Vol. 129 July 15, 2015 Update on FDA & Sunscreens and Bath Salts

July 15, 2015



“Herbal incense” may sound organic,
but it sure ain’t good for you.


Sunscreens (1)
Previous blogs have noted that the FDA has limited authority over and regulations for sunscreens, but it does have some. Despite “the common wisdom” that the FDA is slow to approve new prescription drugs, its approval process is generally faster than Europe’s and in 2014 the FDA approved the highest number of new drugs in 18 years – 41 products. (1)

Over-the-counter (OTC) products like sunscreens are regulated by a different process using the standard:  “ generally recognized as safe and effective”. But, in 2014 the FDA declined to permit use of 8 new ingredients in sunscreens even though they have been in use in Europe for 5 years. It cited lack of safety studies, gaps in data, and reports of adverse events. This action prompted an understandable, if   a bit of an over-the-top reaction, from the Wall Street Journal calling to “strip the sunscreen police of all powers over the stuff.”

It is obvious that the FDA has mixed, and unfunded, responsibilities for review of OTC products. A new law, the Sunscreen Innovation Act of 2014 (only in America could we come up with a name like that), tried to clarify the situation, but no new resources were allocated to implement it. In the meantime both the FDA and the CDC continue their efforts to discourage use of tanning beds and promote prevention measures against melanoma which claim 10,000 deaths a year in the U.S.

Synthetic Cannabinoids (SC) (2)

Synthetic cannabinoids (SC) arrived in the U.S. from Europe in 2008 as herbal incense, spice, and bath salts “not for human consumption”. Since 2011 the DEA has placed over 40 SCs into Schedule I of controlled substances which means they are obtainable only by prescription. The problem is that manufacturers of these SCs merely change one or more chemical bonding group or a single chemical chain and the new compound falls outside such a regulation. The compounds are easily obtained on the internet for use in e-cigarettes or are added to energy drinks. They are still labeled “not for human consumption”, and may even carry the assurance that the product “contains no regulated compounds”.

Widespread distribution and marketing have led to recent clusters of serious illness and even deaths, particularly among the young and inexperienced users. Many users reported that they used SCs in order to get high without risking a positive drug test. SCs are NOT detected by the usual urine or blood lab tests, have no available antidote, and can produce serious symptoms which are not readily identifiable as symptoms specific to SC toxicity. Some users have died before reaching an emergency department.

The number of adverse events is increasing. During a two month period in early 2015 Mississippi reported 1200 SC-related visits to the ER and 17 deaths. One reason for this uptick may be the distribution of novel SC compounds that are easily and rapidly synthesized and marketed in response to regulatory actions. They can have new, unknown effects resulting in idiosyncratic toxicity such as delirium, seizures, psychosis, kidney failure, hallucinations, coma, and death.

Ninety-one per cent of users interviewed in one study inhaled vaporized SCs from refillable e-cigarette cartridges. E-cigarettes seem to be garnering more very bad “unintended consequences” than originally predicted by its advocates.

1. NEJM July 9, 2015, pg. 101; A Spotlight on Sunscreen Regulation; J.A. Sharfstein, MD, Johns Hopkins School of Public Health
2. NEJM July 9, 2015, pg. 103, Synthetic Cannabinoids – Related Illnesses and Deaths, DEA, CDC, and University of California

Vol. 64 April 1, 2012 Breaking Medical News

April 1, 2012


The Food and Drug Administration announced yesterday approval of the new drug, Viagrator, a combination of Viagra and Lipitor. Pfizer has been seeking lost revenues since Lipitor’s patent expired,and the demographics of the users of Viagra and Lipitor are almost identical. Combining the two into one capsule is a slam dunk. Viagrator will still carry a warning about the need to call a doctor if effects last for more than 4 hours, but new information that a double-cheese omelet can reverse it will be added.

Pfizer is searching for an appropriate celebrity to serve as a symbol of both sexual prowess and high cholesterol to promote its new product. Industry sources report that Newt Gingrich is the leading candidate, but doubt that a contract can be signed before November.


