Medical Articles by Dr. Ray

Aug

2003

Modify Risk Factors For Erectile Dysfunction (ED) In Elderly Men

By Ray Schilling | Diabetes, Health, Men's Health, Stroke

Erectile dysfunction (ED, impotence) is a subject that is difficult to research because of its personal nature. Very few good studies are available regarding the question as to how common it would be among older men.

A team of medical experts under Dr. Constance G. Bacon from the Harvard School of Public Health and other institutions have investigated this problem in men older than 50 years and published the results in the August 5, 2003 issue of the Annals of Internal Medicine.

31,724 men aged 53 to 90 years were taking part in the Health Professionals Follow-up Study. Since 1986 they had been filling out detailed questionaires biennially. In 2000 detailed questions about sexual function were also included. Erectile dysfunction was defined as “having poor or very poor ability to have and maintain an erection sufficient for intercourse without treatment during the past 3 months”. The investigators found that about 1/3 of the men above the age of 50 had a sexual dysfunction. Such factors as orgasm, ability to have intercourse, sexual desire and overall sexual function were all affected more and more with every year after the age of 50. When this was further analyzed using multivariate analyses an interesting pattern of reasons for this emerged. The following factors were identified to be independent risk factors for the development of erectile dysfunction.

Modify Risk Factors For Erectile Dysfunction (ED) In Elderly Men

Each of the factors from this table is an independent risk factor and can be managed separately. For instance, the investigators found that a higher level of physical activity was associated with much less ED. The best group (men with no ED) was found among those who were always conscious about disease prevention and who had none of the conditions listed in this table or other chronic medical conditions. Leanness and physical activity were associated with good sexual functioning in this study.

Risk factors leading to erectile dysfunction (ED)
Symptoms:	Comments:
increasing age	aging likely affects the blood supply to the swelling bodies of the penis; it also clamps down on testosterone production of the testicles
smoking	accelerates aging and hardening of arteries
diabetes mellitus	affects circulation and nerve impulse transmission
stroke	interferes with brain centers of arousal
antidepressant medication	anticholinergic side-effect interferes with penile erection
beta-blocker medication	reduction of libido (likely at the brain level from sympathetic nerve block)
alcohol consumption	alcohol is a nerve poison that interferes with pudendus nerve function (lack of erections)
TV viewing time	due to prolonged sitting there is a chronic lack of exercise that leads to nerve conduction and circulatory problems resulting in ED

This summary is based on a paper published in the medical journal of Annals of Internal Medicine 2003;139:161-168 by Dr. Constance G. Bacon and co-workers.

Here is a brief chapter on erectile dysfunction from Dr. Schilling’s web-based free Net Health Book.

Last edited October 26, 2014

Aug

2003

HRT; Findings From The British Million Women Study

By Ray Schilling | Cancer, Hormones, Women’s Diseases

In the latest issue of the Lancet (Lancet 2003;362:414-415,419-427) a study from Great Britain was published regarding the risk of breast cancer. Over 1 million women were followed from 1996 to 2001. They were in the age group of 50 to 64. Of these 80% were postmenopausal, and these formed the basis of the study. Dr. Valerie Beral (from the Cancer Research group UK in Oxford) was the lead investigator. About half of the women were on various forms of hormone replacement therapy (HRT), the others were not and served as a control. Risks were always expressed in comparison to the controls without any hormone replacements. Here is a tabular summary of the various hormone replacement therapies and their risks of leading to breast cancer.

The relative risk of developing breast cancer did not significantly change whether HRT was taken orally, transdermally or through implanted formulations. Tibolone is a synthetic steroid used for postmenopausal symptoms and treatment of endometriosis.

Dr. Beral’s group has estimated that in Great Britain in the past 10 years about 20,000 additional cases of breast cancer were caused by HRT for menopause among women aged 50 to 64. Out of these about 75% were due to the use of the combination of estrogen/progestin.

HRT; Findings From The British Million Women Study

An accompanying editorial by Dr. Chris van Weel stated that “general practitioners should discourage HRT for their patients” and, if used, should last “no longer than 3-6 months”. The investigators of this study suggested that “discontinuing HRT should be suggested in as supportive a way as possible, because no one will benefit from panic or over-reaction”.

