Is it the same thing?

Discussion in 'Health and medical' started by Francispoon, Jan 31, 2004.

  1. Francispoon

    Francispoon Guest

    My ENT doctor told me that a bp of 130/80 achievable through using diurectics is less preferred to
    one achieved through a blood dilator such as calcium channel blocker for the simple reason that the
    former is achieved using 'thick' blood while the latter thinner blood.

    Any comment?

    FP
     
    Tags:


  2. Matti Narkia

    Matti Narkia Guest

    31 Jan 2004 05:11:54 -0800 in article
    <[email protected]> [email protected]
    (francispoon) wrote:

    >My ENT doctor told me that a bp of 130/80 achievable through using diurectics is less preferred to
    >one achieved through a blood dilator such as calcium channel blocker for the simple reason that the
    >former is achieved using 'thick' blood while the latter thinner blood.
    >
    If blood "thickness", i.e. risk of thromboembolism is a problem, take about 100 mg aspirin daily.
    Read also the following clippings (or the whole articles if you have time):

    Ubel PA, Jepson C, Asch DA. Misperceptions About beta-Blockers and Diuretics. J Gen Intern Med. 2003
    Dec;18(12):977-83. PMID: 14687255 [PubMed - in process] <URL:http://www.ncbi.nlm.nih.gov/entrez/que-
    ry.fcgi?cmd=Retrieve&db=PubMed&list_uids=14687255&dopt=Abstract>

    "... CONCLUSIONS: Despite numerous clinical trials showing no difference in the effectiveness or
    side-effect profiles of these 4 classes of drugs, most physicians believed that diuretics were
    less effective and beta-blockers were less tolerated than other medications. Moreover, their
    prescription practices were associated with their provision of free samples provided by
    pharmaceutical representatives, even after adjusting for other demographic characteristics.
    Efforts to increase physicians' prescribing of beta-blockers and diuretics may need to be
    directed at overcoming misunderstandings about the effectiveness and tolerability of these
    medicines."

    Doctors More Likely to Prescribe Pricey New Blood Pressure Drugs Despite Standards
    <URL:http://www.newswise.com/articles/view/502414/>

    "Even though research has shown inexpensive treatments for high blood pressure are just as
    effective as pricey new drugs, doctors perceive the new drugs as more effective and think they
    carry fewer side effects, according to a new study by a University of Michigan Health System
    physician.

    [...]

    “These new, more expensive medications are being more heavily promoted by the drug companies,
    and one way or another that information influences how people perceive the drug’s
    effectiveness,” says study author Peter A. Ubel, M.D., associate professor of internal medicine
    at the U-M Medical School and director of the U-M Health System’s Program for Improving Health
    Care Decisions.

    [...]

    “The industry influence is pervasive,” says Ubel, who is also a research investigator at the
    Ann Arbor Veterans Administration Health Center. “I think a lot of physicians do rely on sales
    representatives to tell them about the latest medications out there. How else do you find this
    out? It is very hard to keep up on the medical literature. Doctors feel it’s an educational
    visit, but the sales reps hand out samples.”"

    This matter doesn't seem to have changed much in five years. In September 1998 The Lancet
    published the study

    Malcolm Maclure, Colin Dormuth, Terryn Naumann, James McCormack, Robert Rangno, Carl Whiteside,
    James M Wright. Influences of educational interventions and adverse news about calcium-channel
    blockers on first-line prescribing of antihypertensive drugs to elderly people in British Columbia.
    The Lancet Volume 352, Number 9132, 19 September 1998, pp. 943-948.
    <URL:http://www.thelancet.com/journal/vol352/iss9132/full/llan.352.9132.original_research.6005.1>

    from which one can conclude that new widely reported scientific observations only very slowly affect
    the doctor's prescribing behavior. The above study has been commented in the article

    Prescribing habits often slow to change
    http://dailynews.yahoo.com/headlines/hl/story.html?s=v/nm/19980918/hl/pop10_1.html
    http://www.thriveonline.com/health/news/RB/1998Sep18/740.html

    The links are now obsolete, but I happen to have saved the following citation:

    "Many Canadian doctors continued to prescribe certain drugs for patients with high blood
    pressure even after an avalanche of media coverage on the possible health risks of these drugs,
    and against recommendations published in professional guidelines, according to a new study.

