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The Power of Positive Thinking

Norman Vincent Peale wrote a bestselling book in the 1950’s,
“The Power of Positive Thinking.”  I read
it a few years ago and found it to be a tad simplistic but it had an undeniable point: a positive attitude is important in
life.

In my last post I described the dangers of magical thinking
– since it opens the door to pseudoscience-touting snake oil salesmen.  But now we will turn our attention to
positive thinking – a favorable psychological condition.

There is no doubt that there is a mind-body connection that
affects health.  “Type A personalities
are known to engage in behaviors that increase the risk for heart attack;
anxiety and perceived stress can cause higher output of adrenaline and
cortisol, and in turn contribute to inflammation, atherosclerosis, heart
disease, sleep disturbances, and weight gain.
Depressed individuals (for example) are more likely to suffer from pain
syndromes
, and may have impaired immune function.

Because our mind influences the health of our body, it is
physically therapeutic to focus attention on peace of mind as a preventive
health measure.  And in so far as
techniques are developed to reduce stress, decrease mental anguish, and improve
psychological wellbeing – they are helpful in keeping the body in a healthier
state.

Now, the temptation is to
exaggerate the benefits of peace of mind – that one might be able to avoid
cancer (for example) with the right attitude, which is blatantly false.  So this is where positive thinking and
magical thinking can be confused.
Magical thinking ascribes excessive value to a treatment, while positive
thinking understands the limitations of treatments and yet respects the reality
of the mind-body connection.

Let’s consider back pain, for example.  A magical thinker would look for the “secret
cure” for their back pain, and turn over every stone – fully anticipating that he would discover a miracle solution that others don’t know
about.  He would read books promising the
ultimate back treatment “that your doctor doesn’t want you to know about” and
would spend a great deal of money on treatments that have been
rumored to have some benefit in treating back pain (without any supporting evidence).  The magical thinker is vulnerable to snake
oil, and would rather risk thousands of dollars on experimental treatments than
consider traditional modalities first.

A positive thinker, on the other hand, will realize that
back pain is difficult to treat, has variable causes, and responds to different
therapies based on an individual’s unique circumstances.  A positive thinker would have a realistic
view of recovery, would accept the limitations of therapeutic options, but
would focus on his abilities rather than his disabilities and look for ways to
make the best of his current circumstances.
He would actively participate in physical activity, perhaps join a support
group, get good rest and engage in a healthy lifestyle while working towards a
brighter tomorrow one step at a time.

Definitions for clarity:

Snake oil is a treatment whose efficacy is knowingly exaggerated by those who wish to turn a profit on its sale.  E.g. diet pills that will “miraculously correct morbid obesity in a matter of weeks.”

A placebo is a treatment that has no known plausible mechanism for a physical effect – but may affect the individual through the mind-body connection.  E.g. a sugar pill that is substituted for a pain killer may cause a patient to experience his pain differently, though there is no active ingredient in the pill.

An untested treatment is neither snake oil nor a placebo but could be used as either under certain circumstances.  It is simply a proposed intervention of unclear clinical significance.  There are many of these currently undergoing scientific review, and it takes patience to analyze their potential efficacy and safety.

A magical thinker is a person who is willing to accept snake oil as a valid treatment option for his condition despite a vast preponderance of evidence to the contrary.  Magical thinking is belief-based, rather than evidence-based.  Many very good and reasonable people are tempted to adopt magical thinking under duress.

A positive thinker is a person who choses to look for the positives in all circumstances, and approaches health with a can-do attitude.  Realistic and yet optimistic, the positive thinker will focus on abilities rather than disabilities – and reach out for support as needed to optimize his psychological well being.

All of this is simply to say that a positive attitude, peace of mind, stress reduction techniques and a healthy lifestyle are an important foundation for good health.  Placebos are most relevant for influencing psychological well being or pain perception (obviously they’re not appropriate for treating infections, type 1 diabetes, and the like), and magical thinking and snake oil are dangerous hindrances to wellbeing.  Stay positive and protect yourself from snake oil salesmen.  Knowledge is power. There are voices of reason to guide you here at Revolution Health.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Morning Sickness and Breast Cancer?