Findings from the British Million Women Study on HRT
Detail of hormone replacement:	Breast cancer risk compared to control:
overall risk of HRT for all groups of HRT	1.66-fold
women who stopped HRT the previous year	1.14-fold
estrogen only use currently	1.30-fold
estrogen-progestagen combination	1.88-fold
tibolone users	1.45-fold
combination HRT user less than 5 years	1.7-fold
combination HRT user more than 5 years	2.21-fold
equine estrogen combined with medroxyprogesterone acetate and taken at least 5 years	2.42-fold
death rates from breast cancer associated with current use of HRT	1.22-fold

Discussion: Please keep in mind that the British authors of this study were using the drug manufactured synthetic hormone-like substances and NOT bio-identical hormones. The outcome with bio-identical hormones would have shown the opposite, namely that women would not have developed heart attacks, strokes or cancer and they would not have died prematurely. Read more about bio-identical hormone replacement in the links below.

Here is a link to a chapter on menopause from Dr. Schilling’s Net Health Book.

This link deals with bioidentical hormone replacement (see lower half of that page).

Last edited October 26, 2014

Aug

2003

Reduction Of Complications After A Stroke

By Ray Schilling | Prevention, Stroke

Following an acute stroke, it used to be taught in medical school that lowering the blood pressure would be something to avoid for fear that this would lower circulation to the brain and could make a stroke worse. A new study, called ACCESS (Acute Candesartan Cilexitil Therapy in Stroke Survivors), is proving this teaching wrong and demands a 180° turnaround.

Dr. Joachim Schrader has pablished this landmark study recently in the Medical Journal “Stroke” (Stroke – 01-JUL-2003; 34(7): 1699-703). This study followed 339 stroke patients after an initial angiotensin type 1 receptor blocker was given right away versus a control group who got it only 1 week later. In other words, the test here was to see what would happen, if treatment would be started right away during the acute phase of the stroke. Up to now this was only done in the stable period after 1 or 2 weeks (the conventional approach). The 1 year follow-up data showed that the overal death rate from all causes (summing up all complications) was 47.5% less in the treatment group than in the control group. In other words by using intervention with this newer type of blood pressure lowering medication, such as the angiotensin type 1 receptor blocker candesartan (Atacand), complications such as extension of the stroke or heart problems and other complications were averted. The end result were fewer deaths and better quality of life in those who survived.

The Medical Post in its July 29, 2003 edition (p. 1 and 54) interviewed Dr.Ashfak Shuaib, professor of neurology of the University of Alberta in Edmonton, regarding the significance of this study. He felt that there likely would be a new hormonal effect on the brain from the lining of the arteries in the brain that gets blocked and that leads to an increase of blood supply to the brain.

Reduction Of Complications After A Stroke

This in turn would rescue the brain tissue around the stroke preventing the late complications. He said that this line of research would be very solid data, but that it would have to be confirmed by an independent study from other investigators. Dr. Shuaib’s group of researchers are planning an imaging study where they will study the blood flow following strokes under the same conditions using candesartan (Atacand).

Link to a chapter on stroke of the Net Health Book.

Last edited October 26, 2014

Aug

2003

Parkinsons Disease From Too Much Meat And Too Little Vitamin B2

By Ray Schilling | Nutrition, Parkinson’s disease, Prevention, Vitamins and supplements

Parkinsons disease (correct medical spelling is ” Parkinson’s disease”) is a degenerative disease of the brain stem that presents with symptoms of shaking, tremor and gait problems.

It is a neurological disease of the elderly and often is a cause of disability leading to institutionilisation. New research at the University of Sao Paulo (UNIFESP) in Brazil has found that a diet rich in vitamin B2 and low in meat has helped to improve patients with Parkinsons disease.

It appears that it may not only be useful in alleviating symptoms of existing disease, but even more importantly to prevent this neurological disorder from developinlg. Dr. Cicero Galli Coimbra stated that in Buenos Aires (where the study was done) the consumption of meat is one of the highest in the world as is the rate of Parkinsons disease. Under his guidance a research team found that about 15% of the population do not absorb vitamin B2 adequately. In combination with excessive red meat intake a significant proportion of the population does not absorb enough of this vitamin resulting in Parkinsons disease.