    The study findings ``are consistent with other research showing that physicians are cautious
    about changing their prescribing practices,'' the research team writes this week in The Lancet.

    Dr. James Wright of the University of British Columbia in Vancouver and colleagues looked at
    over 4,400 physicians in British Columbia who prescribed a diuretic, a beta-blocker, an angiotensin-
    converting enzyme (ACE) inhibitor drug or a calcium channel blocker for the first time for a
    total of 36,507 hypertensive patients between 1993 and 1996.

    The researchers report that about 22% of these patients were prescribed calcium channel blockers
    as first-line therapy in 1994 although professional guidelines suggested that beta blockers or
    diuretics were more appropriate as a first choice.

    And prescribing practices did not change in early 1995 after a study reported that patients
    taking some calcium channel blockers might be at higher risk of heart attack than those taking
    other drugs.

    But the team did find that small shifts in prescribing in July 1995 and in early 1996, after the
    release of more reports on the risks of these drugs in some patients.

    ``Our main finding was that, despite many news reports, a warning letter and two issues of a
    regular newsletter, physicians continued to prescribe... (calcium channel blockers) as first-
    line therapy to at least 33% of patients, contrary to guidelines,'' the authors write.

    ``We conclude that, for new evidence to have an immediate impact on prescribing, innovative
    forms of continuing medical education and new ways of warning physicians must be developed
    and evaluated,'' they conclude. ``In the meantime, prescribing can be expected to improve
    only gradually in response to multiple messages delivered by multiple methods, including the
    lay media.''

    SOURCE: The Lancet 1998;352:943-948."

    More about this topic in the abstract of the study

    Manolio TA, Cutler JA, Furberg CD, Psaty BM, Whelton PK, Applegate WB. Trends in pharmacologic
    management of hypertension in the United States. Arch Intern Med. 1995 Apr 24;155(8):829-37.
    Review. <URL:http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=771779-
    1&dopt=Abstract>

    A citation:

    "CONCLUSIONS: Use of calcium antagonists and angiotensin-converting enzyme inhibitors in
    hypertension has increased dramatically in the past 10 years. Without convincing evidence of the
    advantages of these agents, it is difficult to explain the continued decline in the use of less
    expensive agents, such as diuretics and beta-blockers, which are the only antihypertensive agents
    proved to reduce stroke and coronary disease in hypertensive patients."

    Comments in the articles

    Study: Calcium Antagonists and ACE Inhibitors Overused in Hypertension
    http://www.pharminfo.com/pubs/msb/ccbace_ovr.html (link no longer worksi)

    "Manolio et al. explored possible reasons for the shift to newer types of drugs. These included
    improved efficacy in preventing cardiovascular morbidity and mortality, rising incidence of
    concomitant illnesses necessitating the use of newer drugs, improved blood- pressure-lowering
    effects, improved side effect profiles, lower cost, and increased marketing pressure and
    attractiveness of newer drugs.

    The investigation showed that changes in drug use could not be explained by any of the first
    five reasons."

    [...]

    "The investigators concluded, "Although there may be legitimate reasons, such as coexisting
    angina or congestive failure, to choose newer agents in selected patients, this does not appear
    to justify their use as routine therapy in uncomplicated hypertension. No data are currently
    available to demonstrate the superiority of calcium antagonists and ACE inhibitors in reducing
    cardiovascular morbidity and mortality from hypertension, but there is ample evidence of their
    greater cost. While health costs are under sharp attack, it seems irrational to divert
    substantial resources by substituting unproven and more expensive remedies for tried and tested
    drugs. Since the vast majority of hypertensive patients can be treated with relatively
    inexpensive, proved agents, the trend toward increased use of costly, unproved agents in routine
    management of hypertension requires careful reconsideration." "

    and

    Doctors Not Prescribing Recommended Drugs to Treat Hypertension
    http://www.heartinfo.com/news97/hbpdrg12497.htm (link no longer works)

    "There are enormous cost implications of prescribing calcium channel blockers instead of
    diuretics, according to the study. Since calcium channel blockers cost close to 60 times the
    price of diuretics, prescribing diuretics could save hundreds of millions of dollars. Possible
    reasons for doctors' prescribing habits mentioned by the authors are that not enough doctors
    were informed of the treatment guidelines, and that physicians may have been influenced by drug
    company advertising."

