Tag Archives: cancer

Cartoon humor: A Prescription for Health!

 

prescription-for-exercise-cropped

Hat tip to Tommy Wood MD, PhD for introducing me to this great cartoon.

So what would happen if your doctor prescribed this? Would you be shocked? Would you follow the advice? Sadly few doctors make such recommendations as explicitly as this cartoon and fewer patients follow the advice.

How important are the elements in this advice?

They are essential. We too often focus on dietary concerns at the expense of ignoring other important low hanging fruit. Early morning  outdoor exercise with exposure to natural light in a green space, even on a cloudy or rainy day, is essential for health. Why? There are many reasons. Click the link above to read fitness expert Darryl Edward’s discussion with references. In fact outdoor exercise in a greenspace is more beneficial than the same exercise indoors. The reasons are many, including but not limited to Vitamin D production.

Early daytime exposure to natural outdoor light helps to maintain our Circadian rhythm and align the biologic clock in all of our cells and organs with the central biological Circadian clock in our brain. Most folks do not know that we have a biologic clock deep within our brain and that all the organs and cells of our body also have clocks. They all need to be synchronized with each other and with the sun for optimal health. When they are not synchronized bad things happen. Night shift workers and other folks with disturbed sleep have higher rates of cancer , depressionhypertension, heart attack and stroke.

Maintaining our circadian rhythm is vital to achieving adequate high quality restorative sleep. In turn, obtaining adequate restorative sleep contributes to lower cardiovascular disease risk in addition to four traditional lifestyle risk factors.

Exposure to artificial light at night disrupts our circadian rhythm and impairs the onset of sleep.

In medical school I learned that our retina has two cell types, rods and cones. But advances in science have revealed a  third cell type called retinal ganglionic cells. 

These cells are  particularly sensitive to blue light and directly connected to our central biological clock . Exposure to artificial light, especially from TV screens, computers, cell phones and other electronic devices after sunset disrupts our sleep cycle and delays the onset of sleep. That is why wearing blue light filtering glasses in the evening helps many folks to improve their sleep quality and duration.

Sleep deprivation for even one night causes elevation in interleukin 6 levels the following day. Interleukin 6 suppresses immune function and excessive levels cause bone and tissue damage (especially cardiovascular). Sleep deprivation  increases  Stress hormones (cortisol, adrenalin), decreases prolactin and Growth hormone , and decreases the nightly production of ATP .

Melatonin , often called the sleep hormone, is produced most abundantly during restorative sleep and essential for tissue healing, immune function, cancer prevention, and defense against tissue oxidation. These are just a few of the roles melatonin and sleep cycles play in determining our health..

So exercise outdoors in a green space daily to help synchronize your biologic clock with the sun, dim the lights in the evening and if you must watch TV or work on electronic devices before bed wear Blue Light filter glasses .

Of course eating an abundance of colorful fresh organic vegetables and fruits, and practicing some stress reduction techniques every day are equally important and essential to health and functional status.

Finally, not mentioned in the cartoon above is another healthy lifestyle choice, intermittent fasting (IF). IF will be discussed in the next post.

Until then, sleep well, exercise regularly out doors in a green space environment, eat clean, learn and practice some regular stress reduction techniques and read the next post about IF.

Bob Hansen MD

More toxic substances proposed for our food supply

I recently received this warning from one of my favorite food safety organizations.

“The U.S. Environmental Protection Agency (EPA) is taking comments on a dangerous proposal that will put our farms, our food, and our environment at risk.

The EPA is proposing a dramatic expansion of the use of the toxic pesticide Enlist Duo. Enlist Duo is a mixture of glyphosate (the active ingredient in Monsanto’s Roundup®) and the even more toxic 2,4-D (part of the chemical mixture Agent Orange). If approved the pesticide cocktail could be used on corn, soy, and cotton in 34 states — up from 15 states where the product was previously approved for just corn and soy.

Tell EPA to reject the expanded use of Dow’s toxic mix of glyphosate and 2,4-D >>

The rush to expand the use of Dow AgroSciences’ toxic chemical concoction of glyphosate and 2,4-D for use on the next generation of genetically engineered crops comes only one year after the EPA asked a court to revoke its previous approval due to the unknown risks it posed, and now EPA suddenly wants to more than double the number of states where the pesticide can be used.”