In this study a group of patients with advanced Parkinsons disease were put on a special diet that included milk (which is a good source of vitamin B2). Other sources of vitman B2 as shown here were cereal, nuts, milk, eggs, green leafy vegetables and lean meat. Within one month 18% of their motor function had returned to normal. After the third month of this diet 60% of the motor function had returned.

Parkinsons Disease From Too Much Meat And Too Little Vitamin B2

Many had improved so much that they were able to drive a car safely again. Riboflavin (=vitamin B2) is an important ingredient in a number of metabolic processes in brain cells that result in the production of dopamine, a brain hormone that is required for regulating muscle coordination in various parts of the brain. This translates into a stable gait, normal muscle strength, good balance and normal cognitive functioning.

These findings were reported in the July 15, 2003 issue of The Medical Post, page 31.

Link to Dr. Schilling’s Net Health Book regarding Parkinsons disease.

Last edited December 9, 2012

Jul

2003

New In Vitro Fertilization (IVF) Gold Standard Declared

By Ray Schilling | Women’s Diseases

At a recent conference in Montreal/Canada about “Measuring Human Embryo Quality” several IVF research groups exchanged the latest on single embryo transfer, which has become the standard for in vitro fertilization. These techniques are important for treating infertile couples.

In the past an in vitro fertilized egg was implanted into the woman’s uterus, but the success rate of a normal pregnancy was extremely low (in the order of 15% to 20%).

Subsequently more than one fertilized egg was implanted to improve the success rate, but this led to twins, triplets and multiple pregnancies with a high complication rate and death due to premature deliveries. Subsequently it was found that the success rate was much higher after a few cell divisions, which were allowed to take place outside the uterus in vitro cultures. Dr. William Schoolcraft (director of the Colorado Centre for Reproductive Medicine at a private clinic in Englewood, Col.) reported that embryos that were cultured for 5 days until the blastocyst stage in vitro are much more stable for implantation.

New In Vitro Fertilization (IVF) Gold Standard Declared

For the past 5 to 6 years they and other groups have only employed this technique, which according to him is now the gold standard. Although they were largely still using two embryos for transfer into the uterus for IVF. It has become increasingly clear that the risk of twin pregnancies in these already high risk situations is ranging from 4- to 10-times the risk of a single embryo transferred (singleton) into the uterus. Because of this his group has decided to only do singleton transfers. The other new finding is that it matters tremendously what culture medium is used for incubating the fertilized egg for the 5 day period in culture and what the exact conditions are. They found that for optimal results they have to use two different growth media, the first 3 days a low glucose or glucose free medium that mimics the environment of the fallopian tube. On day 4 and 5 the medium must mimic the environment inside the uterus, which requires it to be rich in amino acids and contain glucose.

An embryologist, Dr. Barry Behr from the Stanford University Medical Centre in California, reported that the same culture medium is not necessarily suitable for all patients, but individualization and close observation of the wellbeing of the embryo and the mother is necessary. To optimize maximum quality of the embryos growth factors may also have to be introduced into the culture medium and further research is going on in this direction.

This report is based on a summary in The Medical Post , June 24, 2003, page 8.

Here is a useful link regarding the topic of infertility: http://www.nethealthbook.com/articles/infertility.php

Last edited December 9, 2012

Jul

2003

Beware Of Binges

By Ray Schilling | Gastrointestinal Disease, Health, Men's Health, Women’s Diseases

In the June 16, 2003 issue of Time (page 73) an article appeared under the heading “Summertime booze”. A study from the Buffalo University showed that women, in particular, have to be conscious that drinking 3 or 4 drinks at one time on the weekend is not the same as drinking the same 3 to 4 drinks over the course of one week.

A study looking at the frequency of breast cancer in relation to drinking patterns found that the binge drinking women had a 80% higher breast cancer risk than the controls who drank 3 to 4 drinks at a time (but only one drink per day). Jo Freudenheim, the epidemiologist involved in this study, suggested that perhaps with the binge drinking alcohol’s toxic potential for breast cancer cells had been reached whereas with one drink at a time over one week this level was never encountered.

In another study from the Buffalo University liver toxicity as a result of alcohol exposure was examined. These researchers used blood tests to measure liver enzymes, which were leaking from the liver cells as a result of the toxic effect of alcohol. Both men and women were tested and various drinking patterns were also studied. Men who drink several drinks daily had the highest liver enzyme counts (reflecting the toxic effect of alcohol on the liver). However, women who drink only on weekends had even higher counts of the liver enzymes than men! Women who drank on an empty stomach had much higher liver enzymes in these studies than men where this effect did not show (with men it did not matter whether they drank with food or on an empty stomach).