    --
    Matti Narkia
     
  3. francispoon wrote:

    > My ENT doctor told me that a bp of 130/80 achievable through using diurectics is less preferred to
    > one achieved through a blood dilator such as calcium channel blocker for the simple reason that
    > the former is achieved using 'thick' blood while the latter thinner blood.
    >
    > Any comment?
    >

    Your Ear, Nose, Throat specialist does not appear to be a Hypertension specialist.

    Servant to the humblest person in the universe,

    Andrew

    --
    Dr. Andrew B. Chung, MD/PhD
    Board-Certified Cardiologist
    http://www.heartmdphd.com/

    --
    Who is the humblest person in the universe?

    http://makeashorterlink.com/?L21532147
     
  4. I don't think so. A huge study showed that diurectics were safe and effective. They are also far
    cheaper. However, the best (no side effects) way to lower BP is the "Dash" diet developed by the
    NIH. See www.nhlbi.nih.gov/health/public/ heart/hbp/dash/new_dash.pdf Finally, your goal should be
    120/80 not 130/80.

    [email protected] (francispoon) wrote in message
    news:<[email protected]>...
    > My ENT doctor told me that a bp of 130/80 achievable through using diurectics is less preferred to
    > one achieved through a blood dilator such as calcium channel blocker for the simple reason that
    > the former is achieved using 'thick' blood while the latter thinner blood.
    >
    > Any comment?
    >
    > FP
     
  5. Francispoon

    Francispoon Guest

    "Dr. Andrew B. Chung, MD/PhD" <[email protected]> wrote in message news:<[email protected]>...
    > francispoon wrote:
    >
    > > My ENT doctor told me that a bp of 130/80 achievable through using diurectics is less preferred
    > > to one achieved through a blood dilator such as calcium channel blocker for the simple reason
    > > that the former is achieved using 'thick' blood while the latter thinner blood.
    > >
    > > Any comment?
    > >
    >
    > Your Ear, Nose, Throat specialist does not appear to be a Hypertension specialist.

    He said blood flows more easily when it is thin and he believes my tinnitus has something to do with
    my vasecular conditions. Also, he is suspecting the continuous deposit on blood vessels of
    additional potassim from Dyazide and its effects. He advised me to switch from diurectics to Plendil
    for the reason that Plendil as a dilator could help 'treat my migraine or a headache and a ring on
    the left side of my brain. I wonder if Zestril or ACE inhibitor has the same property for that. That
    *seems* to work, but i am not quite sure if it is a correlational or causal relationship. Plendil is
    OK except that it has to be administered with beta-blocker which produces impotence. Also, when i
    was using diurectics, i found it hard to have a nap without subsequent repercussion of more rings
    from my tinnitus. Without plendil, it is OK. I am still experimenting as a desperate person who
    tries to treat the tinnitus.

    By the way, if I were not satisfied with the current combination, could I go back or would the old
    medicine lose their effectiveness once I check out?

    Comments, please.

    FP
    =============================================
    >
    >
    > Servant to the humblest person in the universe,
    >
    > Andrew
    >
    > --
    > Dr. Andrew B. Chung, MD/PhD Board-Certified Cardiologist http://www.heartmdphd.com/
     
  6. Francispoon

    Francispoon Guest

    "Dr. Andrew B. Chung, MD/PhD" <[email protected]> wrote in message news:<[email protected]>...
    > francispoon wrote:
    >
    > > My ENT doctor told me that a bp of 130/80 achievable through using diurectics is less preferred
    > > to one achieved through a blood dilator such as calcium channel blocker for the simple reason
    > > that the former is achieved using 'thick' blood while the latter thinner blood.
    > >
    > > Any comment?
    > >
    >
    > Your Ear, Nose, Throat specialist does not appear to be a Hypertension specialist.
    >
    I am using 10mg of Zestril, 2.5 mg of Plendil and 25 mg of beta-lock soc. Do you think I should move
    out of Zestril and concentrate on (increase) Plendil and beta-blocker in order to acheive better
    effect? I find this combination to complicated. In the long run, I think the combination of Plendil
    and beta-blocker would be optimal. Principally, is that correct?