Unfortunately we will likely see an acceleration of such proposals under the Trump administration. Trump has discussed terminating the EPA altogether. It is going to be a difficult four years for food safety.

Be careful out there. Things are about to become very NASTY.

Bob Hansen MD

Roundup and GMOs, are dangerous to your health and threaten the future of family farms in America

There is a brief discussion of Roundup (Glyphosate) on Medscape.

Our Toxic World; Is Roundup Slowly Killing Us?

The discussion covers several important issues. To Pique your interest in reading further here are a few salient quotes.

Glyphosate is the most used herbicide in the world, the pride and joy (as well as a great cash cow) of mega-giant chemical manufacturer Monsanto. Although ubiquitous as Roundup® and generally presented for many decades as safe for humans and animals, in 2015 The International Agency for Research on Cancer (IARC) of the World Health Organization labeled glyphosate as “probably carcinogenic to humans.”[3]

The European Union (EU) is trying to determine whether Monsanto should have its license to sell Roundup renewed this year. With that renewal in mind, in the spring of 2016, 48 members of the EU Parliament, representing 13 nations, volunteered to have their urine tested for glyphosate. All were found positive by a German lab.[4] In May 2016, a University of California, San Francisco, lab working for The Detox Project, funded by concerned individuals, reported positive urine tests for glyphosate in 93% of 131 urine samples from across the United States.[5]

Is this widespread presence of glyphosate in humans incidental and harmless or are we all in danger of being poisoned by this Monsanto product? That is a very good question.

Remember the gut microbiome? We are learning a great deal about how it influences so much of human health. There is a project called Qmulus, at the Computer Science and Artificial Intelligence Laboratory at the Massachusetts Institute of Technology and funded in part by Quanta Computers of Taiwan. Under its auspices, authors Anthony Samsel and Stephanie Seneff, in a 40-plus-page review[6] with 286 references, paint a very troubling picture of glyphosate’s inhibition of cytochrome P450 enzymes. For example, one role of this enzyme is to detoxify xenobiotics. The authors propose that the consequences of this inhibition, when coupled with other synergistic disruptions, may insidiously induce many diseases associated with a Western diet, including diabetes, obesity, cancer, autism, Alzheimer’s, and others.

A 2015 paper[7] by the same authors takes these and new findings and deductions even further to manganese deficiency in cows fed genetically modified Roundup Ready feed. This update is 55 pages long with 328 supporting references. Both are in open access; peruse them if you choose. [Editor’s note: Links to the full text of these papers are included with the references.]

If you want to learn more about Roundup, GMOs, and the worsening global threat to our food safety (no exaggeration) you can learn more by visiting www.CenterForFoodSafety.org.

I learned about this organization while watching the film The Future of Food. Although this hit the screens in 2004 it is still worth watching. If you think ROUNDUP is safe or that GMO foods are OK, think again. At least give this movie and website a look before you settle back into contentment with Monsanto and all the other bad actors in the food-seed-pesticide industry making decisions that WILL destroy the ability of farmers in the US and possibly world-wide to use their own seeds.

Monsanto has genetically engineered and patented a suicide gene and placed it into all of it’s seeds (cotton, soy, corn) so that farmers must buy seeds EVERY YEAR. This seed produces crops whose seeds are sterile. If this seed is carried by wind, animals, or other common mechanisms, from Monsanto’s’ crops to non-GMO fields, the gene will hybridize with natural seed crops and after several generations render a majority of crops infertile.

Monsanto produces not just pesticides but pesticide resistant seeds that produce sterile crops. Monsanto is playing monopoly and quickly eliminating independent seed producers and destroying family farms that have every year used their own seeds which have been bred to thrive in the local environment of the family farm.

Other issues abound. Roundup resistant crops, eaten by American consumers, have high levels of ROUNDUP and other pesticides that have been demonstrated to cause tumors in > 50% of animals within 1 year. Monsanto only tested ROUNDUP for 3 months in animal studies and declared it safe. The USDA did not test it. The FDA did not test it. Government scientists and university scientists who expressed concerns were silenced by the economic power of this massive multi-national corporation.

When independent scientists published their alarming results (carcinogenesis), Monsanto used it’s financial resources to shut those scientists down. You can learn about this by watching The Future of Food or visiting www.CenterForFoodSafety.org.