In Medicare’s quest to become more like Visa with single swipe payments, timely and understandable statements, and better fraud protection Medicare has announced its own frequent flyer reward points program. Each Medicare dollar spent on medical care will earn points for the patient that can be redeemed for other medical services. The rewards menu is quite complicated. For example, 4 MRI’s earn you enough points for a colonoscopy. Points from 6 EKGs can be redeemed for a week’s supply of Inderal or nitroglycerine. The medical device rewards catalog includes a CPAP machine after 8 visits to a pulmonologist. a walker after 2 visits to an orthopedist or 4 visits to a neurologist, and a high-seat toilet after the second hip or knee replacement.

The AMA has come out strongly against the use of Medicare reward points for travel to other countries for surgery, and the American Society of Plastic Surgeons has refused to participate in the rewards program at all. They are still mostly “cash up-front”. Efforts by the Obama administration to use the program as a Medicare cost-cutter by deducting points for inappropriate care (for example, after 4 visits to an ER in 6 months you would LOSE 200 points) have been rejected by Congress so far.


A new twist to the current controversy about paying for abortion and birth control pills was recently put into the other side of the intercourse equation. An enterprising group of urologists is offering a free pizza if you get a vasectomy in March. The free pizza is touted to help you recover post-operatively as you watch March Madness on the tube. I wonder what you could get for a tubal ligation? … an Easter dinner for 6?


Some Blue Cross/Blue Shield policyholders recently received a notice that in 2012 the healthcare insurer will reimburse up to $150 for fees in health fitness clubs or structured weight loss programs for its subscribers. The response was so positive that BC/BS’s initial caution quickly turned to such enthusiasm that BC/BS plans to make fitness club membership MANDATORY for its subscribers on July 1,2012.

Acturarial analysis suggested that members needing walking assistance devices, specially modified automobiles, or wheelchairs be excluded from this requirement. This suggestion was ignored when AARP pointed out that many “thousands and thousands of AARP members” used canes. Legal counsel expressed concern in today’s environment about potential law suits against this “individual mandate”. BC/BS officials dismissed the concern with “Hey, it’s not like we’re mandating that everyone eat broccoli!


Now that sexting has become prevalent, what’s next? Well, we are in a capitalistic society that rewards entrepreneurs, so you guessed it, a one-day California conference to develop apps for it. Why not unleash, and even incentivize, the most creative, innovative minds of our society to help us deal with “unmentionables”?

The call is out to….“design an app to solve the challenge of providing honest, real-time, private data from youth and young adults about “unmentionable” activities, like sexual behavior, substance use, sadness, and relationship drama to researchers and program experts who work with youth.”

The reason to do this is that…“the health field has been trying to prevent the most common adolescent and young adult health problems since time began: sexually transmitted diseases, depression, substance abuse and dating violence. By the age of 25, more than 90% of young adults will have experienced more than one of these problems, and for some youth, the consequences will be lifelong (infertility, homelessness, brain injuries, etc.).”

“It’s almost impossible to know what works in terms of prevention efforts, as health researchers rely on survey answers given by youth after the fact with questions such as: How many times did you use a condom for sex in the last six months? Now, really, who remembers?”

“We want to put the best and brightest minds in tech behind the solution. We want an app where young people are enticed and excited to share their Unmentionable data – data about the whos, whats, wheres and whens of their risk behaviors – in the moment or soon after.”

Interested? Too bad, it’s already over. March 31 in San Francisco.


Vol. 61 February 15, 2011 Nothing But Good News

February 15, 2012


Several readers have remarked on the “downers” in some of my most recent posts, from child abuse to good things that weren’t so good to hazards of negotiating emergency rooms, so here is a post of mostly good news.


If you are a Massachusetts resident over 50 years of age, watched the Super Bowl game, and did NOT have a heart attack then that is good news for you, so far.

A study in Los Angeles revealed that cardiovascular deaths in men increased by 15% and in women by 27% on the day of, and up to 14 days after, the Los Angeles Rams lost the 1980 Super Bowl. The death rates were even higher in those over 65 years. The Rams’ 1984 win dropped the death rate by 1%.

There has been a steady decline in cardiovascular deaths in the U.S. from 1950 to present from approximately 450 deaths per 100,000 annually to 100 deaths per 100,000.