    THX

    FP
    >
    > Servant to the humblest person in the universe,
    >
    > Andrew
    >
    > --
    > Dr. Andrew B. Chung, MD/PhD Board-Certified Cardiologist http://www.heartmdphd.com/
     
  7. Francispoon

    Francispoon Guest

    Matti Narkia <[email protected]> wrote in message news:<[email protected]>...
    > 31 Jan 2004 05:11:54 -0800 in article <[email protected]>
    > [email protected] (francispoon) wrote:
    >
    > >My ENT doctor told me that a bp of 130/80 achievable through using diurectics is less preferred
    > >to one achieved through a blood dilator such as calcium channel blocker for the simple reason
    > >that the former is achieved using 'thick' blood while the latter thinner blood.
    > >
    > If blood "thickness", i.e. risk of thromboembolism is a problem,

    My ENT specialist relates this problem to my poor blood circulation which he believes has given rise
    to my tinnitus. As a matter of fact, ALL the doctors i have seen point to poor blood circulation as
    the culprit of my tinnitus. Strangely, none of the participating doctors or experts in ALT is
    willing to look into that direction.

    take about
    > 100 mg aspirin daily. Read also the following clippings (or the whole articles if you have time):
    >
    > Ubel PA, Jepson C, Asch DA. Misperceptions About beta-Blockers and Diuretics. J Gen Intern Med.
    > 2003 Dec;18(12):977-83. PMID: 14687255 [PubMed - in process] <URL:http://www.ncbi.nlm.nih.gov/ent-
    > rez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14687255&dopt=Abstract>
    >
    > "... CONCLUSIONS: Despite numerous clinical trials showing no difference in the effectiveness
    > or side-effect profiles of these 4 classes of drugs,

    I disagree. I like diurectics because it solves my constipation

    THAT IS EMPIRICAL TO *ME*. The test of the pudding is in the eating, not in some graduate papers
    writen by professionals who are running out of topics for their ph.d dissertations.

