2012-08-30

The Return of Whooping Cough

The Return of Whooping Cough

In today's New England Journal of Medicine, one of the country's top experts in infectious diseases, James D. Cherry, MD, presents the fact that we are right now in the middle of the worst outbreak of whooping cough in 50 years.  There is so much whooping cough, or pertussis, around, that we are at levels approaching a full 1/3 of the rates seen before the pertussis vaccine was invented!

So what is pertussis, and what about our current epidemic?

Pertussis is an infection caused by a certain bacteria called Bordetella pertussis.  This bacteria infects mainly the lungs and airways (e.g., nose, throat).  The older you are, the milder the infection, so in young infants it can be quite dangerous.   

For infants less than 2 months of age, about 1 in 100 actually will not survive a bout of pertussis.  For infants ages 2-11 months old, the chance of dying from this infection is a bit less than 1 in 200.  For older children and adults, this infection causes mainly misery, death is quite rare from it.  

The main problem older children and adults have from pertussis is cough.  The cough is very persistent and can last several months.  In fact, in the article by Dr. Cherry, the claim is made that if an adolescent or adult is coughing for more than 3 weeks, the chance the cause is pertussis is 13-20%.  Screening a large number of adolescents and adults has found about 1-6% have had a recent case of pertussis.  Other problems it can cause the older child and adult include pneumonia, broken ribs from coughing, fainting, pneumonia, and insomnia.  Rarely it can cause seizures and dysfunction of the brain.

The number of people with pertussis is at a 50 year high, why?  One reason is that it is easier to test for it, and more doctors are aware that older kids and adults get it frequently.  So more tests are being done and more people found to have it.  

Another more troubling reason is that in an effort to make immunizations cause less fever and discomfort, the pertussis vaccine was weakened in the 1980's.  This was the move from whole cell to acellular pertussis vaccines.  The acellular variety is why the initial has a small "a" in it.   Immunizations to protect against pertussis are combined with tetanus and diphtheria vaccines.  The original version is DTP, the newer acellular version then is, DTaP.  The adult version is called TDaP.  Both are the acellular, weaker pertussis vaccine.

Yet another concern is that the pertussis bacteria, B. pertussis, is a clever enemy.  Even getting a full infection with this germ offers no or little immunity, you can get this illness over and over.  This is the main reason the immunizations for pertussis don't last very long.  After the first pertussis immunization, you are only protected for a few weeks.  After 5 such immunizations spanning the first 5 years of life, the immunization lasts only 7 or so years.  This is why the TDaP is being urged as a vaccine at age 12 and in adulthood.

Bottom Line
Whooping cough, or pertussis, is back.  We are in the midst of the biggest epidemic of it in 50 years.  Right now, up to 20% of all older children and adults with a cough lingering more than a couple of weeks have it.
This illness causes a lot of misery in older kids and adults, but is actually very dangerous to the life of infants.
What to do?  
  1. Make sure everyone in your entire family is up to date on pertussis immunization.
  2. If you have a cough lasting more than 2 weeks, the fact that a pertussis epidemic is on, means we are going to test for it more often.

Dr. Arthur Lavin




*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

2012-05-13

Parenting: Attachment, Nurturing, and Guiding

Parenting:  Attachment, Nurturing, and Guiding

Time magazine featured a cover photo that could have not possibly made breast-feeding more provocative.

A young mother was dressed in tight, stretchy clothes, with one breast out and being suckled by a three year old boy in a nice suit, standing up, on a stool.

Not one of these features is typical of the usual breast-feeding scenario except for the fact that it included a mother and child and that the mother was young.  More typically, children are breast fed in a setting of more quiet intimacy, cuddled, out of the glare of the paparazzi, with neither mother nor child dressed for business success.

So the first comment on the Time magazine cover is that it was designed in nearly every aspect to be provocative, and it worked, here we are talking about it!

But it also gives us the opportunity to look at a popular philosophy of parenting, attachment parenting.

Attachment parenting derives from a very strong and valuable tradition of parenting often referred to as nurturing parenting.   Nurturing parenting is based on the stance that the key role of parenting is to offer nurturing care and love to our children.  It has its roots in the studies of childhood that helped launch the modern era of psychology in the late 19th and early 20th centuries.  It is worth noting that one of Sigmund Freud's greatest observations was that events that take place in infancy and childhood can have profound consequences in that person's adult life.  This was a powerful and earth-shattering observation at the time it was made, even though most of us would consider it an obvious fact today.  From Freud, the concept grew in the hands of the great English pediatrician and psychoanalyst, D.W. Winnicott and his intellectual heirs, including the wonderful Haim Ginott and Selma Fraiberg.   

