Womens Health

Women's Health Newsletters 9/19/04 - 11/28/04



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 ********** Health Newsletter ***********
              September 19,  2004
Biweekly from BackupMD on the Net

1. Physical activity, obesity and diabetes in women
2. Living with celiac disease 
3. Reader submitted Q&A - Sea salt and shellfish allergy
4. Irritable bowel syndrome effect on quality of life
5. Health tip to share - Flexibility problems
6. Humor is healthy

1. Physical activity, obesity and diabetes in women

An interesting study was published in the Journal 
of the American Medical Association (JAMA) which 
looked at both body mass index (obesity) and 
amount of daily physical activity and its effect 
upon diabetes. Both increased weight and low 
amounts of physical activity are known to be 
related to diabetes and heart disease events like 
myocardial infarction. Since obesity and low 
physical activity often tend to travel together, 
it is difficult to know which is more important 
losing weight or increasing physical activity. 
Doctors always tend to recommend both. 

The reason this study was so interesting is that 
it found that overweight/obesity was worse than 
low physical activity for developing diabetes. The 
increased risk was as follows: 

Category               Risk Ratio

normal-weight inactive   1.15   
overweight active        3.68
overweight inactive      4.16 
obese active            11.5 
obese inactive          11.8  

In a companion article in the same issue looking 
at the relationship between weight, physical 
fitness and heart attacks in women who had been 
suspected of having heart ischemia (low blood flow 
to the heart), authors found that good physical 
fitness was more protective against heart attacks 
and was independent of weight. This is the 
opposite of the effect of physical fitness on 
diabetes where weight was the more important 

Physical activity, obesity and diabetes in women

2. The journey of Parkinson's disease 

The average age of onset of Parkinson's disease is 
about 65 years although it sometimes can start 
earlier as in the case of Muhammad Ali. The course 
of the disease is often not well communicated to 
newly diagnosed patients. Sometimes the doctors 
themselves are not as familiar with the course of 
the disease so that anyone who is newly diagnosed 
with Parkinson's disease should seek out a 
specialist in that treatment. Parkinson's is known 
as the "shaking palsy" and it can be caused by 
past head trauma, past neurological infections, 
arteriosclerosis of certain parts of the brain or 
just totally be of unknown cause. 

People will ask if Parkinson's will make them to 
die earlier. In general it does not shorten life 
span unless they develop illness from malnutrition 
or infection because they are unable to care for 
themselves. The main problem is the eventual 
worsening of the shaking symptoms such that a 
person has a difficult problem with any self care. 
It is a journey that requires someone to help and 
the most important aspect is knowing what to 

Sometimes doctors may discuss many of the good 
treatments for Parkinson's but they fail to 
mention that there is no cure. All of the 
treatments are just to control the symptoms as 
best as possible and prolong the time to which the 
palsy and movement difficulty makes self care 
impossible. If you know of anyone with Parkinson's 
disease, have them or their family check out this 
article from the British Medical Journal. 

The journey of Parkinson's disease 

3. Reader submitted Q&A - Sea salt and shellfish allergy

"If I am allergic to fish and shellfish can I 
still eat Sea Salt? Or can microscopic pieces of 
fish protein be stuck in the Sea Salt? I am a 44 
y/o female with food allergies?" -Laura L. 

It is fantastic that you understand that your 
allergy is to the protein from certain fish or 
shellfish rather than to "iodine" as many people 
think. People who have these severe allergies may 
not only react upon eating the shellfish but even 
upon walking through a large seafood market with 
fish "particles" in the air. So the question you 
ask about the sea salt is interesting. 

I honestly do not know the answer to this from 
anything in the medical literature. In other 
words, no one has reported an allergy to sea salt 
nor have doctors tested and found the absence of 
allergic reactions to sea salt among those 
allergic to fish and shellfish. However I did 
learn something about how salt is manufactured 
which may help us. 

Almost all regular salt and sea salt is produced 
by one of two methods: mining salt deposits on 
land (originally the salt was probably from sea 
water) and solar evaporation of sea water. Salt 
that is advertised as sea salt would usually be 
from solar evaporation of sea water in which large 
pools of sea water are exposed to the sun. Then 
when much of the water is evaporated, the saline 
suspension is transferred to smaller and smaller 
containers until eventually you have only salt 

I would guess that most smaller operations of this 
sort would not pump water into the initial holding 
tanks with any whole fish in the water. To be a 
purist, however, you would only want to use sea 
salt that had been derived from sea water that had 
been run through a particle filter before the 
water evaporation process. Some manufacturers also 
"wash" the salt once or twice. 

I do not think I would hesitate to use sea salt if 
I had a shellfish/fish allergy but if I found a 
brand that I was successfully able to use, I would 
stick with that brand. It is extremely unlikely 
that there would be enough fish protein in salt to 
cause any sort of a reaction in someone allergic 
to that protein. 

Does Iodine Allergy Mean a Shellfish Allergy 

4. Irritable bowel syndrome effect on quality of life

Irritable bowel syndrome (IBS) is a poorly 
understood condition in which the large bowel 
undergoes altered muscle function such that one 
has diarrhea or constipation along with crampy 
bowel, lower abdominal or pelvic pain and 
bloating. Often the discomfort worsens or improves 
with a bowel movement but not always. 

There is some evidence that individuals who have 
food allergies, especially with IgG antibodies to 
specific foods, are a part of the overall 
population that has IBS. Unfortunately, IBS 
sufferers have more than abdominal pain and bowel 
dysfunction; they often have other debilitating 
symptoms that significantly affect their quality 
of life. 

A recent study in Los Angeles examined over 700 
people with IBS to look at what factors most 
affected the physical and mental quality of their 
daily living activities. Frequent visits to the 
doctor (more than 5 visits a year), tiring easily, 
low energy and severe symptoms were the most 
significant predictors of altered physical quality 
of life. Feeling tense, feeling nervous, feeling 
hopeless, difficulty sleeping, tiring easily, low 
sexual interest, IBS symptom interference with 
sexual function, and low energy were the 
predominant predictors of altered mental health 

This study indicates that the quality of life in 
patients with IBS is primarily related to non 
gastrointestinal symptoms rather than altered 
bowel function or pain per se. Whether the IBS 
condition causes depressive symptoms or whether 
depression can cause IBS, those symptoms of low 
energy, hopelessness, anxiety, tenseness and 
decreased libido are the major reason that 
patients with IBS feel bad. Perhaps treatment 
needs to be primarily directed toward the 
depressive/anxiousness symptoms rather than just 
the pain or constipation etc. 

