have to sort through them to find what
you want but the choice is appetizing. Take a
look.
Diet information links
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
6. Health tip to share - Yogurt for vulvar pain
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"I have found that using plain yogurt on my vagina
externally helps if I have painful dryness or feel
a yeast infection may be coming on. It doesn't
sound great but I lie in bed on a towel and smear
it on, wait like 15-20 min then shower. I seem to
always feel so much better after this. Sometimes
you can do this twice a day if there is an
infection, its very relieving. The live active
cultures help replace the good yeast! (I think ;)
ANON
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
7. Humor is healthy
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The Love Potion
A very lovely young lady smote a young man.
Unfortunately, she did not return the feeling.
In desperation he went and visited a group of
witches searching for a love potion. They informed
him that they no longer provided such an item. It
was highly unethical to administer a potion to
someone without her permission.
They did have an alternate solution. They sold him
a bottle of small white pellets. He was to bury
one in her yard every night at midnight for a
month.
He returned to the witches six weeks later excited
and thankful. He and the young lady were to wed in
a month. That was a great idea they had, but why
did it work?
The witch told him, ... with a little cackle here
and there...
"Nothin' says lovin' like something from a coven,
and pills buried say it best."
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
That's it for this time.
Your BACKUPMD on the Net.
Rick
Frederick R. Jelovsek MD
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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