How to Lose a Girl in 10 Days

Losing a girlfriend isn't that challenging. It just takes neglect in a few key areas and a willful arrogance in others. In order to not keep a girl, follow these steps. She'll be gone in no time.

Instructions

1. Step 1

   Forget dates. Stand up the girl whenever possible and be unapologetic when it happens. Keep forgetting plans you have together and never give an explanation. Act suspiciously when she asks where you've been.

2. Step 2

   Stare at other girls. Leave your girlfriend wondering whether you are interested in other girls and whether you may be pursuing them when the two of you are not together.

3. Step 3

   Be thoughtless. Forget that she has feelings and say things that are rude and inappropriate. Tell her that her clothes are unflattering and that her home is dirty.

4. Step 4

   Bring friends along every time you are with your girlfriend. Keep your friends there even when the girl makes it plain that they should leave.

5. Step 5

   Be rude to the girl in front of other people. Make sure her friends and yours hear the things you say to her. Be rude to her friends as well for good measure. Allow her friends to talk her out of dating you.

6. Step 6

   Talk about yourself relentlessly. Interrupt anytime she tries to talk about herself. Talk about how great you are with women, including old girlfriends, and how much they all liked you.

Be the Most Popular College Freshman

Follow these steps and you will become one of the most popular college freshman

After being in high school for four years, college freshman are sometimes uneasy and timid when entering their freshman year of college. This article will show you how to stand out from the crowd, and become well known at your new school. College freshman are usually filled with excitement for a new life, and being out own their own for the first time in your life. Many fail to realize it is very important to do key things that can make your college career the very best experience.

Where you are from

Before we can give you tips, you have to first understand where you are from and what has made you as a person so far in your life. Everything you know has been determined by your parents: Where you live, where you go to school, what friends you have, what your hobbies are... all determined by your parents. Your parents chose where you were to grow up, you made friends within the area that your parents chose to live, your hobbies were determined by activities in the area.

What being a college freshman is

Being a college freshman is your first chance on a level playing field to pick your own friends, do what you want to do, have control over your life to finally mold yourself into who you want to be. With this power comes discipline, because with the ability to change your life for the good, you also have the ability to change it for the bad (ex: dropping out). One of the most important lessons you will learn at college is time management and balance. As much as everyone would love to go out and party all day, you must discipline yourself to get your school work done, or else you days at college could be few and numbered.

Your past and reputation means nothing at college

Everything you have done in your life up until college means absolutely nothing. You will be starting over, you need to work hard to become well known. For some this provides a clean slate to forget some unpleasant things that may of happened in the past. Most likely, other students will only know what you do from that point on (and what you tell them), so try not to disclose anything that may come back and haunt you. (Tip: do not tell anyone past nicknames people called you in high school that you hated) You new job during your freshman year at college is to do the right things to get people to know you, like you, respect you, and make you one of the "popular kids on campus".

How to become popular

There is no guaranteed way to instantly become popular, but there are some guidelines to follow to help get off on the right foot.

• Be Confident - This is very important. No one will know who you are, or how great of a person you are if you spend all your time in your room playing video games or watching TV. The first few weeks of college are very critical, and are most important because people will remember you as you were those first few weeks. You only have one change to make a first impression.
• Meet everyone you can - Say hi to people walking to the cafeteria, introduce yourself, smile be nice. The first few hours after you have moved into your dorm (and your parents finally leave) walk around and introduce yourself to other people, especially on your floor. You will be spending the rest of the year with the people on your floor so you should get to know them as soon as possible. Next meet everyone you can in the rest of your dorm, you may meet their friends in other dorms. The first day of each class introduce yourself to people around you. Chances are you are going to have to work with them in groups or need notes if you miss a class, the first day is the easiest time to do this. Find out when and where the college parties are, and try to go to the best ones, and be friendly to everyone.
• Become involved - Join a student organization, ask around first, see what organizations are cool, what people are involved in. Find something you would enjoy and join a club, organization, fraternity, or sorority. Joining a good active organization, will allow you to meet the more important "active" students on campus.
• Be interested in other people - Don't just ramble on about what you have done, or what you plan to do. Listen to others and ask questions, their lives could be interesting, and you may share something in common.

Unsaid things about boys!

Things Guys Want Girls To Know which otherwise remains unsaid and sometimes becomes difficult for them to bring it out. So here you can get a glimpse over the details that these guys want their girl friends to know which they would otherwise never bother to or be able to tell. So lets get into the minds of these boys and know that always it is not that women are complicated and have lots of secrets in mind rather boys can have a lot of secrets in their mind and be as complex as a girl. This can also prove that boys have so much to tell which these people are not abled to bring out with. They want the girls to know all these facts about them and as they cannot bring with it, they prefer to write it.

The boys are not as perverted as the girls think they are. They are sensible class and they too are not as fool as they are thought to be. Though they seem to be very insensible and stupid at times they are not as they look like. So do not underestimate them as they can be clever enough at times. No matter what girls say, their ex-boyfriend is a loser. And they should never try to prove that their ex boyfriend was really smart enough but it could not be continued as this makes the boys really jealous and angry. So girls be careful from the next time.

The boys like girls to give them hugs and kisses sometimes too, though they will tell they do not want it is always at the back of their mind that they feel happy when they get this kind of responses and be happy with the kisses. So girls remember to keep your boy friends and hubbies happy be ready to give your boys hugs and kisses occasionally though they may not demand for it. Never argue with the boys when they call you beautiful. Because occasionally they would come out with these compliments and never lose the chance. Don't treat boys like crap, what goes around comes around. So try to explain them rather than scolding them.

The boys know that the girls are pretty, that's one of the reason's they are going out with girls. So don't have to always wait for them to give compliments and continue to be nagging and make them angry. Never should a girl go into detail about your period. It scares them. Atleast not before the marriage. After marriage it is alright but not before that. They would never want to know the details of it every month. If girls have cramps and guys ask you what's wrong, just tell these boys it's that time of the month and nothing more.