Beware Of Binges

The researchers concluded that binge drinking appears to affect women more than men. Generally speaking the higher the amount of alcohol consumed, the more toxic the effects on body cells and on the liver. Moderation may be in order.

Comments: These type of studies are particularly important in view of the fact of marketing techniques of the wine industry. Wine and alcoholic beverages are being portrayed as being a good source of bioflavonoids that are lowering cholesterol and would prevent or postpone heart attacks. Some of the data on cancer indicates that for ovarian cancer and colorectal cancer there may not be a safe low dose as even one drink per day can have a measurable effect on cancer risk. On the other hand, bioflavonoids are abundantly present in raw vegetables and fruit, so there is no panic about not getting enough heart attack preventing foods. Finally, a bit of common sense does not harm: alcohol is a cell toxin, so it should be diluted (nothing stronger than wine) and if you desire a drink, use it in moderation.

Link to chapter on alcoholism in Net Health Book:

http://nethealthbook.com/drug-addiction/alcoholism/

Last edited October 26, 2014

Jul

2003

Obesity And Metabolic Syndrome

By Ray Schilling | Diabetes, Health, Heart Disease, High Blood Pressure, Hormones, Obesity

In the June 10, 2003 edition, following page24, of The Medical Post there was a minisymposium on obesity and the metabolic syndrome (also known as the “syndrome of hyperinsulinism”).

Four specialists had a discussion about this topic: Dr. Ehud Ur (endocrinologist, Dalhousie University, Halifax, N.S., Canada), Dr. Robert Dent (Director of the Weight Management Clinic, Ottawa Hospital, Ont.), Dr. Dominique Garrel (Director of Department of Nutrition and endocrinologist, University of Montreal, Quebec), and Dr. Arya Sharma (Prof. of Medicine, McMaster University, Hamilton, Ont.).

Introduction:

Obesity is now a health threat that about 25% of the North American population is suffering from. There is still a lot of discussion what the exact criteria should be, but the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) has simplified the detection of the metabolic syndrome.

Obesity And Metabolic Syndrome

The experts agree that when three or more of the criteria mentioned in this table are positive the person would be considered to have metabolic syndrome.

There is a wide age-related variety: in one study only 7% had metabolic syndrome in the age group of 20 to 29. The same study found 40% of study participants had the metabolic syndrome in the age group of 70 years and older. It is thought that too many calories coupled with too little activity over a longer period of time, perhaps coupled in some people with a genetic tendency to develop metabolic syndrome, leads to an accumulation of abdominal (so-called”visceral”) fat.

Because fat cells have their own hormone systems (leptins etc.) there is a change of metabolism including an elevation of the insulin level with associated loss of “insulin sensitivity”. So, the more obese a person becomes, the less effective insulin becomes in transporting blood sugar through cell walls. At the same time the liver metabolism is changing with the good cholesterol (HDL) being less produced and the bad cholesterol (LDL) being overproduced. The liver will produce a different mix of coagulation factors, which leads to a tendency to form clots in the veins of the legs and in the lungs. As the pancreatic capacity for insulin production gets exhausted over a period of time, the patient eventually develops type 2 diabetes mellitus. Due to the risk of the coronary arteries clogging up with the cholesterol changes and the accelerated hardening of arteries from diabetes, the risk for getting severe heart attacks in obese people with the metabolic syndrome when compared to a normal weight population is about 4-fold.

Elements leading to the diagnosis of “metabolic syndrome”
Finding:	Comments:
abdominal obesity	waist circumference more than 102 cm in men or more than 88 cm in women
elevated triglyceride level	level of 150 mg/dl or higher
low HDL cholesterol level	under 40 mg/dl in men or under 50 mg/dl in women
elevated blood pressure	systolic or diastolic blood pressure exceeding 130/85 mm Hg
high fasting blood glucose level	fasting glucose higher than 110 mg/dl

Treatment of metabolic syndrome:

The experts agreed that a reduction of only 5% to 10% of the body weight through a sensible combination of a mild exercise program (e.g. walking 30 to 45 minutes every day) and a calorie reduced food intake will make a significant difference in terms of normalization of the body chemistry. It is my estimate that perhaps 70% to 90% of all cases of obesity and metabolic syndrome can be treated this way.