IBS effect on quality of life

5. Health tip to share - Flexibility problems

"Many physically challenged women probably have 
the same difficulty I do putting on their 
brassiere in the morning.  I have discovered that 
with a front closing bra it works best to turn the 
bra upside down and backwards in front of you, put 
your arms through the arm holes.then flip it over 
your head, pull it down in back and fasten in 
front.  This prevents having the bra twist on you 
when you put your arms through the arm holes.   A 
back closing bra is easier to put on if you just 
put your arms through the arm holes and fasten it 
in back before you put your breasts in. 

If you have trouble reaching things on the floor 
or on shelves or in your clothes dryer and you do 
not have a regular reacher, barbecue tongs are a 
good temporary solution."  Gladys L. 

6. Humor is healthy
"Marriage Seminar"

While attending a Marriage Seminar dealing with 
communication, Tom and his wife Grace listened to 
the instructor,  "It is essential that husbands 
and wives know the things that are important to 
each other." 

He addressed the man, "Can you describe your 
wife's favorite flower?" 

Tom leaned over, touched his wife's arm gently and 
whispered, "It's Pillsbury, isn't it?" 

The rest of the story gets rather ugly, so I'll 
stop right here. 

That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

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********** Health Newsletter ***********
              October 3,  2004
Biweekly from BackupMD on the Net

1. Physical therapy for low back pain
2. Healthy lifestyle for the elderly
3. Reader submitted Q&A -  Continuous BC Pills
4. Knee injury especially ACL ligament
5. Health tip to share - Heart attack symptoms
6. Humor is healthy

1. Physical therapy for low back pain

Low back pain is a common problem and often 
doctors will refer patients for physical therapy 
to improve the discomfort of low back pain. 
Physical therapy consists of exercises, massages, 
heat and other non surgical modalities. While low 
back pain sufferers often feel better after such 
physical therapy, there is question as to whether 
it really results in any improvement of physical 
limitations from the pain, i.e., can you perform 
functions you were previously unable to because of 
the level of pain. 

A recent study in the UK looked at over 280 
patients with low back pain for at least six weeks 
with or without leg pain or neurological signs. 
They excluded patients with serious conditions, 
including systemic rheumatological disease, 
gynecological problems, ankylosing spondylitis, 
tumors, infection, past spinal operations, and 
treatment for physical problems in the previous 
month. They gave half of the patients five or more 
30 minute physical therapy sessions and to the 
other half they only gave a one hour assessment 
and educational (advice) session on how to self 
treat with exercises. 

While the group who had the standard physical 
therapy multiple sessions claimed that they felt 
better than the advice only group, there was no 
difference in the disability measures one year 
after treatment between the two groups. Multiple 
physical therapy sessions were not an advantage 
over only one educational instruction session. In 
other words once you know what to do, that is as 
good as having multiple visits to the physical 

Physical therapy for low back pain

2. Healthy lifestyle for the elderly

While hundreds of articles have looked at the risk 
of dying by analysis of diet, physical activity, 
drinking and smoking, they have not always been 
able to simultaneously control for every factor to 
see which factors are the most important. A recent 
study reported in the Journal of the American 
Medical Association (JAMA) looked at the combined 
results of two long term European studies that 
followed a cohort of over 2300 men and women aged 
70-90 followed for 10 years or more. They looked 
at the specific risk factors in all of these 
elderly people. 

Low risk factors include:

1) a Mediterranean diet which is low in meats 
except fish and high in fruits, vegetables and the 
ratio of mono unsaturated to saturated fat has been 
shown to be heart healthy. 

2) moderate daily physical activity 

3) moderate alcohol consumption has also been 
shown to be good for the heart. 

4) non-smoking - smoking of course, is bad for the 

Since many of these elderly people died during the 
length of the study, investigators were able to 
calculate which of these factors would put a 
person at the lowest risk for dying. They found 
that individuals who had all 4 low risk factors 
died at only a 35% rate compared to those who had 
none or one low risk factor. 

Number low risk factors  Risk ratio 

Zero/none                1.0
One low risk factor      1.0    
Two low risk factors      .62
three low risk factors    .45
four low risk factors     .35

Basically, the more of these low risk factors that 
apply to you when you are over age 70, the longer 
you can expect to live. 

Healthy lifestyle for the elderly

3. Reader submitted Q&A - Continuous BC Pills

"I recently skipped my period by not taking the 
sugar pills in the pack of oral contraceptives. Is 
it normal to still receive some bleeding by 
tricking the body into thinking it is not 
menstruating?"- CW 

The answer is yes. You can still have some 
bleeding even though you skip the placebo sugar 
pills and just start the next pack of pills so 
that you are taking continuous estrogen and 
progesterone. Many women will skip menses when 
taking the continuous pill regimen but 
approximately 30-40% will have some bleeding 
ranging from spotting to full menses. 

Traditional birth control pills have 3 weeks of 
active hormone and 1 week of inactive pills. Your 
menses usually starts during the week of no 
hormones. Even though you are off of the active 
pills for a week, you are still protected from 
pregnancy as long as you do not go longer than the 
7 days with no hormones. A newer regimen of 
continuous pills, 3 months of active, hormonal 
pills, is used by many women to avoid problem 
menses such as severe cramps, heavy bleeding, and 
severe PMS symptoms. You can also use it like you 
did in an abbreviated form over two cycles just to 
skip a menses because of your other activities. It 
is not a perfect regimen, however, hence the 
breakthrough bleeding which you had. 

There are now pills (Seasonale(R)) that are 
packaged with 3 months of active pill. Then you 
are off of them about 4-7 days and resume another 
continuous pack. About 60% of women will stick 
with that regimen over time while the others drop 
out presumably due to problems such as break-
through bleeding. DepoProvera(R) the contraceptive 
shot also functions similar to this. 

4. Knee injury especially ACL ligament

With sports or exercise regimens there is always a 
risk of injury to the knees. A common injury is to 
tear the ligament which holds the thigh bone 
(femur) against the shin bone (tibia). This 
ligament is called the anterior cruciate ligament 
(ACL) of the knee. It is often injured with a 
sudden overextension of the knee joint or a 
twisting motion of the joint. Once torn, the 
ligament does not heal. 