Nurturing parenting also was a reaction to the strictures of authoritarian parenting, a stance that cared little for the thoughts and feelings of children and instead placed most value on the imposition of adult authority and its rules.  This was the dominant mode of parenting in post- World War II middle class America and remained so until the rise of nurturing parenting with the publication of Dr. Benjamin Spock's seminal book and the work of Dr. T. Berry Brazelton.

I was honored to have been trained in my understanding of child development by Dr. Brazelton and had the opportunity to personally observe the power of loving responsivity to bring out the best in children and their parents.  The work of Dr. Brazelton and others profoundly changed the way America raises its children.
Where once toilet training was forced on children at young ages with physical punishment taking place when they failed to pee or poop on command, now toilet training is left mainly up to the child, to be approached and managed as they see fit and when they choose to do so.

This revolution took place in the late 1960's and not much has really changed in the philosophy of American parenting since those days.

From this perspective the work of the Sears family sits firmly in the current traditions.  In this perspective, parents are expected to care very deeply about their child's needs and desires, to be knowledgeable about how these change from one phase of childhood to another across development, to be responsive from moment to moment to the child's emotional abilities and states.  We know from much study and research that the child gains much from this approach, it helps and it works.

But we have also found that there is one piece missing from this picture, and that is guidance.  One of the unspoken assumptions about the nurturing stance of parenting is that the child will be profoundly grateful, that in return for an expert, caring, and responsive parent, the child will also be caring and responsive.  And why not?  After all, if someone was attending to your every need, wouldn't you take kindly to them?

And yet, we have observed that starting at about 18 months of age, this is not the case for nearly every family.  For some striking reason, nearly every child sometime between 18 and 24 months of age starts doing something no nurturing parent expects or looks for, they start picking fights.  This is no casual event. Recent studies in human evolution and cultural anthropology demonstrate beyond a doubt that this provocative behavior is programmed to emerge at that age, likely as a central feature of the emergence of human consciousness which actually also happens at that age.

This behavior appears important to help children learn what rules really count, how to negotiate, how to learn to problem solve.  In short, the provocative nature of the 1-2 year old serves many important purposes.  

It is this set of behaviors, however, in which our current models of nurturing parenting find their limits.  A careful look at the approaches of attachment parenting will also find a substantive approach to these provocations lacking as well.   At its heart attachment parenting suggests that the stronger the attachment the better the parenting.  This is a powerful fact, but should not be the entire extent of what parents bring to their children.  It is true that without good attachment there can be no good parenting.  But that does not mean that attachment is the only activity parents should pursue.

Love is at the heart of parenting, but it is not the case that simply loving will solve all problems.  What if your child asks how tall your father is, to take a silly example, it would not help matters to answer that question with only a lot of love.  The love would be welcome, but not actually help your child deal with the issue at hand.  So it is with the common provocations of young children over 18 months of age.  As noted, children at this age are actually built to provoke, and they do.  The most common issues they test and push their parents on are well known to all:
1.  Discipline- breaking rules to see what parents will do
2.  Food fights- challenging parental desires on what they will eat
3.  Toilet training- resisting the leap to caring for their own poop and pee
4.  Sleeping all night- pushing parents to wake up several times a night to be with them

In our experience, what is at the heart of these behaviors is the child's hunger for guidance.


The cover of Time magazine sparks the wrong controversy in our opinion.  For too long the nation has been consumed with a false choice.  The choice placed before us seems to force us to choose to either be too harsh or too lenient with our children.  Often the choice is expressed as whether we will love our children or make them cry.  But this dichotomy places all parents in a very uncomfortable position because both choices turn out to be inadequate to the task as hand.  Of course, taking as a goal to make your child cry is a nonsensical position to take, it has no value, and no one we know ever actually adopts this choice.  The other choice, to love your child, is extreme in the other direction, that is, it is what we all do.  There is no thoughtfulness in this choice, it is more of starting point than a level of skill and ability attained.

To our mind the best stance to take on parenting can be put very simply, though achieving it can be challenging.  That stance is:  yes, love your child, but do not stop there, also guide them.
We fully support the nurturing model of parenting and promote it.  But the challenging 2 year old demands more than love, he or she demand guidance.  They want to be taught, to be led, to be engaged.
We develop this concept more fully in our book on parenting, Who's the Boss? Moving Families from Conflict to Collaboration.  But it is clear that if parents do not learn how to guide, their children will continue to demand this from them, so parents might as well take it upon themselves to learn how to teach, to guide, as well as nourish the wonderful role of loving and nurturing.