This is the weird correlation of the week: women who suffer with symptoms of morning sickness during their pregnancies may be less likely to develop breast cancer later on in life.  A group of epidemiologists in Buffalo recently reported this finding at a scientific meeting (Society for Epidemiologic Research).  No one is sure what this means, and I dare not speculate… but perhaps there’s some kind of link between a woman’s hormone levels produced during pregnancy, the nausea they cause, and the hormonal milieu that is the background for breast cancer?  Or maybe this study has turned up a false association.  Only time – and a lot more research – will tell.  Of course, if anyone should speculate on this, it’s the breast cancer oncologists like Dr. Gluck.  So I dropped him an email to ask him what he thinks.

Dr. Gluck said that first of all, the association between morning sickness and decreased breast cancer risk is relatively weak.  So here’s what the numbers mean: For the average 50 year old woman, the standard risk for developing breast cancer is about 2% (one in
50). According to this study, that same woman (if she had severe morning sickness at some point during pregnancy), is about 1.4%  (~30%
less).

Dr. Gluck speculates (and this is quite fascinating) that women with morning sickness are subjected to a hormonal milieu that may result in permanent alterations in their breast tissue.  The breast tissue (having been exposed to surges of hormones, insulin, and changing blood pressure and blood sugar levels) might be less vulnerable to the genetic mutations that cause cancer.

We’ve known for a long time that women who have children are at lower risk for breast cancer than women who don’t… now it seems that there might be something about women who are really sick when they’re pregnant and decreased risk of breast cancer as well.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Night Float in the Hospice

During my residency I kept a diary as a way to relieve some of the sadness related to the death and dying that I witnessed.  I recorded various encounters in a series of vignettes.  Although these are a bit long for a blog, I thought I’d share a few now and then in the hope that they’d preserve the memory of those who are gone.  All personal data have been removed so that the identity of the patients is protected.

***

It’s 3:00am and I was paged to examine yet another patient who had fallen out of bed – to rule out a hip fracture.

Too tired to read the chart prior to examining the patient,
I thought I’d leap right into the physical exam.  I assumed that the patient would be the usual
elderly woman who, in her sickened delirium, thought she was at home and tried
to walk by herself to the bathroom and fell en route.

I marched into the room and stopped at bed 23.  All my pre-conceived notions evaporated as I
looked at the young man before me.
Emaciated and stiff, with all four limbs contracted, he lay on the bed,
clinging to a thin white sheet.  The
whites of his eyes flashed in the darkness.

“Hi there.” I said, trying to seem casual at the sight of
the living corpse before me.  “I’m Dr. Jones.  I heard that you fell.  Are you in any pain?”

His eyes suddenly fixed themselves on me and he spoke, not
with a thin raspy voice, but with the robust youthful voice appropriate to his
age rather than the decrepitude of his body.

“I’m in no pain,” he said.
“I was trying to sit down on the chair.
I thought it was against the wall, but it was actually a couple of feet
away.  So when I leaned on it, it slid
and I fell on the floor.”

“Do you think you broke anything?” I asked, trusting in his
judgment as his mental status was clearly in tact.

“No, I just scraped my butt,” he said, pointing a frail
finger towards his sacrum.

“Did you hit the floor hard?” I asked as I used my pen-light
to examine his back side.

“Not really,” he said.

“Would you like me to order an X-ray of your pelvis to see
if you broke anything?”

“I don’t think I need it,” he said.

“Well let me see if it hurts when I rotate your leg in your
hip socket, ok?”  I pulled down the sheet
and asked the young man to allow his right leg to fall to the side.  As I looked down at his hip I gasped slightly
as his inner thigh came into view.  A
gaping ulcer lay before me, deep to the bone, exposing tendons and ligaments
with pus, and red knobs of flesh surrounding a football sized hole in the man’s
groin.  His paper-thin scrotum lay stuck
to his left thigh.  The smell overcame
me, it was at once wet and fetid, with a hint of chemical odor from the
antibiotic ointment that was clinging ineffectively to the fringes of the wound.

“Oh my God.  Does that
hurt?” I stammered.

“No, not at all.”

“And does it hurt when I rotate your leg in your hip
socket?” I asked, trying desperately to remain focused on the task at hand.

“No, it doesn’t.”