If the girls really liked these boys as they are then they would let the boys think that their mustache, beard, or sideburns looked cool on them and never complain about it to them. Because they might have replies that would sound harsh. These boys will never shave their legs. So it is better for girls to get over it and be happy with however they are. NEVER ask boys if they can put makeup on their face . It's just wrong on the part of girls to expect such a thing from them. Don't make bets about boys, it is dangerous to prich their ego and make them conscious. When boys tell girls that they are not fat, believe them and never argue with them on these matters as they are right judge of it all. These boys absolutely do not care about the Backstreet Boys, or what any other guy looks like for that matter never pester them to look like someone else and wear clothes like others. They prefer to be themselves.

Whenever the girls are wrong they should apologise to the boys and not just neglect the whole issue as if nothing has happened. The girls expect them to say and do sweet things for them, but it would be nice if you did the same every once in a while. We like to know that you love us and always demand form us. They can't always be spontaneous, so try to help them make the plans. Don't ask the boys to beat up another guy for you, cause you might get what you wish for. Never kick the boys in the nuts just to see what they would say. That really seems nasty. Never pretend that you are going to break up with the boy that you are moving around with . Pamela Anderson's boobs aren't fake anymore, as boys love her and never like her to be criticized but they like their girl friends boobs better anyway.

Size and shape of a girl doesn't matter, except to idiots who don't want a relationship. If the girls want boys to put the seat down when we're done, the girls should put it up when they are done. Don't tell the boys how cute your ex-boyfriend was. That doesn't turn them on rather they get irrigated. And always remember: The way to a guys heart is through his stomach, so take care of his food and start learning to cook as it is easy to keep your man happy only by this method. Never ask boys to kiss other guys. You might be that comfortable with your friends as girls can easily do that, but to them it's just wrong. The boys know that the girls are not always right, but we'll pretend like you are anyway okay and try to neglect the matter so always take care of the issues as the boys try to be very patient and considerate enough so never try their patience.

What should you do to win a girl's heart?

Answer

Most girls worth anything like a guy that listens to them and realizes they have a brain

Don't be afraid to express what you want in the future and be sure to ask what she wants

Don't tell her everything about yourself because women like a man with a bit of mystery to him and vice-versa

Treat her with respect and if she doesn't treat you the same way let her know right then and there you aren't putting up with it. Women like men that can stand on their own two feet. Even though women act independent and many are, they always fall back on the fact they want to know they can lean on their guy when they need to.

Be a gentleman without hanging all over her.

Be proud to show her off to family and friends

If she earns it, then always speak highly of her

If you think she's pretty/cute then say so and that goes for any other compliments you may have for her.

Make any dates with her earlier in the week. Take her to movies, clubs, etc. Do what you can afford. Sometimes it's just nice to grab some roasted peanuts from a vender and go for a romantic walk along a beautiful beach or by a lake.

Never forget to always act yourself and never try to be someone you aren't.

Good luck Marcy

Answer

Buy her things.

Also, allow her to love herself through your eyes. Make her feel cool and smart.

Answer

Be yourself, thats the only way to win her heart. If its meant to be it will be.

H5N1 pandemic flu vaccine developed by Glaxo SmithKline successful

GlaxoSmithKline (GSK) plc today announced headline data showing that its H5N1 pandemic flu vaccine achieved a high immune response at a low dose of antigen. The vaccine, which uses a proprietary adjuvant, enabled over 80% of subjects who received 3.8�g of antigen to demonstrate a strong seroprotective immune response.

This level of seroprotection meets or exceeds target criteria set by regulatory agencies for registration of influenza vaccines. Efficacy results at these levels of antigen dosage have also not been reported for any other H5N1 vaccine in development to date, including those using other adjuvants such as alum.

Commenting on the data, JP Garnier, GlaxoSmithKline�s Chief Executive Officer, said: �These excellent clinical trial results represent a significant breakthrough in the development of our pandemic flu vaccine. This is the first time such a low dose of H5N1 antigen has been able to stimulate this level of strong immune response.

There is still a lot more work to be done with this programme, but this validation of our approach provides us with the confidence to continue developing the vaccine, including assessment of its ability to offer cross-protection to variants of the H5N1 strain. All being well, we expect to make regulatory filings for the vaccine in the coming months.�

The results were based on an interim analysis of a clinical trial conducted in Belgium which involved 400 healthy adults aged 18-60 years of age. The vaccine tested was produced from inactivated H5N1 virus and contained a novel, proprietary adjuvant. An adjuvant is an ingredient which stimulates the immune system and increases response to the vaccine. Trial participants were vaccinated twice during the course of the trial and four different levels of antigen dose were tested, with 3.8�g being the lowest dose assessed.

The impact of smoking and genes on rheumatoid arthritis

Rheumatoid arthritis (RA) is one of the most common systemic autoimmune diseases, and one of the least understood. Smoking is the major known environmental risk factor for RA, though little is known about the mechanisms involved. HLA-DR shared epitope (SE) genes are a widely recognized genetic risk factor for RA, though little is known about how these genes affect autoimmune reactions that lead to chronic inflammation and progressive joint and organ damage.

To better understand the interactions between smoking and HLA-DR SE genes in RA, a team of researchers in Sweden focused on the disease's distinctive autoimmune hallmark: citrulline, an amino acid not normally present in protein. While extremely rare in healthy individuals and relatively rare in other inflammatory conditions, citrulline-modified proteins are common in about two-thirds of RA patients and may be an underlying factor in the development of the disease. To investigate whether smoking and SE genes trigger immune reactions to citrullinated proteins, the team conducted a case-control study involving patients with recent-onset RA. The results, featured in the January 2006 issue of Arthritis & Rheumatism, suggest that smokers with SE genes are more susceptible to anticitrulline antibody-positive RA.

The study's 930 early RA patients, drawn from the Epidemiological Investigation of Rheumatoid Arthritis Study Group, ranged in age from 18 to 70 years. 383 healthy controls, drawn from the blood bank of northern Sweden, were matched for age, gender, and residential area. All participants completed questionnaires about their past and present smoking habits, as well as genotyping profiles. In addition, bronchial fluid was obtained from a representative sample of RA patients, including both current heavy smokers and lifelong non-smokers, and tested with immunostaining for the presence of citrullinated protein in cells.