Like big Pharma executives cycling between the pharmaceutical industry and the FDA, Monsanto executives and lawyers cycle in and out of the FDA and USDA. We have allowed the fox to guard the chicken pen and the stakes are high. Family farms have been put out of business by Monsanto’s unethical and predatory behavior, eliminating generations of private seed banks and wreaking havoc for family farms across America. Don’t believe it? Watch the movie. Many farmers have gone bankrupt fighting legal battles with Monsanto because the wind has blown Monsanto’s patented seeds onto their private lands and Monsanto successfully sued them for patent infringement. This predatory behavior has been going on below the radar for many years and it started when the Supreme Court ruled that Monsanto can patent seeds.

In fact, Monsanto has gone into the US national seed banks, collected samples of thousands of different seeds, and patented them! This outrageous and ridiculous scenario has allowed a private company to patent thousands of heritage crop seeds.

If this sounds incredible, you are right, but it is true.

In the meantime, support mandatory GMO labeling and support food retailers who have promised to carry only NON-GMO foods.

To your health.

BOB Hansen MD.

Nutrition Journals and the influence of the food industry

Ever wonder why the public is so confused about nutrition recommendations? Just follow the money and you will understand that most of the professional societies that publish nutrition articles are funded by big food companies that are trying to sell more sugar, refined carbs and junk food. I recently read an excellent post about this topic here:

The Vilest Villain: American Society of Nutrition

This theme is repeated by medical journals that are “The Official Journal of the Society of >>>>>>” Just fill in the blanks for just about any medical society. Funding comes from big pharmaceutical companies the same way that funding in the nutrition Journals comes from large (junk) “food” manufacturers.

Don’t get me wrong, there are plenty of very valuable, life-saving drugs out there.

But most chronic human disease in developed societies is generated by various combinations of poor nutrition, lack of exercise, disruption of circadian rhythm, inadequate restorative sleep, stress and lack of social support systems.

The obesity and diabetes epidemics continue to worsen yet the failed dietary advise of major health organizations is slow to respond to the data. Excess refined carbs (especially in the form of “food” made with flour) and added sugar (especially in the form of HFCS) are the major driving forces for obesity, diabetes and cardiovascular disease. Red meat is not the culprit, provided the meat is properly sourced (hormone and antibiotic free, grass fed) and cooked in a manner that does not create carcinogens and inflammatory mediators (cook with slow, low, moist heat, high temperature grilling and smoking cause problems, but that topic  is for another post).

Americans consume an average 130 pounds per year of added sugar and 140 pounds per year of refined flour. Those are averages so there are many people who consume more. The added sugar is not the white stuff people put in their coffee. It comes in all sorts of forms but is found in energy drinks, soda, lattes and mochas, salad dressing,  ketchup, canned soups, canned vegetables, white AND whole grain breads, pasta (even “whole grain”), crackers, breakfast cereal,  just about any packaged food that has more than one ingredient on the label. These foods represent 70% of the American diet. The problems created by this situation are enormous and will bankrupt our “healthcare system”. This is a cultural and economic problem.

The solutions are simple but largely ignored in our society. We are creatures of habit and convenience.

Eat whole foods, nothing from a package that has more than one ingredient. Eat meat, seafood, poultry, fresh organic vegetables (6-9 servings per day), fresh organic fruits, and nuts. Meat should be hormone and antibiotic free (free range, grass fed). Seafood should be wild. Poultry should be free range and the eggs should come from free range chickens, ducks, geese.

Do not worry about eating fat as long as it comes from healthy animals and sources such as coconut oil, extra-virgin olive oil, avocado oil and clarified butter (ghee).

Do not use any “vegetable” oils (corn, soy, and other oils from grains or seeds) The vegetable oils are highly refined and inflammatory. They contain easily oxidized omega 6 fats that feed the production of inflammatory mediators in your body and create oxidized LDL leading to atherosclerosis.

Exercise daily, preferably outside in a green space. Twice per week spend 20-30 minutes  doing resistance training (lift weights, work against the resistance of bands, use your own body weight doing pushups, pull-ups etc)

Reduce stress with mediation, yoga, tai chi, dancing, engaging in fun sports and social activities. Walk on the beach, by a lake, river or stream, in the woods, listen to music.

Get some sunshine regularly especially during the morning to get your circadian rhythm in order and to produce adequate amounts of vitamin D.

