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Friday, May 29, 2009

More on Hypothyroidism

Hypothyroidism:  The Silent Epidemic

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

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

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

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

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

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

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

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

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

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

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

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

email from David S. Klein, MD, FACA

Monday, May 25, 2009

Thyrotoxicosis & Thyroid Storm

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

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

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

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

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

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

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

Source: Medscape CME Online

Thursday, May 21, 2009

Wednesday, May 20, 2009

Really this is ONLY A JOKE

I love this Doctor

cid:1.107666107@web37303.mail.mud.yahoo.com
Q: Doctor
, I've heard that cardiovascular exercise can prolong life. Is this true?
A: Your heart is only good for so many beats, and that's it.... don't waste them on exercise. Everything wears out eventually. Speeding up your heart will not make you live longer; that's like saying you can extend the life of your car by driving it faster. Want to live longer? Take a nap.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CONCLUSION

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

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

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

Friday, May 15, 2009

Mediterranean Diet Pyramid


Source: Oldways


Thursday, May 14, 2009

Metabolic Syndrome, Chromium & Vanadium

Weight Gain, Insulin Resistance and Metabolic Syndrome “X”

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

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

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

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

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

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

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

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

Wednesday, May 13, 2009

Letter from President Obama


May 13, 2009

Good afternoon,
You are receiving this email because you signed up at WhiteHouse.gov. My staff and I plan to use these messages as a way to directly communicate about important issues and opportunities, and today I have some encouraging updates about health care reform. The Vice President and I just met with leaders from the House of Representatives and received their commitment to pass a comprehensive health care reform bill by July 31. We also have an unprecedented commitment from health care industry leaders, many of whom opposed health reform in the past.
Monday, I met with some of these health care stakeholders, and they pledged to do their part to reduce the health care spending growth rate, saving more than two trillion dollars over the next ten years -- around $2,500 for each American family. Then on Tuesday, leaders from some of America's top companies came to the White House to showcase innovative ways to reduce health care costs by improving the health of their workers.
Now the House and Senate are beginning a critical debate that will determine the health of our nation's economy and its families. This process should be transparent and inclusive and its product must drive down costs, assure quality and affordable health care for everyone, and guarantee all of us a choice of doctors and plans.
Reforming health care should also involve you. Think of other people who may want to stay up to date on health care reform and other national issues and tell them to join us here: http://www.whitehouse.gov/EmailUpdates Health care reform can't come soon enough. We spend more on health care than any country, but families continue to struggle with skyrocketing premiums and nearly 46 million are without insurance entirely.
It is a priority for the American people and a pillar of the new foundation we are seeking to build for our economy. We'll continue to keep you posted about this and other important issues.
Thank you,
Barack Obama
P.S. If you'd like to get more in-depth information about health reform and how you can participate, be sure to visit http://www.healthreform.gov/.

This email was sent to jpsaleeby@aol.com Privacy Policy
The White House · 1600 Pennsylvania Ave NW · Washington, DC 20500 · 202-456-1111

Monday, May 11, 2009

Zinc (Zn)

Zinc: An Essential Element for Health

by JP Saleeby, MD

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

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

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

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

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

Zinc containing foods

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

(c) 2009

References:

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

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

Thursday, May 7, 2009

1918 Children's Rhyme


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



A human "bird house"
Little House Society

Wednesday, May 6, 2009

A Call for Calm

Lets Reflect Calmly on the Flu Outbreak

-JP Saleeby, MD

Swine Flu vaccine being administered in 1976

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

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

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

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

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


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

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

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