While you would think in this day and age that 
surgical repair of the ligament is easy, it is 
not. Any knee surgery can potentially cause more 
long term pain than it cures and the knee joint 
will still be more subject to injury if you 
continue with high risk sports activities such as 
skiing, soccer, football and basketball. 
Rehabilitation from knee surgery can also put you 
out of work for a longer time than the non 
surgical treatment. You will need to decide if it 
is possible to alter your activities for the rest 
of your life so as not to put the knee joint at 
risk whether or not you have surgical treatment of 
the joint. 

The non surgical treatment of ACL injury usually 
involves leg exercises to make the muscles around 
the knee joint so strong that they keep the joint 
stable and without pain even with the torn ACL. If 
the joint cannot be made stable and the cartilage 
becomes injured then there may be no choice but to 
have surgery to repair the ligament. Professional 
athletes also may choose surgical repair so they 
can continue their livelihood albeit at increased 
risk for re injury at a later time and even more 
permanent damage. 

There is no advantage to having the ligament 
repaired surgically right away after injury so you 
should take your time to decide about it. Let the 
swelling go down. Get started on the leg 
exercises. Surgery at a later time is always an 
option. See this article at Mayo Clinic for help 
in deciding. 

Knee injury especially ACL ligament

5. Health tip to share - Heart attack symptoms
"Heart attack symptoms are often different in men 
than in women. Men tend to have the traditional 
chest pain or "crushing pain" with or without 
radiation of the pain down the left arm. On the 
other hand, women may be more likely to have more 
subtle symptoms such as nausea, sweating, 
lightheadedness, Vomiting, breathlessness, neck, 
shoulder or abdominal discomfort. They may 
manifest unusually extreme fatigue or sleep 
disturbances during the weeks before a heart 
attack."- FRJ 

6. Humor is healthy


During a museum tour the guide explains, "Here you 
can see the beautiful statue of Athena...". 

"Excuse me, madam," a visitor interjects. "Who is 
that man behind her?  Is he her husband?" 

"No, Athena wasn't married. . . She was the 
g~ddess of wisdom." 

That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

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********** Health Newsletter ***********
              October 17,  2004
Biweekly from BackupMD on the Net

1. Ask about X-ray risk
2. Gallstones
3. Reader submitted Q&A - Work up for menopause
4. Obesity surgery risks and benefits
5. Health tip to share - Ginger for GI upset
6. Humor is healthy
The next newsletter will be in two weeks.

1. Ask about X-ray risk

We are bombarded almost daily about the risk of 
"this" medicine or "that" dietary habit. Sometimes 
both the writer of an article or the reader of 
that article lose perspective on whether a two 
fold increase in risk means a jump from 1/1000 to 
2/1000 or from 25% to 50%. "A risk of death of one 
in one million is generally ignored, since we face 
many risks of such magnitude every day, from 
travelling 100 miles by car or 1000 miles by 
aeroplane." However when you get up to a risk of 1 
in a thousand, it becomes pertinent to you as an 

Many x-ray (radiological) procedures can induce 
eventual cancers that can be fatal. Most people 
forget that radiation exposure causes cancers and 
doctors tend to minimize these risks or sometimes 
be totally unaware of the magnitude of these 
risks. As doctors are ordering more and more 
radiological studies because of their fear of 
being sued for missing a condition and patients 
are more and more demanding of radiological 
studies to be performed because they are 
distrustful of the physician's diagnosis, it is 
very important for both parties to know the risk 
of the procedure such as its cancer induction 

For example a CAT scan of the abdomen is probably 
equivalent to 500 chest xrays and has a risk of 
inducing a fatal cancer of about 1/2000 people. A 
thallium scan for the heart has an induced cancer 
risk of greater than 1/1000. Many fluoroscopic 
exams have a risk of 1/1000 also. The graph that 
accompanies the article in the British Medical 
Journal below is a very good representation of 
those risks. 

The point is that those studies may well be worth 
the cancer risk depending upon circumstances but 
in any case, both the patient and the doctor 
should know how much risk is involved. Be sure to 
ask about this when a bone scan, CAT scan, 
thyroid, liver, lung or gallbladder scan are 

Ask about X-ray risk

2. Gallstones
The gallbladder connects to your intestines and 
forms bile salts that help digest the food as it 
passes through. Gallstones are solid deposits of 
cholesterol or bile salts that form in the gall 
bladder in some people. Most people who have 
gallstones never even know about them because they 
do not cause any symptoms. 

It is estimated that 1 in 12 people have 
gallstones but it is more common in women, older 
individuals and people who are obese. Post 
menopausal estrogen replacement therapy also 
predisposes to gallstones. 

About 20% of people who have gallstones will 
develop symptoms and have one or more gall bladder 
attacks if the stones plug up the flow of bile 
salts needed by the intestines. Typical symptoms 
of a gall bladder attack are nausea and a moderate 
to severe pain in the right upper abdomen or in 
the upper middle abdomen. Other symptoms include 
chronic indigestion, bloating and rarely, yellow 
jaundice or gray clay colored stools. 

Gallstones are diagnosed by ultrasound scans, CAT 
scans and radionucleotide scans. Your doctor can 
order one of these if gallbladder disease is 
suspected. There are some non surgical treatments 
of gallstones but they do not tend to work as well 
as surgery. Nowadays, laparoscopic surgery is the 
procedure of choice for removal of the gall 
bladder and its stones. 

Chronic loose stools or diarrhea can be a 
consequence of gall bladder removal so surgery is 
not usually recommended unless you are having 
symptoms for gall stones. If they diagnose 
gallstones in you but you are not having symptoms, 
carefully discuss your treatment options with more 
than one doctor to see if you really need surgery. 


3. Reader submitted Q&A - DX Workup for menopause

"Could you review the medical testing/work up for 
the diagnosis of menopause?  I never had the 
typical hot flashes. 