This decline in deaths is associated with clear scientific advancements in identifying coronary risk factors, use of diagnostic imaging, building of coronary care units, new pharmaceutical agents, open heart surgery, and interventional cardiology. Next to come will be pharmocogenomics, molecular targeting, stem cell biology, regenerative medicine, and other new terms of“precision medicine”. (1)

Your politics may be a result of your birth order, your emotions, or even your DNA, so tell your friends and colleagues to stop trying to change yours.

An older sister can make a younger sibling more liberal, whereas (how is that for sneaking in a lawyer-type word) an older brother can make a younger sibling more conservative. (2) By measuring the time people spent looking at and reacting to  “disagreeable” and “agreeable” pictures University of Nevada scientists were able to distinguish liberals from conservatives and vice versa. “Conservatives are easily appalled;liberals are easily enchanted.” (3) DNA Samples from 60 Wall Street traders revealed that the most veteran traders (presumably the most successful) had genes associated with moderate levels of dopamine activity in the brain; a sign  associated with moderate, balanced risk-taking disposition. Veteran traders were also less likely to trade in volatile markets. (Have you asked your broker about his or her DNA?) (4)

Medicare takes a step toward becoming more like Visa!

Medicare is implementing soft-ware screening technology to spot patterns of potential abuse and fraud PRIOR to a claim being paid. (I remember using my Visa card to buy fuel for my boat in two different states in two days, and Capital One called me the next day to see if the second purchase was really made by me.) Up until this time Medicare would “pay” the claim and then “chase” the suspicious ones. “The largest Medicare frauds are designed at the highest level of companies, with accountants, billing experts and salespeople smoothing over the paperwork so that it will slide past all the proctors.” Don Berwick, Medicare Administrator at the time, said “We’re getting ahead of the game here.” (5)

Gun control works.(6)

The states that have strong gun control laws and low gun ownership have the lowest gun death rates.

Hawaii 9.7% gun ownership – 3.18 gun deaths per 100,000
Massachusetts 12.8% ownership- 3.42 deaths per 100,000
Rhode Island 13.3% ownership – 4.18 deaths per 100,000

The three highest?

Alaska 60.6% gun ownership – 20.64 deaths per 100,000
Mississippi 54.3% ownership – 18.47 deahts per 100,000
Louisiana 45.6%  ownership – 19.32 deaths per 100,000

Most kids who are allergic to milk can eat muffins and pizza without symptoms.

75% of milk-allergic kids in one study could tolerate milk as a baked product. In fact those children who routinely ate baked milk products were significantly more likely to become tolerant of uncooked milk than those who avoided all forms of milk, including baked milk products. Unfortunately, baking peanuts, nuts, and seafood does not modify their allergic properties. (7)

The FDA now requires more nearly honest labeling of sunscreen products.(8)

Sunscreen above UVB 15 SPF can protect against skin cancer and reduce photoaging. Sunscreen below UVB 15 SPF can NOT, but both can be labeled “broad spectrum”. The term “water-resistant” has to be linked with a statement that it’s duration is either “40 minutes” or “80 minutes.” Sunscreen sprays have not been studied and may NOT provide the same protection.  Keep reading the fine print and adopt the Australian slogan, “slip-slop-slap”; slip on a shirt, slop on some sunscreen, and slap on a hat.

Children raised in bilingual homes may have mixed syntax and vocabulary in both languages up until age 2, but then they learn multi-tasking and different ways of solving problems earlier than monolingual children, besides being proficient in two languages.

Newborn infants born to bilingual mothers can differentiate between the rhythms and sounds of the two languages, presumably a prenatal effect. At 4 months infants of bilingual mothers could distinguish between the two languages spoken by the mother on a SILENT videotape of the mother, presumably by watching movements of the face and mouth. (9)

Mothers can take the credit for the good math scores of their sons.