Tobacco smoking

Tobacco smoking is the practice where tobacco is burned and the vapors either tasted or inhaled. The practice began as early as 5000–3000 BC.^[1] Many civilizations burnt incense during religious rituals, which was later adopted for pleasure or as a social tool.^[2] Tobacco was introduced to the old world in the late 1500s where it followed common trade routes. The substance was met with frequent criticism, but became popular nonetheless.^[3] German scientists formally identified the link between smoking and lung cancer in the late 1920s leading the first anti-smoking campaign in modern history. The movement, however, failed to reach across enemy lines during the Second World War, and quickly became unpopular thereafter.^[4] In 1950, health authorities again began to suggest a relationship between smoking and cancer.^[5] Scientific evidence mounted in the 1980s, which prompted political action against the practice. Rates of consumption from 1965 onward in the developed world have either peaked or declined.^[6] They however continue to climb in the developing world.^[7]

Smoking is the most common method of consuming tobacco, and tobacco is the most common substance smoked. The agricultural product is often mixed with other additives^[8] and then pyrolyzed. The resulting vapors are then inhaled and the active substances absorbed through the alveoli in the lungs.^[9] The active substances trigger chemical reactions in nerve endings which hightens heart rate, memory, alertness,^[10] and reaction time.^[11] Dopamine and later endorphins are released, which are often associated with reward and pleasure.^[12] As of 2000, smoking is practiced by some 1.22 billion people. Men are more likely to smoke than women,^[13] however the gender gap declines with younger age.^[14][15] The poor are more likely to smoke than the wealthy, and people of developing countries than those of developed countries.^[7]

Many smokers begin during adolescence or early adulthood. During the early stages, smoking provides pleasurable sensations and thus serves as a source of positive reinforcement. After an individual has smoked for many years, the avoidance of withdrawal symptoms and negative reinforcement become the key motivations.

Daily exercise matters: getting just a half hour of physical activity into each day offers substantial benefits to your health

Picture this scenario: It's lunchtime, and you're taking a brisk walk with a coworker. You know the exercise will help you think more clearly and concentrate better when you get back to work.

Or how about this one: You've just finished an exhilarating workout at the gym and you feel pumped. Your skin glistens with perspiration as you head for the shower.

Nice scenarios, both of them, except that you don't have time (nor maybe the place either) to walk at lunch, and you don't belong to a gym.

Still, you know exercise is essential to good health, and the knowledge nags at you. But what can you do? Between work and family plus trying to get adequate sleep, and maybe squeeze in a social life, you don't know how you can possibly fit exercise in, too.

But you can fit it in--seamlessly, in fact--and it's easy. By following a few simple suggestions, you can reap both the physical and mental benefits of regular exercise, keep the rest of your life on track, and ditch the guilt.

Just 30 minutes a day make a huge difference. And instead of trying to find a 30-minute chunk of time--you already know it isn't there--divide it into smaller pieces. Ten minutes at a time works just fine. "Actually, it's even better, depending on what your goal is," says Connie Tyne, L.M.S.W., at the Cooper Institute of Aerobics Research in Dallas, Texas. One common misconception about exercise, she says, "is the volume theory--that a large volume of exercise is required for improvement in health and well being.... The truth is this only applies if you're seeking a very high level of fitness or you're going to be a competitive athlete....

"Our research has shown that among women 45 and older who don't exercise vigorously, those who start walking the equivalent of an hour a week--which is breaking it down into very small pieces--can lower their risk of coronary artery disease by half. And that was a study with 40,000 female health professionals."

Besides lowering our risk of coronary artery disease, daily exercise also reduces the risk of developing Type II diabetes, helps control weight, increases muscle strength, helps us maintain our independence as we age, and much more.

"Movement is life," says Art Brownstein, M.D., M.P.H., in his book Healing Back Pain Naturally (Harbor Press, 1999), "and when we stop moving certain parts of our body, muscles stiffen and weaken, joints freeze up, and pain increases when we apply a force of any kind to these areas."

But the benefits of regular exercise are a case of one good thing leading to another.

"Regular exercise has been shown to lead to weight loss," he says. "Weight loss decreases the stresses and strains on the spine, improves appearance and self-esteem, lifts spirits, and provides added energy to the body. With weight loss usually comes loss of abdominal belly fat which helps to improve posture and eases the pressure on the lower spine. It can also alleviate depression."

Getting rid of belly fat is particularly important, says Tyne. "It's not the fat in our thighs and hips, it's that stomach fat--the apple-shaped body--that leads to what's called metabolic syndrome, which puts people at higher risk of heart disease, diabetes, high blood pressure, all the conditions that we know are the killers." The danger zone, she adds, is a woman's waist measurement exceeding 35" and a man's exceeding 40".

It's encouraging to know that we don't have to exercise in the way we may normally picture exercising--working out on special equipment, jogging, or playing a sport--to reap the benefits. These are fine, but we can, instead, weave exercise into everyday activities so that we cease to think of it as exercise at all.

Many common activities count as aerobic exercise. Among them are: sweeping or mopping the floor, vacuuming, polishing furniture, carrying and putting away groceries, cleaning out closets, washing woodwork, raking leaves, pulling weeds, playing with our children, and walking the dog. If we take this message to heart, we could end up with the cleanest house, best-looking yard, and the happiest children and pets of anyone we know!

Here's more good news about breaking exercise down into 10-minute increments. "A recent journal article in Medicine and Science concluded three short bouts of brisk walking--so 10 minutes here, 10 minutes there--accumulated throughout the day were at least as effective as one continuous bout as far as reducing cardiovascular risks," says Tyne. "People actually lost more weight by breaking their exercise into three 10-minute segments."

To illustrate how this works, she likens it to baking a pizza. First, you heat the oven, then you bake the pizza, then you turn the oven off and it cools down. "When you do the shorter bouts of exercise, you're heating up your body.... You're burning more calories on the way up to exercise, while you're exercising, and then there's a carry-over effect that can last anywhere from 30 minutes to two hours."

Further, she says, several years ago researchers at the Cooper Institute of Aerobics Research did a study called Project Active. The results were published in the Journal of the American Medical Association in 1999. The study compared structured exercise intervention with lifestyle activity. (In the structured group, participants came to the center and did supervised exercise for about six months. Then the study followed them for the next two years while they were on their own.)