However, the remaining cases should continue to see their physician and be followed like the doctor would follow someone who has high blood pressure. There are two types of medications available and they have nothing to do with the Phen-Fen diet pills from not too long ago that were found to cause pulmonary hypertension. These new diet pills are fairly safe and show weight loss results provided the patient co-operates with regard to a modified to low fat diet and some degree of regular exercise.

1. Sibutramine (brand name: Meridia) is a specific brain hormone inhibitor in the area where the appetite zone is located (serotonine and norepinephrine reuptake inhibitor). This medication helps the patient by experiencing satiety sooner so that the patient does not feel deprived despite less calorie consumption.

It is the medication of choice for those who tend to eat a lot. Like with other anti-depressants side-effects are a dry mouth, heart rate increases and sleep loss (insomnia).

2. Orlistat (brand name: Xenical) inhibits fat uptake at the level of the gastrointestinal wall (gastrointestinal lipase inhibitor). This leads to an inhibition of fat absorption by about 30%. The patient needs to keep the fat intake down to about 2 oz. (=60 gm) per day. If the patient consumes more fat, the side-effect of orlistat will be flatulence, abdominal cramps and diarrhea. If the patient is on a strict low fat diet, there would not be enough fat in the gut for the medication to be effective.

At this point it is not known how long the patient should be on such weight loss medication, if this was the chosen route. The experts felt that 1 year would be reasonable, but that the patient should be observed by the treating physician and it may be necessary after some intermission to go for another year of therapy all the way attempting to permanently change eating and exercise habits as an ongoing maintenance program.

Here is a link to another reference about the metabolic syndrome (syndrome of insulin resistance).

Last edited December 9, 2012

Jul

2003

Food And Mood

By Ray Schilling | Health, Mental Health, Nutrition

“Food affects your mood” is the heading of an article by Dr.Susan Biali (practising family physician with a degree in dietetics) in the June 24, 2003 edition of The Medical Post (page 24). According to her there is good evidence in the medical literature to indicate that a number of biologically active brain hormones depend on what we eat. There are 5 major items that she pointed out, which I summarized below in tabular form.

The medical literature points to the importance of these various food factors to allow us to have a balanced brain metabolism. When these ingredients are present our mood is more likely to be normal with more resilience to depression.

The literature centers around various population groups in comparison with the North American population. For instance, in an article of the Dec. 2000 issue of Psychiatric Clinics of North America a study was reported that found that Taiwanese and Chinese people consume a lot more omega-3 fatty acid rich foods such as fish than North Americans.

In the same study the rate of major depression was found to be 10-times more frequent in North Americans and the investigators felt that this was so because of the brain hormone stabilizing effect of the omega-3 fatty acids. Other researchers suggest that chronic stress might lead to a depletion of omega-3 fatty acids in the brain through an oxydation process, which eventually results in depression.

Food And Mood

Several nutritional factors appear to have caused deficiency states of essential brain nutrients, one being the junk foods like candy bars, French fries, hamburgers etc. leading to a dysbalance of the omega-6 fatty acid to omega-3 fatty acid ratio. Another factor is the increase of consumption of highly refined carbohydrates (sugar and starch), often also called high glycemic foods. This is known to lead to the metabolic syndrome, also called syndrome of insulin resistance. Finally many people still have too much fat in their diets with a high amount of hydrogenated vegetable oils (see link). It is also important to note that folate, Vit. B6 and Vit.B12 are required for prevention of hardening of the arteries by lowering homocysteine levels.

Brain food components that affect your mood
Food item:	Comments:
omega-3-fatty acids	Chinese and Taiwanese eat much more of these and have 10 times less depression than North Americans
DHA, a long-chain omega-3-fatty acid	our daily intake is 100mg less per day than 50 years ago due to our diet being based on commercial livestock; lack of DHA leads to depression
too much omega-6-arachidonic acid in “junk foods”	ratio of omega-6 to omega-3 arachidonic acid has increased from fast food consumption; this leads to depression
folate and Vit.B12	deficiency associated with depression
tryptophan	an essential amino acid that is needed to make serotonin, a brain hormone without which we experience depression

So what is “brain food” ? Dr. Biali pointed out in her article that it is always best to start with a low fat, well balanced food plan where junk foods are avoided and where vegetables and fruit provide the low to medium glycemic index carbohydrates. Fish should be eaten at least three times per week to provide the brain with the essential omega-3 fatty acids.