“Well, then,” I said, gathering my faculties.  “I don’t think you broke your hip.  And if you don’t want an X-ray, I don’t think
we need one.  Perhaps you’d like to go
back to sleep and get some rest?”

“Yes, that sounds good,” he said, drifting off into a
morphine induced altered state of awareness.

I wandered out towards the nursing station, looking around
vaguely for the patient’s chart to make note of my “fall assessment.”

One of the nurses anticipated my need and handed me the
thick plastic folder.

“What does this patient have?” I asked.

“Oh, he has AIDS and metastatic anal cancer” she said as she collected some sputum in a clear plastic cup.  “He’s 38 years old.”

“The same age as my boyfriend,” I thought to myself.  “And why exactly did he fall?” I asked the
nurse.

“I was trying to help him to get to the commode,” she said printing something on a label.  “He fell because I wasn’t strong enough to
hold him up.  My right arm is a little
bit weak.”

“And why is your arm weak?” I asked, assuming that it was
because of a small strain injury.

“I have breast cancer,” she said, finally making eye contact
with me.

“Oh my God, I’m so sorry,” I said, feeling the weight of her
diagnosis amidst a ward of terminal cancer patients.

“Well, you know the funny thing is that my husband is
particularly upset.  He doesn’t want me
to have a radical mastectomy.  He says
that it would hurt to see my body differently than he’s used to… he likes to
think I’m still the bouncy cheerleader I was when we first met.  To see me with only one breast is upsetting
to him.  And quite frankly, I’m afraid he
won’t be attracted to me anymore.  That’s
what scares me the most,” she said, becoming misty-eyed.

My pager let out a familiar series of beeps.

“I’m so sorry,” I said, squeezing the nurse’s shoulder.  I paused and tried to be encouraging: “Well, even if you need a mastectomy – I’ve seen some great reconstructive surgeries
where the breast can be reformed at the same time with an implant.  Maybe you’ll be a good candidate for that
surgery?  I’m so sorry that I have to
run… can we talk later?”

“Sure,” she said, smiling faintly.

***

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Grand Rounds 3.38 Extended Release

…continued from Grand Rounds 3.38

GRAND ROUNDS XR
(asterisk = honorable mention for great writing)

Happy Posts

*Kerri from Six Until Me tells the heart-warming story of a
Starbucks Barista who understood her diabetic needs and treated her with
special care.

Traveling Doc from Borneo Breezes Blog, submits a post about
the bush pilots of the Canadian north.
Even though it’s summer time you’ll shudder at this arctic tale of a
native woman whose life was saved by a bush pilot and an Australian surgeon.

Tony Chen of Hospital Impact submits a post by Nick Jacobs, the CEO of Winder Medical Center.
In it Christopher apologizes for being ill tempered and snapping at a
woman who posted a paper sign on the wall.

Dr. Jolie Bookspan of the Fitness Fixer Blog offers a
fascinating look at the physical healing power of prayer.  Jolie reports that the movements involved in
Muslim prayer (including standing, bowing, kneeling, and sitting) can promote
flexibility, increase quad strength, and burn up to 80 calories/day.  She explains that similar prayer posturing
(found in Russian Orthodox prayer and some forms of yoga meditation) may be
equally useful.

Rita Schwab at MSSP Nexus Blog writes a really funny post
about disaster preparedness.  She muses
about how she had been taught to hide under her school desk in case of a
bombing, and even then (at the tender age of 8) wondered how the desk vs. bomb
equation would really pan out for her.
But the real amusement comes when you click on her link to the CDC’s
recommended communication releases on such plagues as tularemia.  Yes, the bacterium found in rabbits and
rodents (that perhaps 125 hunters succumb to each year in this country) is not
contagious from human to human and causes flu-like symptoms.  I’d give this a fear factor of 1 out of 10.  [Cartoon]

Dr. Bruce Campbell of Reflections Blog describes the medical
school graduation ceremony – the first time “doctor” is officially tied to the
graduate’s name.  [Cartoon]

Mother Jones, RN from Nurse Ratched’s Place, confesses to
being a trekkie.  She did find a good
role model in nurse Chapel, though.  Now
here’s my confession: I’ve been known to utter a few “Damn it, Jim-s!” when
asked to do non-medical related work at my current job.