I am a 44 year old female. Could being on two 
years of Lupron(R) for endometriosis cause early 
menopause?" - kms 

The medical test performed for diagnosis of 
menopause is a blood serum FSH level (follicle 
stimulating hormone). If your doctor orders it, a 
value of more than 30 IU/L is usually accepted as 
an indication of menopause; a value of under 20 
IU/L would indicate that a woman is not yet 
menopausal. Between 20 and 30 IU/L is 
indeterminate. it could represent menopause or 
just perimenopause. There have been cases 
especially in infertility work-ups with FSH values 
above 30 IU/L in which women have still have some 
more ovulations, i.e., they were not totally 

Home tests for menopause usually turn positive at 
25 IU/L which splits the difference but as you can 
see, it can occasionally lead to an incorrect 
diagnosis. Also it is important to avoid any 
testing, either at home or at the doctor's office, 
at about two weeks after bleeding like a menses. 
That is because there is a midcycle surge in FSH 
that can often get above 20 IU/L. 

Many doctors treating endometriosis with Lupron(R) 
have anecdotal cases of women who had permanent 
suppression of menses after discontinuing 
Lupron(R). Sometimes the women are menopausal, 
sometimes not. However it is not a common side 
effect of Lupron(R) and there have been no studies 
that I could find that have objectively looked at 

4. Obesity surgery risks and benefits
Now that there is a national push against obesity 
as a health problem and insurance companies are 
starting to cover bariatric surgery (gastric 
stapling and by-pass surgery) in their policies, 
we need to look closely at the risks of surgery 
for obesity. Many people will turn to surgery just 
because of multiple diet failures. On the other 
hand, this is serious surgery and people can die 
from it. 

A recent study in JAMA (Journal of the American 
Medical Association) looked at studies in the 
literature of bariatric surgery to summarize the 
benefits of the surgery and also the risks. They 


overall weight loss 61.2% of preoperative weight
  gastric banding 47.5%
  gastric bypass  61.6%
  gastroplasty 68.2%
  biliopancreatic diversion or duodenal switch 70.1%

Diabetes completely resolved in 76.8% of patients
Hyperlipidemia improved in 70% of patients
Hypertension completely resolved in 61.7%
Sleep apnea resolved or improved in 83.6% of patients


Death rate
  gastric banding 0.1% (1/1000)
  gastric bypass  0.5%  (5/1000)
  biliopancreatic diversion or duodenal switch 1.1% (11/1000)

The article did not mention it but patients 
undergoing any of these surgeries tend to have 
gastrointestinal symptoms such a nausea or 
diarrhea the rest of their lives. Sometimes the 
symptoms are major problems, sometime minor 
problems, but they persist because of the 
permanent rearrangement of the stomach and bowel 

Obesity surgery risks and benefits

5. Health tip to share - Ginger for GI upset

"After taking ibuprofen for two months for 
bursitis in my shoulder, my hands and feet began 
to swell.  I discontinued using it, then, started 
taking a ginger root capsule 550 mg two or three 
times a day (sometimes making a tea) for its anti-
inflammatory benefits.    

Prior to taking the ginger,  I had abdominal 
cramping and watery stools after eating head 
lettuce or milk products.  I especially had this 
problem after eating at restaurants.  To my 
surprise,  I could eat anything at any restaurant 
or buffet while taking even a maintenance dose of 
one capsule a day without the cramping, etc." - MH  

6. Humor is healthy

"Classes For Men"

Classes for men at the learning center for adults 
-registration must  be completed by Nov 5th.  
Note: due to the complexity and difficulty level 
of their contents, class size will be limited to 8 
participants maximum. 

Class 1:   How to Fill Up the Ice Cube Trays. Step 
by Step, with Slide Presentation. 
Meets 4 weeks, Monday and Wednesday for 2 hours 
beginning at 7:00 PM. 

Class 2:   The Toilet Paper Roll. Does it Change 
Round Table Discussion. Meets 2 weeks, Saturday 
12:00 for 2 hours. 

Class 3:   Fundamental Differences Between the 
Laundry Hamper and the Floor.  Pictures and 
Explanatory Graphics. 
Meets Saturdays at 2:00 PM for 3 weeks.

Class 4:   After Dinner Dishes. Can They Levitate 
and Fly Into the Kitchen Sink? 
Examples on Video. Meets 4 weeks, Tuesday and 
Thursday for 2 hours beginning at 7:00 PM 

Class 5:   Learning How to Find Things - Starting 
with looking in the right places instead of 
turning the house upside down while screaming. 
Open Forum. Monday at 8:00 PM, 2 hours.

Class 6:   Health Watch - Bringing her flowers is 
not harmful to your health. 
Graphics and Audio Tapes. Three nights; Monday, 
Wednesday, Friday at 7:00 PM for 2 hours. 

Class 7:   Real Men ask for Directions When Lost.  
Real Life Testimonials. 
Tuesdays at 6:00 PM, location to be determined.

Class 8:   Is it genetically impossible to sit 
quietly while she parallel parks? 
Driving Simulations. 4 weeks, Saturday's noon, 2 

Class 9:   How to be the Ideal Shopping Companion. 
Relaxation Exercises, Meditation and Breathing 
Meets 4 weeks, Tuesday and Thursday for 2 hours  
beginning at 7:00 PM. 

Class 10:   How to Fight Cerebral Atrophy - 
Remembering Birthdays, Anniversaries and Other 
Important Dates and Calling When You're Going to 
be Late. 
Cerebral Shock Therapy Sessions and Full 
Lobotomies Offered. Three nights; Monday, 
Wednesday, Friday at 7:00 PM for 2 hours. 

Class 11:   The Stove/Oven - What it is and How it 
is Used. Live Demonstration. Tuesdays at 6:00 PM, 
location  to be determined. 

Upon completion of any of the above courses, 
diplomas will be issued to the survivors. 

That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

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********** Health Newsletter ***********
              October 31,  2004
Biweekly from BackupMD on the Net

1. Common Cold
2. Daily exercises can help dizziness
3. Reader submitted Q&A - Morning neck stiffness
4. Thyroid Cancer
5. Health tip to share - Shingles
6. Humor is healthy
1. Common Cold

With over a billion colds a year in the U.S. and 
the average child having 3-8 colds per year, you 
can see why it is called "common". Symptoms 
generally include nasal congestion, a runny nose 
and sneezing. With only those symptoms, you might 
not be able to tell a cold from allergies. However 
with a cold, there are often other symptoms such 
as a sore throat, headache, cough or muscle aches. 

Colds are caused by over 200 different viruses and 
as such, antibiotics are not helpful at all. The 
first 2-3 days are the most contagious so it is 
best to stay home rather than going to work to 
spread the germs. If you do have to go out, do not 
hesitate to wear a surgical type face mask to 
prevent infecting other people. You can also wear 
one at home to protect your family. It is not 
inevitable that all family members must catch the 
same cold. 