And so we ask parents to look beyond the cover of Time magazine, and the attachment model of parenting. The cover of Time offers only provocation, and the attachment model of parenting only comfort.  We know that parenting is not about provocation and although its foundation is entirely love, it cannot stop there.

Dr. Arthur Lavin










*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

2012-03-16


Having trouble reading this posting? View it in your browser.
 
 
Invite your first-time pregnant friends
to join us for
New Mother's Day
 
As many of you know, Advanced Pediatrics has been collaborating on projects with Berg’s Baby & Teen Furniture for some time. Together, we have even published the book “The 5 Most Important Things to Do During Pregnancy to Ensure the Future Health of Your New Baby.” Berg’s has been recognized as one of the nation’s top baby furniture stores.
 
We are pleased to announce the addition of Alexandria School as the newest member of our collaborative association. Located in Solon, Alexandria School brings the best in training for Newborn Care Specialists and Nannies as well as offering courses to parents and parents-to-be. Alexandria School is one of four schools certified nanny schools in The United States.
 
In contrast to trends in the marketplace, where relationships are cast aside in elusive pursuit of efficiency, the core mission of each of our businesses is creating and nurturing a strong relationship with our clients and customers. We three take pride in basing our activities on thinking about what you need and being as knowledgeable and responsive as possible.
 
On May 12, we join forces to present New Mother’s Day, the first in a series of offerings to the community. The focus is on first-time pregnant women. We ask you to forward this invitation to any and all of your friends who meet that criterion. And, of course, feel free to link up through Facebook.
 
Thanks for your cooperation.
 
Here is the agenda for New Mother’s Day.
 
Topics:
      • Five steps that let your newborn sleep safe
      • How to create a green nursery and why it might be important
        to your baby’s health              
      • How to evaluate and choose the best way to  care for your baby
        when you go back to work
 
Guest Experts:
      Carolyn Stulberg • Alexandria School
      Dr. Arthur Lavin • Advanced Pediatrics
      David Brodsky • Berg’s Baby & Teen Furniture
 
When:
      Saturday, May 12th
      10:00 am to noon                                                             
            10:00 am • Meet and greet, refreshments
            10:30 am • Presentations
            11:30 am • Questions and answers
 
Where:
      Alexandria School
      28500 Miles Road, Suite P
      Solon OH
      The first building west of Miles Farmer’s Market
      all the way at the back
 
Registration and more information:
      440-914-0044 • Alexandria School
 
More information:
      216-591-1515 • Advanced Pediatrics
      440-585-2374 • Berg’s Baby & Teen Furniture
 
 
Dr. Arthur Lavin
Dr. Julie Hertzer
Ms. Kelley Muldoon Rieger, APRN, PNP
 
Friend us on Facebook
 
 








*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

2012-03-07

Cavities are Back in Kids

Cavities are Back in Kids- Time to Act

It's a curious thing.  For most of our lives, the chance our preschoolers would get a cavity has been dropping, at times dramatically.  But now, for the first time in 40 years, the trend is reversing.  In a dramatic turn around, our 2-5 year old children are now more likely not only to have cavities, but to have so much tooth decay that general anesthesia is needed to repair 6-12 teeth at one time!

It's worth thinking about this development for a moment.  Not too long ago, dentists were getting close to celebrate the end of tooth decay in young children.  But that moment appears to have vanished.  In its place is a shocking epidemic of very severe cavities in pre-schoolers.  Unlike the cavities seen in kids 30-40 years ago when money protected against cavities, this epidemic afflicts rich and poor alike.

No one knows exactly why things have gotten so much worse so rapidly.  But here are a few theories:
  1. The rise of juice.  Today more than ever, an expectation has been established that what you drink should be exciting.  
  2. The rise of sweet snacks.  Again, that excitement enticement.   The combination of juice and sugar snacks causes a tremendous bolt of bacterial growth in the mouth with every juice pack and fruit roll up.  When sugar is eaten, the saliva in the mouth turns very acidic for about 20 minutes.  Acid dissolves enamel, which can weaken all of a pre-schoolers teeth very well, opening the door to multiple cavities.
  3. The rise of bottle water.  No real reason this should have happened, beyond successful marketing.  But the move towards bottled water has effectively dropped the protective power that fluoride in tap water offers.  Flouride blocks cavities.  Dropping fluoride invites cavities.
  4. The fall of toothbrushing.  Once a tooth appears, a child should have their teeth brushed twice a day with a small amount of fluoride toothpaste, no more than a pea size.  This action drops the chance of getting tooth decay.  Some kids don't like doing it, but if parents go along with that preference, they effectively increase the chance that cavities will appear.
Put it all together, and we have a very good scenario for a big jump in cavities, a jump that is here.  