Roy
at Shrink Rap pulls a “Jerky Boys” style practical joke on Dinah.  He uses prerecorded audio clips of Dr. Phil
McGraw to simulate a live Skype conversation with her, and gets Dr. Phil to ask
Dinah outrageous questions and give her bizarre advice such as, “I want you to
live as a gay woman.”  Poor Dinah falls
for it for a short time… and it’s rather funny, especially if you enjoyed the
Jerky Boys prank call to Hooters with Arnold Schwarzennegger clips.  [Cartoon]

Laurie at a Chronic Dose tells a hilarious story of 3 chronically ill family members who experience a comedy of errors during a vacation in Cape Cod.  Somewhere between the brain aneurysm, flood, sunburn turned staph cellulitis, and cell phone lost in the ocean, there’s humor in the midst of tragedy.

Susan Palwick from Rickety Contrivances of Doing Good describes the evolution of hand washing requirements for all staff (including chaplans) at her hospital.

Sad Posts

ERnursey from ERnursey: Stories from an Emergency Room Nurse
gives us an eye-rolling perspective on exactly how emergency departments are
abused by drug-seekers and non-emergent cases of ridiculousness.  Triage ain’t easy.  [Cartoon]

*Type B Pre-med from the blog by the same name, offers a
tear jerking slice of life from the ED.
A woman with breast cancer finds out that it has metastasized to her
brain while a 9 year old sexual assault victim waits for the doctor to see him
next.

Christian Bachmann from Med Journal Watch reminds us that
tranquilizing medications are associated with shorter lifespans in the demented
elderly population.  [Cartoon]

Matthew at Path Lab tells the sad story of a bariatric patient’s woes in the hospital, and what daily life is like for nurse assistants.

Hot Buttons

Dr. Tara Smith at Aetiology, discusses the tragedy of
infanticide, and the events that led up to the recent murder of a newborn in Iowa.  She asks whether designated “safe havens”
(where mothers can drop off unwanted babies, no questions asked) are not
promoted enough by the media or if the state of mind of a woman who has just
given birth to an unwanted baby wouldn’t be receptive to that messaging.

Dr. Hsien-Hsien Lei interviews the CIO of Suracell Personal
Genetic Health to try to get to the bottom of whether or not nutrigenomic
testing is a form of hucksterism.  This
quote followed an objection about nutrigenomic supplements costing more
than similar products in health food stores: “Well, our clients like paying
more for what they believe is something better than the cheaper versions.”  Orac should take a look at this.

David Williams of Health Business Blog submits a
thought-provoking podcast of a recent interview he conducted with the founder
(founded in 2002) and creator of Planet
Hospital, Rudy
Rupak.  Rudy starts the podcast
explaining that his company arranges surgical treatment for travelers who need
emergent care in foreign countries, but later on explains that the primary
income stream for Planet
Hospital involves
healthcare outsourcing for American women who are “too wealthy for Medicaid and
too young for Medicare” and want cosmetic procedures or IVF done at a lower
price.  Rudy then explains that he has a
program called “the best of both worlds” where plastic surgeons travel overseas
to perform their procedures for cash – outside of malpractice laws and with
lower overhead. [Cartoon]

Henry Stern, at InsureBlog comments on the recent loss of
Flea and other medical bloggers.  He says
that “There’s a creeping reticence in the blogosphere… and maybe that’s a good
thing.”

Amanda from It’s All About the Walls marries her frustration
with her own health issues with some frustration at the apparent censorship of
certain bloggers.

N=1 from Universal Health offers this challenge – doctors
should try to get outside of their egocentric shells and get to know (and learn
from) all of the knowledgeable, competent allied
health professionals around them, especially nurses. [Cartoon]

Kim at Emergiblog expresses deep inner conflict about going to see Michael Moore’s new movie, Sicko.  If she goes, she donates $10 to his cause, if she doesn’t go she’ll be left out of a hot topic of conversation.  This is a tough call, fair sister.

Helpful Tips

Dr. Auerbach from Healthline describes how to handle
encounters with bears.  I didn’t realize
that humans should respond differently, depending on the kind of bear.  Check out what to do if you run into a
Grizzly versus a Black Bear.

Bertalan Meskó from Science Roll lists some “Web 2.0”
activities for patients and physicians alike.
But Bertalan forgot about Revolution Health!