Spend time with family, friends and colleagues who are supportive and fun to be around.

Sleep in the dark.

Get at least 7 hours of sleep per night. Avoid TV, computer screens and other electronic devices for at least 2 hours before bedtime.

Unplug from the internet, email, etc on a regular basis.

We evolved as hunter-gatherers.

Peace

Bob Hansen MD

 

 

Endocrine Disrupting chemicals in food, containers and environment results “in a range of human diseases and abnormalities.”

The findings of four articles recently published in the Journal of Clinical Endocrinology and Metabolism were presented on March 5 at a press briefing held at the Endocrine Society’s annual meeting, ENDO 2015, Despite the incredible public health implications of these four studies little has been reported in the popular press.

I have previously discussed the Environmental Working Group’s list of the Clean Fifteen and the Dirty Dozen toxic chemicals | Practical Evolutionary Health as well as the impact of environmental toxins on our epidemic of auto-immune disease Babies born with more than 200 toxic chemicals in their blood | Practical Evolutionary Health .

The press briefing and the findings of these four studies were reported on-line Endocrine Disruptors Cause Range of Diseases; Cost 157 Billion Euros

The estimated health effects of pesticides, chemicals used in personal care products, aluminum can liners, flame retardants in clothing, mattresses, furniture,  etc., included the following

From pesticides:

  • 59,300 infants born with intellectual disability
  • 28,200 people aged 50-64 years with type 2 diabetes
  • 13 million lost IQ points in each EU country

From Phtalates used in food wraps, cosmetics, shampoos, vinyl flooring

  • 24,800 deaths among 55-64 year old men
  • 618,000 additional assisted-reproductive technology procedures to treat infertility
  • excess of obesity and diabetes among women aged 50 to 64

Flame retardants in electronics, furniture, mattresses:

  • 3290 intellectually disabled children
  • 873,000 lost IQ points
  • 6830 cases of testicular cancer
  • 4615 children born with undescended testes

Other estimates from endocrine disruptors included:

  • 316 autistic 8 year olds EACH YEAR
  • 31,200 ten year olds with ADHD

Here are some snippets from the on-line Medscape report.The economic costs are reported in Euros since this was a study of European data. Bear in mind that the European Union has more stringent environmental protection than the United States. As a result, a study using US data would likely show even greater damage.

The papers cover overall costs of selected disorders attributed to specific endocrine-disrupting chemicals, as well as more detailed analyses of costs related to endocrine-disrupter–linked obesity and diabetes, neurobehavioral deficits/disease, and male reproductive disorders/diseases.

“Limiting our exposure to the most widely used and potentially hazardous endocrine-disrupting chemicals is likely to produce substantial economic benefit,” lead author of the overview study, Leonardo Trasande, MD, from New York University, said at the briefing.

The European Union defines an endocrine-disrupting chemical as an “exogenous substance that causes adverse health effects in an intact organism or its progeny, secondary to changes in endocrine function.”

With exposures occurring via pharmaceuticals, industrial solvents, personal-care products, aluminum-can linings, plasticizers, pesticides, and environmental pollutants, chemicals known to be endocrine disrupting include diethylstilbestrol, polychlorinated biphenyls (PCBs) , dioxins, perfluoroalkyl compounds, solvents, phthalates, bisphenol A (BPA), dichlorodiphenyldichloroethylene organophosphate/organochlorine pesticides, and polybrominated diphenyl.

Affected hormones include estrogen, androgen, thyroid, retinol, aryl hydrocarbon, and the peroxisome proliferator-activated receptor (PPAR) pathway. In all, 13 chronic conditions have strong scientific evidence for causation by endocrine-disrupting chemicals, Dr Trasande said.

“There are safe and simple steps that families can take to limit their exposure to endocrine-disruptive chemicals. They can avoid microwaving plastic. They can avoid eating from aluminum cans or drinking fluids from aluminum cans. They can eat organic. Or even simply air out their homes every couple of days to remove some of the chemical dust…that can disrupt hormones in their bodies.”

Using estimates based on the literature and established statistical methods adapted from those used by the Intergovernmental Panel on Climate Change, Dr Trasande led a 12-member scientific steering committee, which determined that there was probable causation of endocrine-disrupting chemicals for IQ loss and associated intellectual disability, autism, attention-deficit/hyperactivity disorder (ADHD), childhood obesity, adult obesity, adult diabetes, cryptorchidism, male infertility, and mortality associated with reduced testosterone.