Bottom Line:
Cavities, once nearly vanquished from the lives of our young children, are now back with a vengeance.  Preschoolers now are developing multiple cavities, many requiring general anesthesia for repair.
Take these four steps to protect your young children from this happening:
  • Only give your children water to drink, with the only exception being skim milk.
  • Make sure the water you give is tap water, not bottle water.  
  • If your tap water has no fluoride, make sure your children get fluoride supplements
  • Snacks should be fruits and vegetables, only.
  • Brush every child's teeth twice a day with a tiny bit of fluoride toothpaste
These simple steps will not only protect your child's teeth, but their overall health, too.

Dr. Arthur Lavin

*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

2012-02-25

Sinus Infections:  Myth and Reality

There is probably no more confusing problem amongst common problems than sinus infections and sinusitis.

The confusion comes from the rapidly growing trend to call a cold a sinus infection to open the door to use of antibiotics.

Here is what is typically taking place across the nation.  A person gets a cold, a runny nose and cough follow.
After some number of days, the runny nose and/or cough become so annoying that medical help is sought to relieve the suffering.  So far everything makes sense.

But the next step is where the trouble begins.  Once at the doctors office, either the person or the doctor raises the question of a sinus infection.  Often, the doctor will say one is present and prescribe an antibiotic.

Now, it turns out that antibiotics kill bacteria very well, but if your infection is from a virus, they do no good, only harm.

So what is the story with the "sinus infection?"  What is it, a viral or bacterial infection?  For many, many years, the assumption has been that it is bacterial and antibiotics are needed to get rid of it.

But, finally, someone actually tested that idea.  They took 166 adults who met all the rigorous criteria for having a sinus infection.  A random half got 10 days of antibiotic, the other half got placebo.  And what they found was that the two groups did about the same.  Both missed the same number of days of work, both got better about the same rate, only a slight improvement advantage on day 7 was noted for the antibiotic group.
http://www.nytimes.com/2012/02/21/health/research/in-sinusitis-antibiotics-are-as-effective-as-placebos-study-finds.html?_r=1&pagewanted=print


So, the study is clear, what we call sinus infections do not get better with antibiotics any faster than with sugar pills.  This makes it very likely that sinus infections are viral.

This actually makes a lot of sense.  Every cold, after all, is a sinus infection.  Viruses that cause colds never just infect the nose, they always also infect the spaces behind the nose, the sinuses. That's why when we have colds there is such a great, huge amount of mucus!

Now, it turns out that sometimes that mucus does get infected with bacteria and the mucus turns to pus.  As this study proves, that does not happen very often.  So how do you know when it does?

We would say if  your sinuses start getting very painful that may be a sign.  We do not mean the discomfort we all get with colds, but a shift to a very painful situation where tapping the face is very, very hurtful.

Just as importantly, there are several signs that many think indicate bacteria are now causing infection, but these signs do not mean you have a bacterial infection:

  • mucus turning from clear to yellow or green
  • having cold symptoms for a long time
  • fever
  • even white material filling the sinuses on CT or MRI scan- radiology images cannot distinguish between the mucus of a viral infection and pus of a bacterial infection.
This is why the study reported in the NY Times is so important.  It actually took nearly 200 people, each of whom met very stringent criteria for having sinus infection, each of whom had every reason to believe that their nasal congestion, runny nose, and cough indicated they had moved from a viral cold to a very bacterial infection, and none of them did.  Not a single person responded to antibiotic in a fashion seen in people with bacterial infections.   As noted the antibiotic did about as well as a sugar pill!

Bottom Line
So when you get a cold and have a runny nose, congestion, misery, cough, nose pain, you should know that almost certainly have an infection with a virus.  The very concept of a bacterial sinus infection is becoming suspect, and in most circumstances is simply an excuse to try a course of antibiotic, the famous "Z-Pak," for example.
Colds last a lot longer, create a lot more yucky mucus, and cause far more misery than we expect, or certainly more than we would like.
But we should respect the facts, and avoid use of drugs that we know will not work.
Key Point:  If you are infected with a virus, use of antibiotics can only harm, they do no good.






*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.
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2012-02-20

The Case Against Tylenol Strengthens

Tylenol (KekulĂ© Diagram)                                                        Image via Wikipedia
The Case Against Tylenol Strengthens

In September of 2010, Advanced Pediatrics cited a growing body of evidence that acetaminophen, the main ingredient in Tylenol, which is also found in many cold remedies, might actually cause asthma to occur in children.   http://advancedped.blogspot.com/2010/09/acetaminophen-serious-question-leads-to.html

Since that time there have been reports in The New York Times and now on February 20, 2012 on NPR, that it really is time to stop using Tylenol and any other remedy that contains acetaminophen.