The nasal drainage collects in the windpipe 
(trachea) and lungs causing a cough. This means 
that the best treatment for a cold is a nasal 
decongestant that dries up the secretions so you 
do not cough them up as much. You can get a 
decongestant at a pharmacy or grocery store 
without a prescription. Don't run to the doctor's 
office just to be told to take a decongestant and 
drink plenty of fluids. Even a yellowish or 
yellow-green nasal discharge does not require 
antibiotics unless you have a lung problem such 
asthma or bronchitis. 

A common cold is usually over all by itself in 
about a week. Sometimes a cough can persist for 
another week. If it lasts longer, consider another 
problem, such as a sinus infection or allergies. 
You should see the doctor if you start running a 
fever (for an adult), if the drainage lasts 10 or 
more days or if the throat really hurts with 
swallowing for more than 2-3 days. Once you have a 
cold it is too late to start taking herbs or 
vitamins thought to prevent colds so save your 
money at that point. Lay in a supply of surgical 
masks to have at home. 

Common Cold

2. Daily exercises can help dizziness

Dizziness or loss of balance is very common after 
the age of 75. While there are various medical 
causes of dizziness (vertigo), most often there is 
no obvious explanation for its cause. No matter 
what the cause of dizziness, physical therapy for 
balance control is common to all treatments for 

The exercises are very simple for someone without 
dizziness but very hard for a person who gets 
light-headed every time they move their head.  
Physical therapy patients have to turn their head 
from one side to the other side and to lower or 
raise the head while keeping eyes open (and either 
simultaneously focusing or not focusing on an 
object) or keeping them closed. At first, these 
movements were are made slowly while sitting, then 
faster, and finally while standing or walking. 

After 3 months of performing these exercises, 
individuals have significant improvement in their 

Daily exercises can help dizziness

3. Reader submitted Q&A - Morning neck stiffness

"When I wake up in the mornings my neck is almost 
stiff and my lower back hurts a little bit. 
Doctors say I should correct my sleeping position 
and stop tilting my neck before it becomes a 
permanent problem which will cause problems with 
my nerves. THE MAIN PROBLEM IS: I can't control my 
sleeping position. I wake up many times at night 
trying to do so, but it's becoming quite 
irritating and useless. PLEASE TELL ME HOW TO 

The question you ask is almost impossible to 
answer because no one that I know of has a 
prescription to control movement during sleep. 
Neck position, however can sometimes be controlled 
by special cervical pillows that are shaped 
slightly different than conventional pillows and 
also made of new age foam materials that better 
accommodate the shape of the head and neck to 
provide more even support. With these special 
pillows you do not unconsciously contract your 
neck muscles at night as much when you sleep. 

There was a recent article in Prevention Magazine 
that looked a different pillows to see which ones 
gave their staff more restful sleep with the least 
neck pain. As I remember, the best pillow they 
chose was the ObusForme(R) UltraFoam Deluxe 
Pillow. I have used that and it seems to be quite 
helpful for morning neck pain. 

The neck pain itself usually comes from uneven 
sustained muscle contraction of one or several of 
the many neck muscles. Pillows that are too high 
(plump) or too thin can cause uneven muscle 
contraction of the front muscles if you are laying 
on your back while sleeping or uneven contraction 
of the side neck muscles if you are laying on your 
side. A pillow that keeps your head and neck in an 
unbent position relative to your shoulders will 
help alleviate morning neck pain. 

Sometimes the uneven neck muscle contraction 
during sleep can come from stress, sleeping 
disorders, or even daytime muscle stress from 
work, school or home lifting or positional strain. 
Even sitting for a long time during the day 
looking at a computer monitor that is not straight 
ahead of you can result in uneven night time neck 
muscle contraction. 

People who have chronic neck pain (cervical 
dystonia) usually have weakened neck muscles and 
exercises to strengthen your neck may also help 
relieve some of the morning stiffness. Each 
evening before bed, try about 5 repetitions of the 
following neck muscle exercises from 
preventdisease.com : 

1. Hold one hand against the side of your head. 
Use your hand to resist the movement as you try to 
touch your shoulder with your ear. Hold this 
posture for a count of 5. Repeat to other side. 

2. Hold both hands against your forehead. Try to 
move head forward, but resist the movement with 
your hands. Hold this posture for a count of 5. 

3. Place both hands behind your head. Try to move 
head backwards, but resist the movement with your 
hands. Don't tip chin. Hold this posture for a 
count of 5. 

4. Hold one hand against the side of your head. 
Use your hand to resist the movement as you try to 
rotate your head to one side until your chin is 
lined on top of your shoulder. Hold this posture 
for a count of 5. Repeat to other side. 

Also consider acquiring a cervical pillow even 
though they can be somewhat expensive. 

4. Thyroid Cancer	
Thyroid cancer has been in the news recently but 
it is not one of the more common malignancies. It 
is, however, a very curable cancer (greater than 
90% cure with surgery) so it is important to know 
the signs and symptoms of this. 

Most of the thyroid cancers present as a "lump" in 
the thyroid gland just below the "Adam's Apple" on 
the front of the neck. While most lumps in the 
thyroid are benign nodules (non-cancerous), about 
1 in 20 (5%) are malignant. Sometimes a neck lump 
is not noticed as the first symptom but rather 
presents other symptoms such as voice hoarseness, 
difficulty swallowing, trouble breathing, swollen 
lymph nodes in the neck, or pain in your throat or 
neck which sometimes spreads up to your ears.  
Both benign and malignant thyroid nodules can 
produce these symptoms so just because they are 
present does not mean you have cancer but it does 
mean you need to have the nodule evaluated. 

The diagnosis of whether a thyroid nodule is 
benign or malignant is either by a fine needle 
biopsy or sometimes by a surgical biopsy or 
excision. Prior to that a thyroid scan is usually 
performed to visualize the entire extent of the 
nodule. Also a blood test measurement of thyroid 
function such as the TSH is drawn to determine 
whether the nodule is over functioning in its 
thyroid hormone secretion or not. Sometimes a CT 
scan or MRI scan needs to be performed to 
determine if the cancer has spread to the lymph 
nodes or the windpipe (trachea). 

While the predominant manner of treating thyroid 
cancer is surgical excision, sometimes radiation 
therapy must be used and sometimes medical 
chemotherapy such as that with radioactive iodine 
must be given. 