"I didn't realize it at the time, but my concept of aging was that of my grandparents. You take it easy, people look after you, they come over on Sundays. It wasn't an active vision at all. But on that beautiful day with the sun shining--and I was having such a great time skiing--I thought, I want to be a skiing grandmother!...

"I don't get up in the morning and exercise to lower my cholesterol," she says. "It's just not very exciting. We have to have a vision of who we want to be."

This kind of vision and a commitment to our own well-being can help us to shape and stick with our own daily exercise routine.

How Exercising 30 Minutes a Day Can Improve Health

* Relieves stress

* Produces a sense of well-being

* Improves digestion

* Makes appetite more manageable

* Encourages the body to lose excess weight and keep it off

* Helps prevent heart disease

* Helps control blood pressure

* Improves circulation

* Strengthens the heart and allows it to function with less strain

* Improves skin tone

* Promotes healthy bowel function

* Increases flexibility of joints

* Helps prevent osteoporosis

* Helps prevent Type II diabetes

* Improves mood and attitude

* Counteracts depression

* Helps in anger management by releasing physical tension

* Helps maintain strong, healthy muscles and bones

* Increases energy

* Promotes sound sleep

* Improves memory

* Reduces the risk of developing prostate cancer

* Helps delay or prevent chronic illness in the elderly

* Helps us maintain our health and independence as we age

Cancer Risk Factors

Risk factors

Doctors often cannot explain why one person develops cancer and another does not. But research shows that certain risk factors increase the chance that a person will develop cancer. These are the most common risk factors for cancer:

• Growing older



• Tobacco



• Sunlight



• Ionizing radiation



• Certain chemicals and other substances



• Some viruses and bacteria



• Certain hormones



• Family history of cancer



• Alcohol



• Poor diet, lack of physical activity, or being overweight

Many of these risk factors can be avoided. Others, such as family history, cannot be avoided. People can help protect themselves by staying away from known risk factors whenever possible.

If you think you may be at risk for cancer, you should discuss this concern with your doctor. You may want to ask about reducing your risk and about a schedule for checkups.

Over time, several factors may act together to cause normal cells to become cancerous. When thinking about your risk of getting cancer, these are some things to keep in mind:

• Not everything causes cancer.



• Cancer is not caused by an injury, such as a bump or bruise.



• Cancer is not contagious. Although being infected with certain viruses or bacteria may increase the risk of some types of cancer, no one can "catch" cancer from another person.



• Having one or more risk factors does not mean that you will get cancer. Most people who have risk factors never develop cancer.



• Some people are more sensitive than others to the known risk factors.

The sections below have more detailed information about the most common risk factors for cancer. You also may want to read the NCI booklet Cancer and the Environment.

The most important risk factor for cancer is growing older. Most cancers occur in people over the age of 65. But people of all ages, including children, can get cancer, too.

Tobacco

Tobacco use is the most preventable cause of death. Each year, more than 180,000 Americans die from cancer that is related to tobacco use.

Using tobacco products or regularly being around tobacco smoke (environmental or secondhand smoke) increases the risk of cancer.

Smokers are more likely than nonsmokers to develop cancer of the lung, larynx (voice box), mouth, esophagus, bladder, kidney, throat, stomach, pancreas, or cervix. They also are more likely to develop acute myeloid leukemia (cancer that starts in blood cells).

People who use smokeless tobacco (snuff or chewing tobacco) are at increased risk of cancer of the mouth.

Quitting is important for anyone who uses tobacco - even people who have used it for many years. The risk of cancer for people who quit is lower than the risk for people who continue to use tobacco. (But the risk of cancer is generally lowest among those who never used tobacco.) Also, for people who have already had cancer, quitting may reduce the chance of getting another cancer. There are many resources to help people stop using tobacco: Staff at the NCI's Smoking Quitline (1-877-44U-QUIT) and at LiveHelp (click on "Need Help?" at http://www.cancer.gov) can talk with you about ways to quit smoking and about groups that help smokers who want to quit. Groups may offer counseling in person or by telephone. A Federal Government Web site, http://www.smokefree.gov, has an online guide to quitting smoking and a list of other resources. Doctors and dentists can help their patients find local programs or trained professionals who help people stop using tobacco. Doctors and dentists can suggest medicine or nicotine replacement therapy, such as a patch, gum, lozenge, nasal spray, or inhaler.

Sunlight

Ultraviolet (UV) radiation comes from the sun, sunlamps, and tanning booths. It causes early aging of the skin and skin damage that can lead to skin cancer.

Doctors encourage people of all ages to limit their time in the sun and to avoid other sources of UV radiation: It is best to avoid the midday sun (from mid-morning to late afternoon) whenever possible. You also should protect yourself from UV radiation reflected by sand, water, snow, and ice. UV radiation can penetrate light clothing, windshields, and windows. Wear long sleeves, long pants, a hat with a wide brim, and sunglasses with lenses that absorb UV. Use sunscreen. Sunscreen may help prevent skin cancer, especially sunscreen with a sun protection factor (SPF) of at least 15. But sunscreens cannot replace avoiding the sun and wearing clothing to protect the skin. Stay away from sunlamps and tanning booths. They are no safer than sunlight.

Ionizing radiation

Ionizing radiation can cause cell damage that leads to cancer. This kind of radiation comes from rays that enter the Earth's atmosphere from outer space, radioactive fallout, radon gas, x-rays, and other sources.

Radioactive fallout can come from accidents at nuclear power plants or from the production, testing, or use of atomic weapons. People exposed to fallout may have an increased risk of cancer, especially leukemia and cancers of the thyroid, breast, lung, and stomach.

Radon is a radioactive gas that you cannot see, smell, or taste. It forms in soil and rocks. People who work in mines may be exposed to radon. In some parts of the country, radon is found in houses. People exposed to radon are at increased risk of lung cancer.

Medical procedures are a common source of radiation:

• Doctors use radiation (low-dose x-rays) to take pictures of the inside of the body. These pictures help to diagnose broken bones and other problems.