It is probably not recommendable to take tryptophan as a supplement: in 1989 several fatalities occurred from impurities in commercial tryptophan and many researchers are concerned about dysbalancing the network of brain hormones by giving an overdose of only one amino acid, but not giving enough of the others. It is much safer to simply eat enough protein (meat, soy protein, milk products) and the body can pick and choose what it needs in terms of amino acids including tryptophan. With folates one needs to be careful not to exceed 0.8 mg per day as with mega-doses of folate in the 15 mg range toxic symptoms of vivid dreams, disturbed sleep patterns and even occasional seizures developped. A good multivitamin supplement will not only provide the right folate dose, but also Vit. B12, which is also needed to prevent depression.

Last edited December 9, 2012

Jul

2003

High Blood Pressure On The Increase In The US

By Ray Schilling | Heart Disease, High Blood Pressure, Prevention, Stroke

High blood pressure on the rise

Dr. Hajjar, of the University of South Carolina in Columbia and Dr. Kotchen, of the Medical College of Wisconsin in Milwaukee have compared a large group of people in the US in the years 1999-2000 with prior studies in 1988-1991and 1991-1994 where peoples’ blood pressures were measured.

The latest study involved more than 5000 people, the prior studies more than 9000 people each. Almost 29% of the population has a blood pressure of 140/90 or higher in the latest study.

Compared to the 1988-1991study this is a significant increase of 3.7%. More than half of this was explained on the basis that the population’s weight (measured by body mass index calculation) had increased. The sub groups who had the largest increase in blood pressure were as follows:

1. diabetics with high blood pressure. In this high risk group only about 25% had a blood pressure readings of less than 130/85, which is the target value.

2. Mexican Americans had a significantly poorer awareness and control of their elevated blood pressures than the non-Hispanic whites and non-Hispanic blacks.

3. Women as a group were poorer in blood pressure controlling than men.

4. People above the age of 60 had a much higher rate of uncontrolled blood pressure as well.

The study concluded that by concentrating campaigns and efforts on these four target groups significant gains could be made in terms of control of blood pressure, reduction of strokes, heart attacks and kidney damage.

Here are some links regarding high blood pressure, prevention of strokes and heart attacks to various chapters of my nethealthbook.com:

High blood pressure link

Heart attack link

Stroke link

Last edited October 26, 2014

Jun

2003

Genetic Link Found For Bipolar Disorder

By Ray Schilling | Diabetes, Mental Health, Prevention, Women’s Diseases

A staff psychiatrist at the Dalhousie Medical School in Halifax (Novia Scotia, Canada) has gathered 1100 DNA samples and psychiatric histories from patients with bipolar disorder and family members who do not have this psychiatric disease. Dr. Martin Alda, The Medical Post reports on page 46 of the May 20, 2003 edition, and his medical team were able to identify 4 areas of interest on chromosomes 15, 7, 6 and 21 where molecular markers for bipolar disease were located.

Two additional tools, namely responders to lithium (common bipolar disease stabilizer) and certain ethnic group differences, are being utilized as well. Dr. Alda has already found that unstable genes can be stabilized in the presence of lithium. By studying the genes involved in the expression of bipolar disorder and defining what triggers a depressive response and what triggers a manic episode, the researchers hope to unravel the mysteries that still surround this intriguing disease. Dr. Alda is also studying the connection of diabetes and biploar disease. Patients with biploar disease are 3 times more prone to diabetes than the general population. As these patients (bipolar patients with diabetes) are poor responders to lithium, there is a suggestion that perhaps the newly defined genetic loci are blocked in some way by the hormone changes in diabetics. Further investigations in this direction are planned by the research group.

Genetic Link Found For Bipolar Disorder

Link to bipolar disorder: http://nethealthbook.com/mental-illness-mental-disorders/mood-disorders/bipolar-disorder/

Link to diabetes:

http://www.nethealthbook.com/articles/hormonalproblems_diabetesmellitus.php

Last edited October 26, 2014

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