Thyroid Cancer

5. Health tip to share - Shingles

"I would like very much to share a health tip on 
shingles/herpes. Exercise is very important to 
prevent breakouts. It took me 10 years to realize 
what a difference this would make in controlling 
breakouts. Since I started to workout at the gym 
3-4 days a week, I have not experienced a breakout 
in 6 months. Usually I have a breakout every 2 
months. I also take a multivitamin. This really 
works for me. I hope I can help someone with 
sharing this info." - Mellissa 

6. Humor is healthy


At a Santa Fe gas station:
"We will sell gasoline to anyone in a glass 

In a New York restaurant:
"Customers who consider our waitresses uncivil 
ought to see the manager." 

On the wall of a Baltimore estate:
"Trespassers will be prosecuted to the full extent 
of the law. --Sisters of Mercy" 

On a long-established New Mexico dry cleaners:
"38 years on the same spot."

In a Los Angeles dance hall:
"Good clean dancing every night but Sunday."

In a Florida maternity ward:
"No children allowed."

In a New York drugstore:
"We dispense with accuracy."

In the offices of a loan company:
"Ask about our plans for owning your home."

In a New York medical building:
"Mental Health Prevention Center"

On a New York convalescent home:
"For the sick and tired of the Episcopal Church." 

On a Maine shop:
"Our motto is to give our customers the lowest 
possible prices, and workmanship." 

At a number of military bases: 
"Restricted to unauthorized personnel." 

On a display of "I love you only" Valentine cards: 
"Now available in multi-packs."

In the window of a Kentucky appliance store:
"Don't kill your wife. Let our washing machine do the
dirty work."

In a funeral parlor: 
"Ask about our layaway plan." 

In a clothing store:
"Wonderful bargains for men with 16 and 17 necks." 

In a Tacoma, Washington men's clothing store:
"15 men's wool suits, $10. They won't last an 

On a shopping mall marquee:
"Archery Tournament -- Ears pierced"

Outside a country shop:
"We buy junk and sell antiques."

In the window of an Oregon store:
"Why go elsewhere and be cheated when you can come 

In a Maine restaurant:
"Open 7 days a week and weekends."

On a radiator repair garage:
"Best place to take a leak."

In the vestry of a New England church:
"Will the last person to leave please see that the 
perpetual light is extinguished." 

In a Pennsylvania cemetery:
"Persons are prohibited from picking flowers from 
any but their own graves." 

On a roller coaster:
"Watch your head."

On the grounds of a public school:
"No trespassing without permission."

On a Tennessee highway:
"When this sign is under water, this road is 

Similarly, in front of a New Hampshire car wash: 
"If you can't read this, it's time to wash your 

And apparently, somewhere in England in an open 
field otherwise untouched by human presence, there 
is a sign that says, "Do not throw stones at this 

That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

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********** Health Newsletter ***********
              November 14,  2004
Biweekly from BackupMD on the Net

1. Will exercise with sore muscles hurt you?
2. Which calcium supplements for bone density?
3. Reader submitted Q&A - Rosacea
4. Dry mouth
5. Health tip to share -  Gingivitis
6. Humor is healthy

1. Will exercise with sore muscles hurt you?

Muscle soreness after any physical activity or 
exercise workout is common unless the muscles have 
been working at that level for at least two weeks. 
The more out-of-shape the muscles are, the later 
the soreness sets in. It is not uncommon to be 
sore the day after rather than the day of, any 
unusual muscle workout. The question becomes "Is 
it safe to push the muscles with more exercise 
when they are already sore?" 

There is no absolute answer to this because it 
depends upon whether there is just generalized 
muscle fiber swelling due to the unaccustomed 
exercise or whether there is tearing (usually 
microscopic) of the muscle fibers. You have no way 
of knowing except by the degree of pain when you 
resume exercise. If light warm-up exercises seem 
to make the pain somewhat less, you are probably 
good to go ahead with a workout no greater than 
what you did the previous day. If the pain seems 
to be made worse or if it localizes to a specific 
muscle rather than being generalized then it is 
best not to try to "exercise through the pain". 
Rather you should confine your workout to muscles 
that are not sore or try a light activity like 
walking and wait another day before exercising the 
very sore muscles. 

If you are really going for muscle strengthening 
rather than just the aerobic work-out, it is more 
important not to stress the same muscles each day. 
Usually a muscle group needs a day of rest in 
between so that if you exercise, for example, your 
abdominal muscles on Monday, wait until Wednesday 
to exercise them specifically again. This gives 
the muscle time to adapt rather than to be "broken 

Will exercise with sore muscles hurt you?

2. Which calcium supplements for bone density?

Calcium is a basic mineral needed for many bodily 
functions other than strong bones. Heart rhythm, 
nerve conduction and hormone secretion are among 
those physiological functions that need calcium. 
Calcium mostly comes from our diet, especially 
meat and dairy products but often it is not 
enough. Supplements containing calcium come in 
different forms with different side effects and 

Look on the supplement bottle label for "purified" 
or for the USP (United States Pharmacopeia) 
symbol. This will help protect against 
contaminants. Most experts recommend to avoid 
calcium from unrefined oyster shell, bone meal or 
dolomite, since these in the past have contained 
high lead levels or other toxic metals. Different 
forms of calcium include: 

calcium carbonate (Caltrate(R), TUMS(R), Coral calcium)
calcium phosphate (Solaray(R))
calcium citrate (Citracal(R) or Solgar(R))
calcium gluconate (Solgar(R))
calcium lactate (Twinlab(R))

While the daily calcium requirements are 
calculated at 1000-1200 mg a day, remember that 
some calcium always comes from your diet. A milk 
product serving, eg., milk cheese, yogurt, cottage 
cheese etc. contains about 300 mg of calcium. On 
the other hand, you must look at the supplement to 
see how much "elemental" calcium is released from 
that supplement because only the elemental calcium 
counts toward your daily requirement. For example 
a 500 mg tablet of calcium carbonate may only 
provide 200 mg of elemental calcium (40% is 
absorbed). Calcium citrate is better absorbed 
(about 60%) because it is more acidic. Calcium 
lactate 740 mg may only provide 100 mg of 
elemental calcium, however for a specific person 
the calcium lactate form may be better tolerated 
in the gastrointestinal tract than calcium 

Both calcium citrate and calcium phosphate are 
less constipating and produce less "gas" than 
calcium carbonate but they may be more expensive 
forms of calcium. You will have to find the right 
form of calcium for you depending upon cost and 
side effects. 