Sarah (a bubbly Aggie from Texas A&M) has some
practical tips on how to get into medical school.

Dr. Joshua Schwimmer from Healthline explains that
Gadolinium used to be the contrast agent of choice for patients with kidney
disease (since the regular iodine-based agents can cause “contrast
neuropathy”) but now new cases of a scleroderma-like condition (called
“nephrogentic systemic sclerosis”) have been associated with Gadolinium.   Bottom line: if you have kidney disease, any
sort of contrast dye is risky!

Dr. Lisa Marcucci from Inside Surgery offers up the
technical how-to’s for an open pyloromyotomy to repair baby stomachs.  Some little ones are born with a narrow,
thickened area in the junction between the stomach and the intestine so food
can’t pass through.  But thank goodness
for surgeons like Lisa who can fix them in a jiff!  [Cartoon]


Chronic Babe describes her impulsive eating habits and what
she’s going to do to try to avoid chocolatey, salty days in the future.  [Cartoon]

Case Reports

Dr. Ves Dimov of Clinical Cases and Images – Blog –
discusses the New England Journal’s recent case report of Acute Wiiitis
(contracted as an overuse injury from the Nintendo video game Wii remote
control).  He rightly points out that as
far as medical nomenclature is concerned, “itis” is more appropriately appended
to the name of the affected body part (e.g. tendon-itis).  As far as we know, a Wii remote is not part
of the human body – though one can see how the NEJM editors couldn’t resist
accepting the resident physician’s title selection.

Dr. Iñarrito-Castro from Unbounded Medicine presents a
fascinating case report of an exceedingly rare pancreatic tumor.  Beautiful imaging and photos.


Uncategorized

Dr. Keith Robison of Omics! Omics! Blog describes his
thought process of what it might take to determine the underlying genetic cause
for one little girl’s unknown syndrome.
In the end he suggests that it might cost $1 million (to map her entire
genome) and result in no clinically useful benefit.  In this cost-benefit analysis, it looks as if
mom got it right – love the child as she is, and spend your money on mobility
enhancing equipment.

Dr. Joe Wright submits his commencement speech (for
Harvard’s graduating class of MDs and DDSs) for your consideration.

Girlvet from Madness: Tales of an Emergency Room Nurse
describes some promising research in Alzheimer’s Disease and how her own mom died in a nursing home from complications of the disease.  [Cartoon]

Nurse JC Jones from Healthline, highlights the recent
Wellcome Trust announcement of significant advances in the genetic
underpinnings of several major diseases. She includes a recent photograph of
James Watson (of Watson and Crick fame), who is now 79 years old.

Rachel from Tales of My Thirties highly recommends a book
about Type 2 Diabetes.

SPECIAL BONUS POSTS

Now, because Dr. Val has a keen eye and is very meticulous, she has rounded up some savory morsels that she found on her own – these posts were not formally submitted to Grand Rounds 3.38, but will be included because she’s sure their authors wouldn’t object:

Dr. Richard Reece from MedInnovationBlog summarizes Regina Herzlinger’s arguments for consumer driven healthcare.

PandaBearMD explains why he believes that Chiropractors are quacks – and other controversial issues.

Kevin, MD points out that while websites designed to allow patients to rate doctors are gaining acceptance, websites that allow clients to rate lawyers are causing a legal meltdown.

Dr. Stanley Feld (former President of the American Association of Clinical Endocrinologists) takes a very well argued swipe at Dr. Steve Nissen’s recent article about Avandia in the New England Journal of Medicine.

Dr. Charles exposes the quackery of Dr. Heimlich (of the Heimlich maneuver).

Dr. Au from the Underwear Drawer accidentally summarizes the difference between men and women in a conversation with her husband about whether or not to save an old medical school name tag.

Dr. Rob from Musings of a Distractible Mind offers some hilarious genetic explanations for male/female differences.

Hallway Four captures a fascinating disconnect between what a patient thinks a doctor is doing and what a doctor is actually doing.

Dr. Hildreth at the Cheerful Oncologist gives us 8 ways to cope with a malpractice lawsuit.

Dr. Scalpel presents a case of a scratch (plus toenail fungus) sufferer presenting for a work excuse.