• Doctors use radiation therapy (high-dose radiation from large machines or from radioactive substances) to treat cancer.

The risk of cancer from low-dose x-rays is extremely small. The risk from radiation therapy is slightly higher. For both, the benefit nearly always outweighs the small risk.

You should talk with your doctor if you are concerned that you may be at risk for cancer due to radiation.

If you live in a part of the country that has radon, you may wish to test your home for high levels of the gas. The home radon test is easy to use and inexpensive. Most hardware stores sell the test kit.

You should talk with your doctor or dentist about the need for each x-ray. You should also ask about shields to protect parts of the body that are not in the picture.

Cancer patients may want to talk with their doctor about how radiation treatment could increase their risk of a second cancer later on.

rheumatoid arthritis

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system is a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.

While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability.

A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles.

In some patients with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and be progressive. Moreover, studies have shown that the progressive damage to the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the joints.

Rheumatoid arthritis is a common rheumatic disease, affecting approximately 1.3 million people in the United States, according to current census data. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age, but it most often starts after age 40 and before 60. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.

What causes rheumatoid arthritis?

The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited. It is also suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body's own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes.

Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF, interleukin-1/IL-1, and interleukin-6/IL-6) are expressed in the inflamed areas.

Environmental factors also seem to play some role in causing rheumatoid arthritis. For example, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.

What are the symptoms and signs of rheumatoid arthritis?

The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical.

When the disease is active, symptoms can include fatigue, loss of energy, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).

In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars, can become difficult during flares. The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, including cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of the voice.

Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing, shortness of breath, or coughing. The lung tissue itself can also become inflamed, scarred, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with an enlarged spleen (referred to as Felty's syndrome) and can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. Nerves can become pinched in the wrists to cause carpal tunnel syndrome. A rare, serious complication, usually with long-standing rheumatoid disease, is blood vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death (necrosis). This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

How is rheumatoid arthritis diagnosed?

The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. The doctor reviews the history of symptoms, examines the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and X-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a rheumatologist.

The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis.

Abnormal antibodies can be found in the blood of patients with rheumatoid arthritis. An antibody called "rheumatoid factor" can be found in 80% of patients. Citrulline antibody (also referred to as anti-citrulline antibody, anti-cyclic citrullinated peptide antibody, and anti-CCP) is present in most patients with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid arthritis when evaluating patients with unexplained joint inflammation. A test for citrulline antibodies is most helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Another antibody called the "antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis.

A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is used as a crude measure of the inflammation of the joints. The sed rate is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. Blood testing may also reveal anemia, since anemia is common in rheumatoid arthritis, particularly because of the chronic inflammation.

The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.

Joint X-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses, X-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint X-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, can demonstrate the inflamed joints. Bone scanning, a radioactive procedure, can also be used to demonstrate the inflamed joints. MRI scanning can also be used to demonstrate joint damage.

The American College of Rheumatology has developed a system for classifying rheumatoid arthritis that is primarily based upon the X-ray appearance of the joints. This system helps medical professionals classify the severity of your rheumatoid arthritis.

Stage I

• no damage seen on X-rays, although there may be signs of bone thinning

Stage II

• on X-ray, evidence of bone thinning around a joint with or without slight bone damage



• slight cartilage damage possible



• joint mobility may be limited; no joint deformities observed



• atrophy of adjacent muscle



• abnormalities of soft tissue around joint possible

Stage III

• on X-ray, evidence of cartilage and bone damage and bone thinning around the joint



• joint deformity without permanent stiffening or fixation of the joint



• extensive muscle atrophy



• abnormalities of soft tissue around joint possible

Stage IV

• on X-ray, evidence of cartilage and bone damage and osteoporosis around joint



• joint deformity with permanent fixation of the joint (referred to as ankylosis)



• extensive muscle atrophy



• abnormalities of soft tissue around joint possible

Rheumatologists also classify the functional status of people with rheumatoid arthritis as follows:

• Class I: completely able to perform usual activities of daily living



• Class II: able to perform usual self-care and work activities but limited in activities outside of work (such as playing sports, household chores)



• Class III: able to perform usual self-care activities but limited in work and other activities



• Class IV: limited in ability to perform usual self-care, work, and other activities

The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Analysis of the joint fluid in the laboratory can help to exclude other causes of arthritis, such as infection and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.

How is rheumatoid arthritis treated?

There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as monitored on X-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.

Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs" (also referred to as disease-modifying antirheumatic drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate, and hydroxychloroquine (Plaquenil), promote disease remission and prevent progressive joint destruction, but they are not antiinflammatory agents.

The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with uncommon, less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be managed with rest, pain and antiinflammatory medications alone. In general, however, patients improve function and minimize disability and joint destruction when treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most patients require more aggressive second-line drugs, such as methotrexate, in addition to antiinflammatory agents. Sometimes these second-line drugs are used in combination. In some patients with severe joint deformity, surgery may be necessary.

cervical disk disorders

Background

Cervical disc disorders encountered in physiatric practice include herniated nucleus pulposus (HNP), degenerative disc disease (DDD), and internal disc disruption (IDD). (See image below and Image 1.) HNP implies extension of disc material beyond the posterior margin of the vertebral body. Most of the herniation is made up of the annulus fibrosus. DDD involves degenerative annular tears, loss of disc height, and nuclear degradation. IDD describes annular fissuring of the disc without external disc deformation. Cervical radiculopathy can result from nerve root injury in the presence of disc herniation or stenosis, most commonly foraminal stenosis, leading to sensory, motor, or reflex abnormalities in the affected nerve root distribution.^1,2

Sagittal magnetic resonance imaging (MRI) scan demonstrating cervical intervertebral disc protrusions at C3-C4 and C7-T1.

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Sagittal magnetic resonance imaging (MRI) scan demonstrating cervical intervertebral disc protrusions at C3-C4 and C7-T1.

Understanding cervical disc disease requires basic knowledge of anatomy and biomechanics. The intervertebral disc absorbs shock, accommodates movement, provides support, and separates vertebral bodies to lend height to intervertebral foramina. The disc consists of an eccentrically located nucleus pulposus and a surrounding annulus fibrosus separating each segmental level between the C2-T1 vertebrae. No disc exists between C1 and C2, and only ligaments and joint capsules resist excessive motion. Disc degeneration and/or herniation can injure the spinal cord or nerve roots and result in stenosis³ and/or myofascial pain.