Using mid-point estimates for probability of causation, the panel calculated a median cost of €157 billion, or 1.23% of the EU gross domestic product, with a lower median range of €119 billion and a high end estimate of €270 billion.

Dr Trasande summarized results from the four papers at the briefing, including these data points:

  • By health effect, the greatest cost was for neurological problems, including ADHD, at €132 billion. By endocrine-disrupting chemical type, pesticides were the most costly, accounting for €120 billion.
  • Pesticides accounted for 13 million lost IQ points in each EU country, costing €124 billion in earning potential. They were also responsible for 59,300 infants born with intellectual disability (€24.6 million), and 28,200 people aged 50-64 years with type 2 diabetes, at a cost of €835 million.
  • Phthalates, used in food wraps, cosmetics, shampoos, and vinyl flooring, resulted in 24,800 additional deaths among 55- to 64-year-old men, costing €7.96 billion in lost economic productivity; and 618,000 additional assisted-reproductive-technology procedures, costing €4.71 billion, Dr Trasande reported. Phthalates also accounted for an excess of obesity and diabetes among women aged 50 to 64, totaling more than €15.6 billion.
  • Flame retardants used in electronics, furniture, and mattresses resulted in 873,000 lost IQ points, leading to €8.4 billion in lost earning potential; 3290 intellectually disabled children, costing an additional €1.9 billion; 6,830 new cases of testicular cancer, at €850 million; and 4615 children born with undescended testes, at €130 million.
  • Other estimates of burden and disease and costs include 316 autistic 8-year-olds each year from multiple endocrine disrupting chemicals, costing €199 million; 31,200 10-year-olds with ADHD (also from multiple endocrine-disrupting chemicals), at €1.7 billion; and BPA used in aluminum-can linings and thermal-paper receipts, being associated with 42,400 obese 4-year-olds at an annual cost of €1.54 billion.

Dr Trasande said that a similar analysis for the United States would be “the logical next step” and that he would anticipate analogous findings, although there are some differences. Brominated flame retardants are more stringently limited in Europe, for example, but levels of phthalates have decreased 17% to 37% in the United States between 2001 and 2010.

Keep in mind that these studies were published in the peer-reviewed Journal of Clinical Endocrinology and Metabolism. They do not represent a governmental agency report, which is frequently tainted by the influence of lobbyists and scientists with conflicts of interest. Whether the European governments respond to this data in a meaningful way remains to be seen. Given the Republican majority in both the US Congress and US Senate as well as the sad state of journalism in the US it is likely that this scientific data will fall on deaf ears.

Nevertheless, we all have the opportunity to educate ourselves about these dangers to the health of our families and make changes in our daily lives that might limit the damage to our personal health and the health of those we love.

Do not drink water from plastic bottles. Do not drink soda or fruit juices from plastic or aluminum containers. Do not microwave food in plastic containers or store warm food in plastic containers. Eat organic vegetables and fruits whenever possible and avoid especially non-organic produce from the Dirty Dozen

Despite the manufacturers claims to the contrary, BPA used to line aluminum cans is not safe, same for BPA used in thermal paper receipts. “BPA free” hard plastic containers and metal containers lined with BPA replacements will likely prove to be unsafe in the future.

That “new-car” smell and “new-furniture” smell may contain endocrine disrupting flame retardants off-gassing. So open your windows and get rid of those odors, use HEPA air-filters at home. Consider having your old furniture reupholstered instead of buying new furniture. Apply only safe personal care products to your body (visit the EWG website for more information)Consumer Products | Environmental Working Group

Live clean, eat clean.

BOB

Over-diagnosis and Over-treament, Less is sometimes more

There have been many books published recently by physicians concerned about over-diagnosis and over-treatment. One very emotional area that caused great controversy when new prevention guidelines were published (regarding mammograms) relates to early detection and treatment of cancer. It would seem intuitively obvious that early detection and early treatment of cancer would save lives but it turns out this is not always so straight forward. Some cancers are very slow growing and early detection and treatment can cause more harm than good. This has been argued relative to screening for breast cancer, cancer of the uterus and prostate cancer, among others. For these particular cancers the screening tests are mammograms, pap smears and PSA blood test. To understand how and why less could be better you should read  Overdiagnosed.