#1 Dinosaur argues that obese doctors are more empathic counselors for obese patients who wish to lose weight.

TBTAM recounts a sexual history dialogue in which a patient had condoms delivered at 5am from a local deli.

Ian from ImpactEDnurse continues the condom refrain with an interesting analogy: how practicing “safe nursing” is like practicing safe sex.

FLASHBACK:  And for the all time coolest classic blog post… let’s go back to GruntDoc circa 2004 for a look at the scariest menace in the ED: “Some Dude.”

Thanks for reading!  Hope you’ll tune in for our regular Wednesday feature of Revolution Rounds – the best of the 27+ person Revolution Medical Blogger team posts, organized and served up friendly by yours truly.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Is that your real skin?

I’ve been thinking about skin cancer lately.  A young, fair skinned friend of mine
recently had a small mole removed from her leg.
It turned out to be melanoma!  It
didn’t take me too long to make the connection between her complexion and mine,
and the fact that I’d been avoiding the dermatologist for several years,
worried that I’d come out like a punch biopsy pin cushion since I have quite a
few freckles and moles (and I’ve heard that dermatologists like to err on the
side of caution and biopsy anything remotely suspicious).  But the melanoma story galvanized me into
action.  I made an appointment with a
dermatologist (yes, I had to wait 4 months to get an appointment!) and got a
skin check.  Luckily for me, all was fine.  But I started to reflect on various conversations
I’ve had about my skin recently.  All you
Irish types out there will relate…

Conversation 1

Coworker A: Val, are you ok?
You look kind of sick.

Me: I’m just fine.

Coworker A: But Val, you look a little… bluish…

Me: That’s just my skin color.  My veins show through my skin because it has
no melanin.

Coworker A: (Appearing sympathetic) Oh, well glad you’re
alright.

Conversation 2

Coworker B: (in the middle of a conversation with me, sitting
across from one another on chairs.  I’m wearing a skirt.  Suddenly she lunges forward
and touches my knee and gasps).  Is that
your real skin?

Me: Um… yes.  What
else would it be?

Coworker B: Well, I thought you were wearing white pantyhose.

Me: Nope.  It’s too
hot for pantyhose so I just go bare legged.

Coworker B: (still in shock).  But that’s your skin?  Just like that?

Me: Yeah.  I don’t
tan.

Coworker B: (appearing sympathetic) Oh, wow.

Conversation 3

Dermatologist: Hi, I’m Dr. XXX. (Peering at me, seated on the examining table
in a paper gown.)  Are you Scandinavian?

Me: No, I’m part Welsh – you know, “Jones.”

Dermatologist: Oh, well the Vikings probably invaded Wales
at some point.

Me: (to myself) well thanks for alluding to the raping and pillaging
of my ancestors.

Dermatoligst: You’re high risk for skin cancer.  People like you need to have careful skin
exams every year.

Me: Yes I know.  But
please don’t take any unnecessary biopsies!
I think my moles are all fine.

Dermatologist: Well let’s see…(tearing the paper gown in two).  You definitely need to wear SPF 50…

Me: Sigh.  I know…

Conversation 4:

Husband: (giving me what I thought was a tender look.  He leans in…) Your eye lids are kind of pinkish purple

Me: Yes, that’s the color of the capillaries that show
through my lid skin.  Hard to get a tan
there you know.

Husband: You don’t need a tan – I like your color.  Kind of pastel pink and blue. (He leans in even closer to inspect my eye lids.)

Me: Yeah, not exactly attractive in a bathing suit. (I pull away.  He laughs.)

Husband: Well, yeah.
It’s better not to be out in the sun or on the beach, but you can still
go outside!

Me: Thanks.

Conversation 5:

Asian manicurist: (looking at my hands) Your skin is so white!

Me: Yes, I’m afraid my past efforts to alter that have failed.

Asian manicurist: How did you get your skin so white?

Me: I didn’t do anything.
It’s like that naturally.

Asian manicurist: (looking closer at my hands) I wish I had skin like yours.

Me: Why? (Hoping she’d say something flattering after all).

Asian manicurist: It looks clean.

And so I guess despite all the people I’ve worried with my vaguely cyanotic appearance, there’s one thing for sure: I look clean.  I guess I can live with that.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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