    FP
    ===========================================================

    most physicians believed that diuretics were less
    > effective and beta-blockers were less tolerated than other medications. Moreover, their
    > prescription practices were associated with their provision of free samples provided by
    > pharmaceutical representatives, even after adjusting for other demographic characteristics.
    > Efforts to increase physicians' prescribing of beta-blockers and diuretics may need to be
    > directed at overcoming misunderstandings about the effectiveness and tolerability of these
    > medicines."
    >
    > Doctors More Likely to Prescribe Pricey New Blood Pressure Drugs Despite Standards
    > <URL:http://www.newswise.com/articles/view/502414/>
    >
    > "Even though research has shown inexpensive treatments for high blood pressure are just as
    > effective as pricey new drugs, doctors perceive the new drugs as more effective and think they
    > carry fewer side effects, according to a new study by a University of Michigan Health System
    > physician.
    >
    > [...]
    >
    > ?These new, more expensive medications are being more heavily promoted by the drug companies,
    > and one way or another that information influences how people perceive the drug?s
    > effectiveness,? says study author Peter A. Ubel, M.D., associate professor of internal
    > medicine at the U-M Medical School and director of the U-M Health System?s Program for
    > Improving Health Care Decisions.
    >
    > [...]
    >
    > ?The industry influence is pervasive,? says Ubel, who is also a research investigator at the
    > Ann Arbor Veterans Administration Health Center. ?I think a lot of physicians do rely on
    > sales representatives to tell them about the latest medications out there. How else do you
    > find this out? It is very hard to keep up on the medical literature. Doctors feel it?s an
    > educational visit, but the sales reps hand out samples.?"
    >
    >
    > This matter doesn't seem to have changed much in five years. In September 1998 The Lancet
    > published the study
    >
    > Malcolm Maclure, Colin Dormuth, Terryn Naumann, James McCormack, Robert Rangno, Carl Whiteside,
    > James M Wright. Influences of educational interventions and adverse news about calcium-channel
    > blockers on first-line prescribing of antihypertensive drugs to elderly people in British
    > Columbia. The Lancet Volume 352, Number 9132, 19 September 1998, pp. 943-948.
    > <URL:http://www.thelancet.com/journal/vol352/iss9132/full/llan.352.9132.original_research.6005.1>
    >
    > from which one can conclude that new widely reported scientific observations only very slowly
    > affect the doctor's prescribing behavior. The above study has been commented in the article
    >
    > Prescribing habits often slow to change
    > http://dailynews.yahoo.com/headlines/hl/story.html?s=v/nm/19980918/hl/pop10_1.html
    > http://www.thriveonline.com/health/news/RB/1998Sep18/740.html
    >
    > The links are now obsolete, but I happen to have saved the following citation:
    >
    > "Many Canadian doctors continued to prescribe certain drugs for patients with high blood
    > pressure even after an avalanche of media coverage on the possible health risks of these
    > drugs, and against recommendations published in professional guidelines, according to a new
    > study.
    >
    > The study findings ``are consistent with other research showing that physicians are cautious
    > about changing their prescribing practices,'' the research team writes this week in The
    > Lancet.
    >
    > Dr. James Wright of the University of British Columbia in Vancouver and colleagues looked at
    > over 4,400 physicians in British Columbia who prescribed a diuretic, a beta-blocker, an
    > angiotensin-converting enzyme (ACE) inhibitor drug or a calcium channel blocker for the
    > first time for a total of 36,507 hypertensive patients between 1993 and 1996.
    >
    > The researchers report that about 22% of these patients were prescribed calcium channel
    > blockers as first-line therapy in 1994 although professional guidelines suggested that beta
    > blockers or diuretics were more appropriate as a first choice.
    >
    > And prescribing practices did not change in early 1995 after a study reported that patients
    > taking some calcium channel blockers might be at higher risk of heart attack than those taking
    > other drugs.
    >
    > But the team did find that small shifts in prescribing in July 1995 and in early 1996, after
    > the release of more reports on the risks of these drugs in some patients.
    >
    > ``Our main finding was that, despite many news reports, a warning letter and two issues of a
    > regular newsletter, physicians continued to prescribe... (calcium channel blockers) as first-
    > line therapy to at least 33% of patients, contrary to guidelines,'' the authors write.
    >
    > ``We conclude that, for new evidence to have an immediate impact on prescribing, innovative
    > forms of continuing medical education and new ways of warning physicians must be developed and
    > evaluated,'' they conclude. ``In the meantime, prescribing can be expected to improve only
    > gradually in response to multiple messages delivered by multiple methods, including the lay
    > media.''
    >
    > SOURCE: The Lancet 1998;352:943-948."
    >
    >
    > More about this topic in the abstract of the study
    >
    > Manolio TA, Cutler JA, Furberg CD, Psaty BM, Whelton PK, Applegate WB. Trends in pharmacologic
    > management of hypertension in the United States. Arch Intern Med. 1995 Apr 24;155(8):829-37.
    > Review. <URL:http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=77177-
    > 91&dopt=Abstract>
    >
    > A citation:
    >
    > "CONCLUSIONS: Use of calcium antagonists and angiotensin-converting enzyme inhibitors in
    > hypertension has increased dramatically in the past 10 years. Without convincing evidence of the
    > advantages of these agents, it is difficult to explain the continued decline in the use of less
    > expensive agents, such as diuretics and beta-blockers, which are the only antihypertensive
    > agents proved to reduce stroke and coronary disease in hypertensive patients."
    >
    >
    > Comments in the articles
    >
    > Study: Calcium Antagonists and ACE Inhibitors Overused in Hypertension
    > http://www.pharminfo.com/pubs/msb/ccbace_ovr.html (link no longer worksi)
    >
    > "Manolio et al. explored possible reasons for the shift to newer types of drugs. These
    > included improved efficacy in preventing cardiovascular morbidity and mortality, rising
    > incidence of concomitant illnesses necessitating the use of newer drugs, improved blood- pressure-
    > lowering effects, improved side effect profiles, lower cost, and increased marketing pressure
    > and attractiveness of newer drugs.
    >
    > The investigation showed that changes in drug use could not be explained by any of the first
    > five reasons."
    >
    > [...]
    >
    > "The investigators concluded, "Although there may be legitimate reasons, such as coexisting
    > angina or congestive failure, to choose newer agents in selected patients, this does not appear
    > to justify their use as routine therapy in uncomplicated hypertension. No data are currently
    > available to demonstrate the superiority of calcium antagonists and ACE inhibitors in reducing
    > cardiovascular morbidity and mortality from hypertension, but there is ample evidence of their
    > greater cost. While health costs are under sharp attack, it seems irrational to divert
    > substantial resources by substituting unproven and more expensive remedies for tried and tested
    > drugs. Since the vast majority of hypertensive patients can be treated with relatively
    > inexpensive, proved agents, the trend toward increased use of costly, unproved agents in
    > routine management of hypertension requires careful reconsideration." "
    >
    > and
    >
    > Doctors Not Prescribing Recommended Drugs to Treat Hypertension
    > http://www.heartinfo.com/news97/hbpdrg12497.htm (link no longer works)
    >
    > "There are enormous cost implications of prescribing calcium channel blockers instead of
    > diuretics, according to the study. Since calcium channel blockers cost close to 60 times the
    > price of diuretics, prescribing diuretics could save hundreds of millions of dollars. Possible
    > reasons for doctors' prescribing habits mentioned by the authors are that not enough doctors
    > were informed of the treatment guidelines, and that physicians may have been influenced by
    > drug company advertising."
     
