Ryan Haight Act affects Online Pharmacy Practices

What is the Ryan Haight Act?

by Rhiannon Coppin
Wednesday, 14 January 2009

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

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

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

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

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

Post & Courier Article on Thanksgiving Day

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

Local doctor pays house calls

with mobile medical service

By Jessica Johnson

The Post and Courier

Thursday, November 26, 2009

Photo by Jessica Johnson

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

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

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

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

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

Visit www.carolinamobilemd.com.

Reach Jessica Johnson at jjohnson@postandcourier.com.

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Hyptis crenata (Brazilian Mint Tea) as pain reliever

Cup of mint tea is an effective painkiller

Graciela Rocha with one of her Brazilian mint plants

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

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

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

The study is published in the journal Acta Horticulturae.

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

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

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

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

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

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

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

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

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

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

'Interesting research'

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

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

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

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

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

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

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

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

Carbon Monoxide Poisoning

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

Ugly Numbers

Some Ugly Numbers

- JP Saleeby, MD

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

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

Some Ugly numbers:

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

source: Medical Economics Journal 10/2009

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

Ezetimibe (Zetia) shown INFERIOR to Niacin (B3)

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

Zetia Tablets

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

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

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

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

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

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

------
Beyond Cholesterol

By JP Saleeby, MD (posted April 2005)

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

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

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

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

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

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

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

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

Hypothyroidism article

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

Hypothyroidism: The Silent Epidemic

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

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

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

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

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

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

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

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

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

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

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

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

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

MSM and Performance Athletes

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

The Spinal Withdrawal Reflex and Athletic Performance

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

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

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

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

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

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

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


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

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

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

Vitamin D-3 & Viral Infections

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

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

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

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

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

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

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

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

Policosanol vs Statin Drug

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

The side effects of statin drugs [are]:

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

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

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

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

5. Headaches, Joint and Abdominal Pain.

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

7. Sexual function problems, fatigue, dizziness.


Dosage and Administration of Policosanol:


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

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

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

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

source:  www.suffernomore.com

** additions by JP Saleeby, MD

Dr. Saleeby's Medical Antique Collection up for grabs

Dr. Saleeby's Antique Medical Instruments& Books

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

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

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

Quote of the day

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

Ovarian Cancer

Ovarian Cancer (Ab ovo)

By JP Saleeby, MD

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

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

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

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

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

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

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

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

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

References:

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

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

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

© 2009

Dr. Casey Mann's last day at MPH

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

Quote of the day:

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

RH

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

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Dr. J P Saleeby, MD

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