The issue is that studies demonstrate a clear trend.  When we look at any group of children, the more acetaminophen they take, the higher the chance they will develop asthma.  Further, when a country adopts use of acetaminophen, that country's incidence of asthma goes up.

These are the two facts that led Advanced Pediatrics in 2010 to advise stopping use of acetaminophen.  Now we are hearing that study after study has found the same observations, time and again.  This has led a highly respected pulmonologist at Akron Children's, Dr. McBride to adopt the same line of advice Advanced Pediatrics offers:  Stop Using Tylenol and other drugs containing Acetaminophen.  This is the recommendation featured in the NPR story.

In the NPR story, some doctors correctly pointed out that we do not yet have proof that acetaminophen causes asthma to develop.  The data so far establish an association, children who take lots of acetaminophen develop lots more asthma.  But that may because those kids have other problems more than others, problems that really cause the asthma.  Further asthma, they point out, is likely caused by many factors.

But in our experience, whenever a drug, particularly an optional drug, is observed to cause a problem the more you take it, we find it prudent to stop using it until it is know to actually cause the problem or not.

BOTTOM LINE
We strongly recommend all families stop giving their children acetaminophen at this time.

Dr. Arthur Lavin





*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.
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2012-02-17

Arsenic and Our Food

Arsenic and Our Food

A investigator from Dartmouth College has done us all a favor and exposed the fact that certain foods we give our children have elevated levels of arsenic.


Two key conclusions can be drawn from his findings:
  1. The level of arsenic found in these foods was clearly over the permitted level.  The reported concentrations in the food were as high as 10-12 times the permitted level.
  2. The level of arsenic has not been shown to have caused any harm in any known individual.  This is a very important point.  Every substance has a toxicologic profile, meaning that there is an amount under which it is harmless and over which it begins to cause harm.  Obviously, if your exposure to a given substance is under the level that causes harm, the exposure will not be harmful at all.   We do not know if anyone exposed has had an amount of arsenic that will cause harm.
The Arsenic contaminated products

All of the products containing arsenic trace the arsenic to a brown rice syrup.   If a food you have contains no brown rice syrup, this warning is not for you.

Here is a list of those products we have ascertained contained the arsenic via the brown rice syrup.
YOU SHOULD DISCARD ALL SUCH PRODUCTS IN YOUR HOME NOW.
  1. Organic infant formula-  two brands of 17 tested had arsenic both had brown rice syrup as an ingredient.  One of those brands is Baby's Only Organic Formula
  2. Cereal Bars- again arsenic limited to those containing brown rice syrup
  3. Energy Shots- three brands tested, one had arsenic, and as before, contained brown rice syrup
Many wonder, how did a poison like arsenic end up in infant formula, especially an organic brand?  The answer is that all these foods were grown organically and so none had any arsenic applied to them.  But arsenic is present in the Southern rice fields from the days when those fields grew cotton.  Cotton is not eaten so nearly unlimited amounts of toxic pesticides can and are applied to those plants.  The arsenic applied in those times remains in the soil forever, and rice is a plant quite adept at sucking up arsenic in the soil.  And so, even on an organic farm, rice planted in arsenic containing soil will have arsenic in it.


Should you be worried?  No.

The next question now is just how much to be worried?  The answer is, not much.
The real impact of this finding is that we need to track the presence of toxic elements like arsenic in our food supply.  The fact that arsenic is present makes me think we should look for it and reduce its levels in our food.

The story mentions that arsenic is in some foods up to 12x the level set as safe.  Keep in mind that the level set as safe, as noted above, may be much lower than the level that will actually start causing symptoms.  We have actually heard from Dr. Brian Jackson, the lead investigator on this study from Dartmouth, who is an expert on arsenic.  A family in the practice has been in touch with him and passed these words from him along, "...you don't need to panic here, these are not acutely toxic concentrations."

No one has been reported with even one symptom or sign of any harm from arsenic exposure from these foods.  And, the scientist most concerned about arsenic states there is no reason for concern of any harm being done, as long as the food is no longer eaten.

Bottom Line
  • Scientists at Dartmouth have found arsenic in organic foods containing brown rice syrup.  These include 2 brands of infant formula (Baby's Organic Formula is one), cereal bars, and energy shots.
  • The amount in these foods exceeded safety thresholds, but was too little to cause any acute harm.
  • All foods with brown rice syrup should be eliminated from your home, but it appears no harm has been done to date.
  • This episode pushes me to want rules in place to keep arsenic out of our food and drink.
Dr. Arthur Lavin







*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.