There is such a  thing as too much calcium. Some 
people who tend to form kidney stones will need to 
watch out. No one should really take in more than 
2500 mg of calcium a day. 

Calcium supplements for bone density

3. Reader submitted Q&A - Rosacea

"Is there any hope of a cure for rosacea in the 
future? I am a 43 year old male who has had 
rosacea for 11 years." - SD 

To the best of my knowledge there is not a cure 
for rosacea on the near horizon but I would not 
rule it out forever. The rosacea classic symptoms 
are patchy flushing (redness) and inflammation, 
particularly on the cheeks, nose, forehead, and 
around the mouth. Rosacea typically appears 
between the ages of 30 and 50 and affects more 
women than men. 

Rosacea is a disorder of the blood vessels that 
causes them to swell, leading to flushing. There 
is a genetic predisposition combined with certain 
environmental factors that may irritate the skin. 
There can be Clogging of the sebaceous gland 
openings with skin mites called Demodex 
folliculorum, which live in facial-hair follicles. 
Acne, psoriasis, eczema and atopic dermatitis may 
look similar to rosacea so it is important to have 
this diagnosed by a dermatologist and not just 
guess that a reddened face rash is always rosacea. 

For people with rosacea, stimulants such as 
coffee, tea, alcohol, cigarettes, and excessive 
sugar from sweets and soda are vascular dilators 
and should be avoided. Diet sodas containing 
aspartame and or NutraSweet cause excessive 
redness in approximately 30% of rosacea sufferers 
and should be avoided. Many rosacea sufferers may 
have food allergies or triggers that perhaps do 
not cause the rosacea but will aggravate the 
symptoms by causing blood vessel dilatation. 

Topical skin cleansers, topical antibiotics or 
even laser therapy may be recommended by 
dermatologists. The treatment can be complex and 
be different for different people so it is 
beneficial if you can find a dermatologist who 
will work with you to try those different 
treatments that have been shown to improve 
rosacea. Certain brands of cosmetics can be useful 
to cover up the redness and these are used even by 

4. Dry mouth

You would not think that having a dry mouth is 
much of a health problem but it can be. It can 
lead to increased tooth decay, it can cause 
difficulty in tasting, swallowing or speaking. It 
can lead to sores of the mouth or it can be a sign 
of adverse medication reaction or disease 
conditions. Dry mouth (xerostomia) is due to not 
having enough saliva (spit) from the glands of the 

Causes of dry mouth include:

medicine side effects - there are many medicines 
that cause the salivary glands to make less 
saliva. Anti-hypertensives and anti-depression 
medicines often cause this 

diseases - Sjögren's Syndrome, HIV/AIDS, diabetes, 
and Parkinson's disease can all cause dry mouth. 

radiation therapy - from cancer treatment, 
radiation can damage the salivary glands 
chemotherapy - drugs used to treat cancer can make 
saliva thicker, causing the mouth to feel dry. 

nerve damage - head or neck injury can damage the 
nerves that tell salivary glands to make saliva 

Treatment for dry mouth may include stopping or 
substituting any medications thought to block 
salivary gland secretion. Sometimes an artificial 
saliva may need to be used. 

Dry mouth

5. Health tip to share - Gingivitis
"My dentist told me if I didn't start flossing I 
would get gingivitis, (my gums were very red and 
sore - I hated to floss),  and have to be seen 
every 3 months.  I started using Listerine(R) or 
an alcohol based mouth wash every day morning and 
night.  It went away and I have had no problems 
since.  My dentist was amazed." - DS 
6. Humor is healthy
"Faux HMO memo to all Hospital Staff"


To: All Hospital Staff
From: Administration/Groundskeeping
Subject: New Cost Cutting Measures

Effective immediately, this hospital will no 
longer provide security. Each charge nurse will be 
issued a .38 caliber revolver and 12 rounds of 
ammunition. An additional 12 rounds will be stored 
in pharmacy. In addition to routine nursing 
duties, Charge Nurses will rotate the patrolling 
of the hospital grounds. A bicycle and helmet will 
be provided for patrolling the parking areas. 

In light of the similarity of monitoring 
equipment, ICU will now take over the security 
surveillance duties. The ward clerk will be 
responsible for watching cardiac monitors and 
security monitors as well as regular duties. 

Food service will be discontinued. Patients 
wishing to be fed will need to let their families 
know to bring something or may make arrangements 
with Subway or Pizza Hut to deliver. Coin-operated 
telephones will be available in patient rooms for 
this purpose as well as for other calls the 
patient may wish to make. 

Housekeeping and Physical Therapy will be 
combined. Mops will be issued to those patients 
who are ambulatory, thus providing range of motion 
exercises as well as a clean environment.  
Families and ambulatory patients may also sign up 
to clean the rooms of non-ambulatory patients for 
special discounts on their final bill. Time cards 
will be provided. 

As you can see on the "from" line above, hospital 
administration is assuming the grounds keeping 
duties. If an administrator cannot be reached by 
calling his/her office, it is suggested that you 
walk outside and listen for the sound of a lawn 
mower, weed-whacker, etc. 

Maintenance is being eliminated. The hospital has 
subscribed to the Time-Life "How to..." series of 
maintenance books. These can be checked out from 
administration, and a toolbox will be standard 
equipment on all nursing units. 

We will be receiving the series at a rate of one 
volume every other month. We already have the 
volume on "Basic Wiring," but if a non-electrical 
problem occurs, please try to handle it as best 
you can until the appropriate volume arrives. 

Cutbacks in phlebotomy staff will be accommodated 
by only performing blood-related tests on patients 
who are already bleeding. 

Physicians will be informed that they may order no 
more than two X-rays per patient stay. This is due 
to the turnaround time required by Photomat. 

Two prints will be provided for the price of one, 
and physicians are being advised to clip coupons 
from the Sunday paper if they want extra sets. 

Photomat will also honor competitors coupons for 
one-hour processing in emergency situations, so if 
you come across any extra coupons please clip out 
and send these to ER. 

In view of the hot summer temperatures, the 
Utilities Dept. has been asked to install 
individual meters in each patient room, office, 
etc., so that electrical consumption can be 
monitored and appropriately billed. Fans will be 
available for sale or lease in the hospital gift 

In addition to the current recycling programs, a 
bin for collection of unused fruit and bread will 
soon be provided on each floor. 