Pathophysiology

Manifestations of HNP are divided into subcategories by type (ie, disc bulge, protrusion, extrusion, sequestration). Disc bulge describes generalized symmetrical extension of the disc margin beyond the margins of the adjacent vertebral endplates. Disc protrusion describes herniation of nuclear material through a defect in the annulus, producing a focal extension of the disc margin. Extrusion applies to herniation of nuclear material resulting in an anterior extradural mass attached to the nucleus of origin, often via a pedicle. Disc sequestration refers to separation of material from the disc, which ultimately comes to lie in the spinal canal. (See images below and Images 1-3, 8.)

Disc herniation classification. A: Normal disc anatomy demonstrating nucleus pulposus (NP) and annular margin (AM). B: Disc protrusion, with NP penetrating asymmetrically through annular fibers but confined within the AM. C: Disc extrusion with NP extending beyond the AM. D: Disc sequestration, with nuclear fragment separated from extruded disc.

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Disc herniation classification. A: Normal disc anatomy demonstrating nucleus pulposus (NP) and annular margin (AM). B: Disc protrusion, with NP penetrating asymmetrically through annular fibers but confined within the AM. C: Disc extrusion with NP extending beyond the AM. D: Disc sequestration, with nuclear fragment separated from extruded disc.

Axial magnetic resonance imaging (MRI) scan (C3-C4) demonstrating left-sided posterolateral protrusion of the nucleus pulposus with compression of the cerebrospinal fluid.

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Axial magnetic resonance imaging (MRI) scan (C3-C4) demonstrating left-sided posterolateral protrusion of the nucleus pulposus with compression of the cerebrospinal fluid.

Sagittal magnetic resonance imaging (MRI) scan demonstrating cervical intervertebral disc protrusions at C3-C4 and C7-T1.

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Sagittal magnetic resonance imaging (MRI) scan demonstrating cervical intervertebral disc protrusions at C3-C4 and C7-T1.

Postdiscography axial computed tomography (CT) scan demonstrating right posterolateral subligamentous protrusion.

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Postdiscography axial computed tomography (CT) scan demonstrating right posterolateral subligamentous protrusion.

Herniation typically occurs secondary to posterolateral annular stress. Herniation rarely results from a single traumatic incident. Acute traumatic cervical HNP serves as a major etiology of central cord syndrome. The C6-C7 disc herniates more frequently than discs at other levels.

Acute disc herniation causes radicular pain through chemical radiculitis in which proteoglycans and phospholipases released from the nucleus pulposus mediate chemical inflammation and/or direct nerve root compression. Interleukin 6 and nitric oxide are also released from the disc and play a role in the inflammatory cascade. The chemical radiculitis is a key element in the pain caused by HNP as nerve root compression alone is not always painful unless the dorsal root ganglion is also involved. Herniation may induce nerve demyelination with resulting neurologic symptoms. Cervical HNP may be resorbed during the acute phase. Indeed, studies documenting frequent herniation resorption and correlating herniation regression with symptom resolution support conservative treatment of cervical radicular pain.

A rare trauma-induced high cervical (C2-C3) HNP syndrome manifests as nonspecific neck and shoulder pain, perioral hypesthesia, more radiculopathy than myelopathy, and more upper limb motor and sensory dysfunction than lower limb symptomology. Decreased middle and/or lower cervical spine mobility from spondylosis, with consequent overload at higher segments, may precipitate high cervical disc lesions in older patients. A retro-odontoid disc may result from an upwardly migrating C2-C3 HNP. Some case reports describe cervical HNPs causing Brown-Séquard syndrome, as well as atypical nonradicular symptoms in patients with congenital insensitivity to pain.

Cervical radiculopathy results from mechanical nerve root compression or intense inflammation (ie, chemical radiculitis). Specifically, nerve root compression may occur at the intervertebral foraminal entrance zone at the narrowest segment of the root sleeve anteriorly by disc protrusion and uncovertebral osteophytes and posteriorly by superior articulating process, ligamentum flavum, and periradicular fibrous tissue.⁴ Decreased disc height, as well as age-related foraminal width decrease from inferior Z-joint hypertrophy, may impinge subsequently on nerve roots. The cervical region accounts for 5-36% of all radiculopathies encountered. Incidence of cervical radiculopathies by nerve root level is as follows: C7 (70%), C6 (19-25%), C8 (4-10%), and C5 (2%).

The most common cause of cervical radiculopathy is foraminal encroachment (70-75%). The cause is multifactorial, including degeneration of the discs and the uncovertebral joints of Luschka and the zygapophyseal joints. In contrast to lumbar spine disorders, HNP in the cervical spine is responsible for only 20-25% of radiculopathies.

Cervical DDD most commonly is due to age-related changes, but the condition also is affected by lifestyle, genetics, smoking, nutrition, and physical activity. Degenerative disc changes observed on radiographs may reflect simple aging and do not necessarily indicate a symptomatic process.

The disc begins to degenerate in the second decade of life. Circumferential tears form in the posterolateral annulus after repetitive use. Several circumferential tears coalesce into radial tears, which progress into radial fissures. The disc then disrupts with tears passing throughout the disc. Loss of disc height occurs with subsequent peripheral annular bulging. Proteoglycans and water escape through fissures formed from nuclear degradation, resulting in further thinning of the disc space. Vertebral sclerosis and osteophytic formation ultimately follow.⁵

IDD describes pathologic annular fissuring within the disc without external disc deformation. This disorder results from trauma-related nuclear degradation, cervical flexion/rotation-induced annular injury, or whiplash. The innervated outer disc annulus serves as a major pain generator. DDD ultimately may progress to IDD.