  8. francispoon wrote:

    > "Dr. Andrew B. Chung, MD/PhD" <[email protected]> wrote in message
    > news:<[email protected]>...
    > > francispoon wrote:
    > >
    > > > My ENT doctor told me that a bp of 130/80 achievable through using diurectics is less
    > > > preferred to one achieved through a blood dilator such as calcium channel blocker for the
    > > > simple reason that the former is achieved using 'thick' blood while the latter thinner blood.
    > > >
    > > > Any comment?
    > > >
    > >
    > > Your Ear, Nose, Throat specialist does not appear to be a Hypertension specialist.
    >
    > He said blood flows more easily when it is thin and he believes my tinnitus has something to do
    > with my vasecular conditions. Also, he is suspecting the continuous deposit on blood vessels of
    > additional potassim from Dyazide and its effects. He advised me to switch from diurectics to
    > Plendil for the reason that Plendil as a dilator could help 'treat my migraine or a headache and a
    > ring on the left side of my brain. I wonder if Zestril or ACE inhibitor has the same property for
    > that. That *seems* to work, but i am not quite sure if it is a correlational or causal
    > relationship. Plendil is OK except that it has to be administered with beta-blocker which produces
    > impotence. Also, when i was using diurectics, i found it hard to have a nap without subsequent
    > repercussion of more rings from my tinnitus. Without plendil, it is OK. I am still experimenting
    > as a desperate person who tries to treat the tinnitus.
    >
    > By the way, if I were not satisfied with the current combination, could I go back or would the old
    > medicine lose their effectiveness once I check out?
    >

    You should be able to go back.

    Servant to the humblest person in the universe,

    Andrew

    --
    Dr. Andrew B. Chung, MD/PhD
    Board-Certified Cardiologist
    http://www.heartmdphd.com/

    --
    Who is the humblest person in the universe?

    http://makeashorterlink.com/?L21532147
     
  9. francispoon wrote:

    > "Dr. Andrew B. Chung, MD/PhD" <[email protected]> wrote in message
    > news:<[email protected]>...
    > > francispoon wrote:
    > >
    > > > My ENT doctor told me that a bp of 130/80 achievable through using diurectics is less
    > > > preferred to one achieved through a blood dilator such as calcium channel blocker for the
    > > > simple reason that the former is achieved using 'thick' blood while the latter thinner blood.
    > > >
    > > > Any comment?
    > > >
    > >
    > > Your Ear, Nose, Throat specialist does not appear to be a Hypertension specialist.
    > >
    > I am using 10mg of Zestril, 2.5 mg of Plendil and 25 mg of beta-lock soc. Do you think I should
    > move out of Zestril and concentrate on (increase) Plendil and beta-blocker in order to acheive
    > better effect? I find this combination to complicated. In the long run, I think the combination of
    > Plendil and beta-blocker would be optimal. Principally, is that correct?
    >

    That would have to be empirically determined.

    >
    > THX
    >

    You are welcome, Francis :)

    Servant to the humblest person in the universe,

    Andrew

    --
    Dr. Andrew B. Chung, MD/PhD
    Board-Certified Cardiologist
    http://www.heartmdphd.com/

    --
    Who is the humblest person in the universe?

    http://makeashorterlink.com/?L21532147
     
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