Families, patients, and the few remaining 
employees are asked to contribute discarded 

Pharmacy will utilize this for antibiotic 
production. These will be available for purchase 
and, coincidentally, will soon be the only 
antibiotics on our HMO's formulary. 

That's it for this time. 
Your BACKUPMD on the Net.
Frederick R. Jelovsek MD 

Back to top

********** Health Newsletter ***********
              November 28,  2004
Biweekly from BackupMD on the Net

1. Hair removal 101
2. Over-the-counter wrinkle creams - do they work?
3. Reader submitted Q&A - Baker's cyst of knee
4. Exposure to solvents may affect your baby
5. Health tip to share - Cinnamon vs sugar
6. Humor is healthy
The next newsletter will be in two weeks.

1. Hair removal 101

There are many different ways of removing unwanted 
hair. Some methods are cheap (shaving) while 
others can be quite expensive (laser removal). 
Some of the methods result in permanent hair 
removal while with others, the hairs eventually 
grow back. Almost all of the hair removal 
techniques can produce skin irritation, redness, 
increased pigmentation, acne and swelling. With 
some techniques, adverse skin changes are worse 
than others. 

Permanent hair removal techniques include laser, 
electrolysis and prescription chemical treatments 
such as eflornithine (Vaniqa(R)). Laser hair 
removal is expensive but there is not usually as 
much skin reaction as with electrolysis or 
eflornithine. The downside of laser is that 
occasionally there can be some increased skin 
pigmentation causing dark blotches. The 
prescription cream, eflornithine, stops hair 
growth and is approved for treating facial hair 
growth in women. Electrolysis is effective but it 
should be done by someone who is trained in it, 
not just using a home kit which seems to result in 
more scarring an increased pigmentation. 

Waxing, tweezing and sugaring can remove hair for 
2-8 weeks and they tend to be more painful 
techniques of hair removal. Sugaring involves 
making a sugar paste which is applied to the hair 
and when it dries, it is peeled off taking much of 
the hair with it. It is not quite as effective as 
waxing but there may be less skin burning with it. 

Keep in mind that all of these methods of hair 
removal should only be used after you have had a 
hormone assessment to make sure there is not an 
excess of male hormone testosterone in the blood. 
If there is, medicines should be taken to reduce 
the level otherwise all of the hair removal 
efforts will be for naught. 

Hair removal 101

2. Over-the-counter wrinkle creams - do they work?

Advertising for wrinkle creams that you can 
purchase without a prescription, always makes the 
product sound too good to be true. "Just rub this 
cream on and watch the wrinkles disappear!" But do 
they really work? Are the ingredients in them 
known to reduce wrinkles? 

The web site at MayoClinic.com has a good review 
of those ingredients that are effective, possibly 
effective and possibly ineffective. Vitamin A and 
hydroxy acids are the two main ingredients known 
to improve wrinkles. Retinol is a vitamin A 
derivative used in OTC anti-wrinkle creams. It is 
an antioxidant that is not quite as strong as the 
prescription cream tretinoin, but it produces less 
skin redness and irritation. Hydroxyacids cause 
the outer layer of old dead skin to shed leaving 
new skin underneath that is more smooth and evenly 

Possibly effective ingredients include:

Alpha-lipoic acid (ALA)
Coenzyme Q-10
Copper peptides
Growth factors such as kinetin
Soy isoflavones (phytoestrogens)
Tea extracts
Vitamin C
Vitamin E

Most of these are strong antioxidants which help 
repair and prevent sun skin damage. They have been 
shown in animal trials to reduce wrinkles. Some of 
them have been shown in medical human trials to be 
effective against wrinkles but the evidence is not 
overwhelming yet. The biggest problem with over-
the-counter creams is that the levels of these 
active ingredients may not be high enough to be 
effective. This is especially true with vitamin C 
in which very high levels are needed to have a 
beneficial effect. 

If you are interested in the specific products 
which contain these ingredients, be sure to visit 
the Mayo Clinic site below. 

Over-the-counter wrinkle creams - do they work?

3. Reader submitted Q&A - Baker's cyst of knee

"Can you tell me what a bakers cyst is?" - Betty

A Baker's cyst is a swelling of the posterior knee 
capsule. It is a fluid reaction to arthritis or 
trauma such as a torn meniscus of the knee joint. 
The fluid fills the knee joint and pushes out at 
the weakest part of the joint capsule, usually at 
the back of the  knee. It causes a dull aching 
pain that is made worse with walking or standing. 
On rare occasions the cyst can rupture. Usually, 
however, a Baker's cyst will not cause long-term 
harm and long-term disability is very rare. Most 
cases improve with time or arthroscopic surgery. 

The cyst can be diagnosed on physical exam by 
feeling it behind the knee joint. MRI (magnetic 
resonance imaging) can also be used not only to 
diagnose the Baker's cyst but also to see if there 
are any tears in the cartilage (meniscus) of the 

Treatment of a Baker's cyst of the knee is usually 
non surgical at first. Rest and elevation of the 
leg usually give some immediate relief. The key is 
to eliminate inflammation of the joint. Avoid 
those activities that worsen the pain and swelling 
such as "squatting, kneeling, heavy lifting, 
climbing, and even running." Use anti-inflammatory 
medicines such as naproxen or ibuprofen. A knee 
brace may be helpful to reduce pain. Sometimes 
heat from a heating pad can also ease the 
discomfort and promote healing. 

The next step is to strengthen the quadriceps 
muscle and knee cap tendon. Strengthening 
exercises help keep the knee joint from 
unnecessary movement and more pain. If the cyst 
does not regress spontaneously in several months 
or if it just produces continuous severe pain, one 
should consult with an orthopedic surgeon for 
possible arthroscopic surgery. 

4. Exposure to solvents may affect your baby

Many women have jobs in manufacturing and 
industrial plants in which they are exposed to 
organic solvent chemicals such as benzene, carbon 
tetrachloride, carbon disulfide, chloroform, 
toluene, phenol and others. They are found in jobs 
involving painting and plastic adhesives, nail 
salons, dry-cleaning operations, and medical 
laboratories among others. Solvents are easily 
inhaled producing a chronic exposure rather than a 
limited one such as if you just spill a solvent on 
your ski
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