Frequency

United States

HNP may be observed with magnetic resonance imaging (MRI) in 10% of asymptomatic individuals aged younger than 40 years and 5% of those older than 40 years. Degenerative disc disease (DDD) may be observed with MRI in 25% of asymptomatic individuals aged less than 40 years and 60% of those aged more than 40 years. The true incidence and prevalence of cervical radiculopathy is uncertain; however, 51% of adults experience neck and arm pain at some time. In a population-based study in Rochester, Minn, the annual incidence of documented cervical radiculopathy for men and women from all causes was 107.3 and 63.5 cases per 100,000 population, respectively.⁶

International

A study from Italy in 1996 reported a prevalence of cervical spondylotic radiculopathy as 3.5 cases per 1000 people.⁷

Mortality/Morbidity

Occasionally, an acute HNP can herniate centrally and cause a myelopathy. This can manifest as hyperreflexia, positive pathologic reflexes (such as Babinski and Hoffman signs), and sphincter disturbances. If left untreated, the effects can be irreversible.

Sex

Kelley suggests that the male-to-female incidence of cervical disc herniation is approximately 1:1.⁸ Marchiori and Henderson cite women as reporting higher disability with increasing levels of DDD than men.⁹

Age

HNP typically affects younger patients (ie, <40>40 y).

Clinical

History

• Pertinent history should include the following information:
  • Information about pain onset (eg, abrupt onset suggests acute injury)
  • Time since injury
  • Mechanism of injury
  • Percentage of axial versus peripheral pain (eg, 90% neck pain vs 10% upper limb)
  • Review of systems to uncover possible systemic illness (eg, fever suggests infection, weight loss suggests malignancy).
• Discogenic pain without nerve root involvement typically is vague, diffuse, and distributed axially.
  • Pain referred from disc to upper limb usually is nondermatomal.
  • Activities that increase intradiscal pressure (eg, lifting, Valsalva maneuver) intensify symptoms. Conversely, lying supine provides relief by decreasing intradiscal pressure.
• Vibrational stress from driving also exacerbates discogenic pain.
• Depending on whether primarily motor or sensory involvement is present, radicular pain is deep, dull, and achy or sharp, burning, and electric.
  • Such radicular pain follows a dermatomal or myotomal pattern into the upper limb.
  • Cervical radicular pain most commonly radiates to the interscapular region, although pain can be referred to the occiput, shoulder, or arm as well.
  • Neck pain does not necessarily accompany radiculopathy and frequently is absent.
  • Patients may present with distal limb numbness and proximal weakness in addition to pain. Atrophy may be present.
  • A study has demonstrated cervical HNP-induced thermal changes (ie, thermatomes) in specific upper extremity distributions.
  • Mechanical stimulation of cervical nerve roots has shown that the distribution of referred radicular symptoms (ie, dynatome) may be different from sensory deficits outlined by traditional dermatomal maps.

Physical

• The patient with radicular pain also displays decreased cervical range of motion (ROM).
  • Pain is exacerbated by neck extension and rotation or by Spurling maneuver (patient's neck is extended, laterally bent, and held down) designed to elicit radicular symptoms.
  • Pain improves with neck flexion or with abduction of the symptomatic upper limb over the top of the head (abduction sign).
  • Decreased sensation to pain, light touch, or vibration may be present in the distal upper limb. Proximal limb weakness manifests when significant motor root compromise exists, but this symptom must be differentiated from pain-related weakness.
  • Diminished or absent reflexes corresponding to the root level may be present.
  • Increased upper and lower limb reflexes or other upper motor neuron signs suggest myelopathy and mandate aggressive diagnostic evaluation.
• The patient with discogenic pain without nerve root involvement demonstrates decreased cervical ROM, normal neurologic examination, and possible pain exacerbation with axial compression and pain alleviation with distraction.
• Myofascial tender or trigger points, which may be primary in origin or secondary to other pathologic processes, commonly are palpable.
• Tenderness with posteroanterior mobilization may suggest disc pathology.

Causes

• HNP results from repetitive cervical stress or, rarely, from a single traumatic incident. Increased risk may accrue because of vibrational stress, heavy lifting, prolonged sedentary position, whiplash accidents, and frequent acceleration/deceleration.
• DDD is part of natural aging, but it is also a consequence of poor nutrition, smoking, atherosclerosis, job-related activities, and genetics.
• IDD can result from cervical trauma, including whiplash, cervical flexion/rotation injury, and repetitive use.
• Cervical radiculopathy results from nerve root compression secondary to herniated disc material, stenosis, or proteoglycan-mediated chemical inflammation released from discs. Smoking and certain occupational activities also predispose patients to cervical radiculopathy

I.V. Colchicine in treating diskal disorder

I have modified the protocol to give an IV Myers Cocktail drip to treat the muscle spasm (see below) and then the colchicine 1 MG is given as a push (it can be mixed with a few CC of saline but this is optional) through the IV port over ~ 2-3 minutes. This is done 1-2 X week for 6-8 doses. Relief usually begins by dose #5. The IV Colchicine must NOT infiltrate, and this is another benefit of giving the IV Myers cocktail, so you know the IV is running well. Check a CBC to be sure the WBC is over 3500, and a chemistry screen to be sure kidney function is OK before treating (not needed after). Take the Energy Revitalization System (Berry or Citrus) vitamin powder, stop smoking (if a smoker) ,and be sure your sleep is good to enhance the effectiveness (all this in combo is why our success rate is over 90%).

Best wishes and I think you'll be pleased with the effect.

The references:
1. Rask, M.R. “Colchicine use in 3000 patients with diskal and other spinal disorders.” Journal of Neurological and Orthopedic Surgery, Vol 6, Issue 3,1985. p1 – 8.
2. Meek, J.B., et al. “Colchicine confirmed effective in disk disorders. Final results of a double blind study.” Journal of Neurologic and Orthopedic Medicine and Surgery, Vol6, Issue 3,1985. p 211 – 218.

Myers Cocktail

For further information about sources of the products and services mentioned in this section, see Appendix J: Resources.