If a cancer is diagnosed by a screening test 3 years before symptoms would have resulted in a diagnosis, but the early treatment does not change the course of the illness compared to treatment latter, it gives the appearance that the patient lived three years longer as a result of early treatment simply because the patient carries the diagnosis for three years longer. This actually turns out to be the case in many situations. Despite this knowledge our emotional response as physicians and as patients refuses to adapt to new data and we continue to follow old habits such as annual pap smears even though the data suggests that pap smears every three years would be equally  effective in saving lives and would actually prevent unnecessary, expensive and anxiety producing follow up procedures and testing. The exception to this recommendation would be for “high risk” individuals that still benefit from more frequent screening.

It turns out that in the US we likely over-diagnose and over-treat many conditions. The benefits of treatment are sometimes not justified by the side-effects and complications of the treatment. As a result of this concern the  Choosing Wisely campaign was created by a consortium of more than 30 Medical Specialty Societies with a goal of avoiding unnecessary testing and treatment. This is similar to the   Too much medicine campaign | BMJ

Medical testing can cause harm directly (complications of the test itself) but also indirectly. False positive results can lead to further invasive testing which can have complications and create anxiety for the patient.

Beyond screening tests for patients without symptoms there are many drugs now being marketed to treat “conditions” that may not need treatment. (read my posts on statins as an example) Big money is behind over-treatment and it is hard to stem the tide. Dr. Malcolm Kendrick | Scottish doctor and author of ‘The Great Cholesterol Con’

The BMJ (formerly the British Medical Journal) has been much more active in addressing these concerns as stated below:

“Has modern medicine undermined the capacity of individuals and societies to cope with death, pain, and sickness? Has too much medicine become a threat to health? Yes, argued Ray Moynihan in a BMJ theme issue in April 2002. He accused the pharma industry of extending the boundaries of treatable disease to expand markets for new products. Barbara Mintzes http://www.bmj.com/content/324/7342 blamed direct to consumer advertising of drugs in the US for portraying a dual message of “a pill for every ill,” and “an ill for every pill.” Elsewhere in the issue, doctors were accused of colluding in and encouraging medicalisation. Leonard Leibovici and Michel Lièvre http://www.bmj.com/content/324/7342/866 wrote : “The bad things of life: old age, death, pain, and handicap are thrust on doctors to keep families and society from facing them.”

Useful links:

Treatment of GERD with prolonged use of a Proton-pump inhibitor results in increased risk of pneumonia and increased risk for vitamin B12 deficiency http://jama which can result in permanent nerve damage, anemia and other ailments. This class of drug has many other potential complications. They cause decreased intestinal absorption of minerals and other nutrients and likely alter the mix of important health-promoting bacteria in your gut. They can lead to  Small intestinal bacterial overgrowth in 35% of patients who use them. They also likely contribute to increased risk of osteoporosis,  fractures and a four-fold increase in certain heart  rhythm disturbances. These drugs are now available as non-prescription medications as well as prescription medications and they are often indiscriminately used for prolonged periods of time.

Sleeping pills are another example of over-prescribed medications. The FDA has approved the use of many of these drugs for just a few weeks at a time but I see patients frequently on these medications for years. They can  lead to addiction within a few weeks, can cause dizziness, drowsiness, memory problems, confusion , hallucinations, and other side effects, and should not be used with alcohol. Sleep walking, sleep eating, sleep driving, and other abnormal-dangerous behaviors have been reported with many sleep medications. In addition to these concerns:

“An analysis of data of clinical trials submitted to the FDA concerning the drugs zolpidem, zalepon, and eszopiclone (Ambien, Sonata, and Lunesta) found that these sedative hypnotic drugs more than doubled the risks of developing depression compared to those taking placebo pill. All studies have been funded by the drug companies without independent research.”

Examples such as this abound in the US, the only developed country that permits direct to consumer advertising of drugs on TV.

Why do we pay almost twice per capita for health care in the US compared to other developed countries while ranking between 20 and 30 on various measures of public health? Over-diagnosis and over-treatment in my opinion, are big factors.

I would encourage you to explore some of the links above to learn more about over-diagnosis and over-treatment so that you can make more informed health-care decisions.

Peace

Bob Hansen MD