1. The following are instructions for making up and administering the slow IV Myers Push (MP).

	Supplies Needed		Amount
1	Bacteriostatic water		7cc
2	Ascorbic acid (500mg/ml), preservative-free (I give 20–40 cc Vitamin C over 30–40 minutes)		1-10cc
3	Magnesium sulfate (MgSO4), 50 percent (0.5g/ml)		2-4cc
4	Pyridoxine (100mg/ml), preservative-free		1cc
5	Hydroxycobalamin (3,000mcg/ml)		1cc IM
6	B-Complex 100		0.5–1 cc
7	Dexpanthenol (250mg/ml)		0.5 cc
8	Glutathione, 200 mg per cc (optional) (Push in separately — do not mix in the same syringe with other nutrients)		2–5 cc
9	20-cc or 25-cc syringes
10	18 gauge, 1 to 1½-inch needles
11	25 gauge, ¾-inch butterfly sets
12	Calcium gluconate, 10 percent, preservative-free (optional)		4–10 cc

Items 1 through 3 and 6 through 12 can be ordered (among other sources) from Harvard Drug Company. (800-783-7103). Item 4 can be obtained from compounding pharmacies, including Pathways and Wellness and Health Pharmaceuticals. Item 5 can be purchased from G.Y. and N. Most of the above items are also available from McGuff or Cape Apothecary.

To make the Myers Push (MP), draw up each ingredient using a separate syringe/needle and squirt it into the mouth of a 20-cc to 25-cc syringe. Attach the 25-gauge butterfly to the large syringe, pushing fluid through the butterfly tubing until the entire tubing and needle are filled. Now the mixture is ready for venipuncture and a slow IV push. The glutathione should be kept in the initial syringe (not mixed with other nutrients) and pushed in over one to ten minutes (1 cc every one to two minutes).

The dose of MgSO4 typically begins at 2 cc. If the patient feels comfortable, without dizziness, nausea, or hypotension (warmth in the neck, face, chest, abdomen, groin, and/or extremities is normal, and is a sign of physiological action of the magnesium as a vasodilator), I usually increase the MgSO4 to 4cc and give it over ten to forty minutes. Alternately, all these nutrients can be added in an IV bag and allowed to drip in over thirty to sixty minutes.

The desired result is to inject at a rate at which the patient feels comfortable warmth without excessive flushing or feeling ill—that is, dizziness, nausea, and headache, symptoms that are rare.

Prior to the injection, it is important for the patient to be instructed to give frequent feedback about any developing warm feeling early on, so that the injection may be slowed down, or even temporarily stopped, before excessive, uncomfortable flushing occurs. Likewise, feedback by the patient needs to be given when the warm feeling has mostly subsided so that the injection may be resumed at a reduced rate. Eventually, the infusion will find the “happy medium” rate of injection, which maintains the “comfortable warmth” (see above).

Also, prior to the first few MP injections, explain that a taste of B vitamins usually appears during the infusion, often early in the push.

The physician needs to consider one major option, which has become routine in many quarters—the possible addition of calcium gluconate, 10 percent injectable. Some of the major reasons for deciding to include calcium are:

• If the patient feels consistently unwell for any reason after the MP (weakness, fatigue, sleepiness, palpitations—all rare and mild, if present).
• If the patient has a history, or laboratory evidence, of calcium deficit.
• If the physician’s clinical judgement dictates it for any reason.

The dose of calcium gluconate 10 percent injectable varies from 4 cc to 10 cc, depending on the clinician’s judgement. T he key is to maintain balance without diluting the magnesium’s positive effects.

A final caveat is that one needs to keep in mind the third of the troika—potassium. Over a period of time, IV magnesium may deplete potassium; the danger is that one may be tempted to increase the dose of magnesium, only to aggravate the low potassium picture. Always keep in mind that a potassium deficit may prevent magnesium repletion and vice-versa.

It is also, of course, possible to create calcium deficit by the MP. However, potassium depletion, in my experience, is clinically more frequent and more symptom-provoking, and at times alarming. (If needed, give the potassium by mouth—not I.V. push potassium is fatal. I use Micro K Extendtabs, 10 MEQ, one to two times a day if potassium levels are under 4.0.)

ocean*s 11

Dapper Danny Ocean (GEORGE CLOONEY) is a man of action. Less than 24 hours into his parole from a New Jersey penitentiary, the wry, charismatic thief is already rolling out his next plan. Following three rules — don't hurt anybody, don't steal from anyone who doesn't deserve it, and play the game like you've got nothing to lose — Danny orchestrates the most sophisticated, elaborate casino heist in history.

In one night, Danny's handpicked 11-man crew of specialists — including an ace card sharp (BRAD PITT), a master pickpocket (MATT DAMON) and a demolition genius (DON CHEADLE) — will attempt to steal over $150 million from three Las Vegas casinos owned by Terry Benedict (ANDY GARCIA), the elegant, ruthless entrepreneur who just happens to be dating Danny's ex-wife Tess (JULIA ROBERTS).

Coincidence or motive? Only Danny knows for sure. To score the cash, he'll have to risk his life and his chance of reconciling with Tess. But if it all goes according to Danny's intricate, nearly impossible plan, he won't have to choose between his stake in the heist and his high-stakes reunion with Tess…or will he?

Warner Bros. Pictures presents, in association with Village Roadshow Pictures and NPV Entertainment, a Jerry Weintraub/Section Eight production, Ocean's Eleven, starring (in alphabetical order) GEORGE CLOONEY, MATT DAMON, ANDY GARCIA, BRAD PITT and JULIA ROBERTS.

The film also stars CASEY AFFLECK, SCOTT CAAN, DON CHEADLE, ELLIOT GOULD, BERNIE MAC, and CARL REINER.

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avril lavigne songs

"Nobody's Home"

I couldn't tell you why she felt that way,
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She wants to go home, but nobody's home.
It's where she lies, broken inside.
With no place to go, no place to go to dry her eyes.
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Open your eyes and look outside, find the reasons why.
You've been rejected, and now you can't find what you left behind.
Be strong, be strong now.
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Don't know where she belongs, where she belongs.
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It's where she lies, broken inside.
With no place to go, no place to go to dry her eyes.
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Her feelings she hides.
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She's lost inside, lost inside...oh oh yeah
She's lost inside, lost inside...oh oh yeah

The best 10 film ever

Titanic

Lucky number slevin

Catch me if you can

A beautiful mind

The six sense

American beauty

The shawshank Redemption

The departed

Saw (all series)

American pie (all series)