While the origin of gender differences of all sorts is a constant cause of discussion and research, one study revealed that mothers, particularly middle-class white mothers, referred to numbers more than twice as much when interacting with their pre-school sons than in talking to their daughters. (10)

1.  NEJM 366;1 Jan 5, 2012 200th Anniversary Article
2.  Br Jour of Pol Sci, Urbatsch, R., 2011
3. Bos Globe Feb. 5, 2012, Kevin Lewis
4. “A Combination of Dopamine Genes Predict Success by Professional Wall Street Traders”, Sapra, PLoS ONE, Jan. 2012
5. Cape Cod Times June 18, 2011
6. Violence Policy Center, CDC Reports, Oct. 2011
7. J Allergy Clin Immun 2011 July
8. FDA press release , Jun 14, 2011
9. NY Times Oct. 10, 2011 Klass, P.
10. Jour Lang and Soc Psych Dec 2010, Chang, A.

Vol. 33 November 15, 2010 More Things That Threaten or Kill…or NOT

November 16, 2010

“When good things go bad,
and vice versa.”


Despite ample scientific evidence to the contrary much buzz continues about cell phone usage causing brain cancer. Why is that ? A recent review in Scientific American magazine points out how hard it is to prove a negative. I am reminded about the story of the English farmer spreading purple dust over his fields last year. When asked why he did that he replied “To keep the lions away”.  The questioner pointed out that there had been no lions in England for at least four centuries. “Works pretty well doesn’t it,” was the proud rejoinder.

A $24 million study (2) of 12,000 regular cell phone users, half of whom already had brain cancer, found no correlation between cell phone use and the two most common brain tumors. A recent article in Skeptic magazine stated that the non-correlation was because,  as my oldest son the engineer often says to me, “It’s just physics.” X-rays and gamma rays can cause cancer because their radiation energy can disrupt chemical bonds inside cells, about 480 kilojoules per mole (it’s just a physics energy term). A cell phone generates radiation of less than 0.001 kilojoules per mole. Whatever kilojoules per mole are, it is clear that cell phones don’t generate very much of them; no where near enough to disrupt chemical bonds. The article’s author notes that probably the only way to hurt someone’s brain with a cell phone is to throw it at his/her head. I would add that since HPV (a virus) is associated with cervical cancer and is more apt to be present in sexually active women, I guess you could cause cancer with a cell phone by sexting!

Italian researchers (God bless those guys) have shown that two or three alcoholic drinks a day reduces heart attacks or strokes by 25% in men who have already undergone cardiac by-pass surgery. Brigham and Women’s Hospital researchers found that women who consume two to four drinks daily in mid-life may have better health at age 70 than those who didn’t imbibe.

At last the definition of “too much to drink” has been quantified. For decades the definition of “drinking too much” was “drinking more than your doctor”. Now moderate drinking has been defined as one drink a day for women and two drinks a day for men. “One drink” is a shot and half of liquor, or 5 oz. of wine, or a 12 oz. glass of beer. One of the reasons that people drink too much is that they are unaware of how much they are becoming “addicted”. Recent data from a Boston Medical Center study (4) suggests that just by having people complete a questionnaire of a dozen questions they become aware that maybe they have an addiction. Fully a third of those “screening positive” on the self-administered questionnaire were voluntarily abstaining from alcohol and drugs six months later.

Of course, if you leave the country your alcohol problem may get worse. What? The alcohol consumption of college kids twenty-one or older DOUBLED their alcohol intake when studying abroad. For those under twenty-one, their alcohol consumption actually TRIPLED.(5) Hopefully that means that they went from one beer a day to three which doesn’t sound as bad somehow.

Of 40 herbal supplements tested by the federal Government Accounting Office 37 contained trace levels of at least one hazardous compound. Presence of steroids and other active pharmaceuticals were also found. The FDA has been “regulating” dietary supplements since 1994, but this new report from the GAO suggests how loose that regulation of a $14.8 billion industry (2007) is. Even pure supplements can cause more trouble than expected. Review of  nine clinical trials involving 118,000 people using Vitamin E revealed that those taking Vitamin E had a 22% higher risk 0f hemorrhagic strokes. (6)

A 24-year-old woman came into MGH with belly pain and shock and spent 61 days in the hospital with the diagnosis of intestinal anthrax. As you might imagine, the state health department (two actually) and the CDC were soon joined by the FBI in pinning down the source of the anthrax. It turned out that she had recently participated in a drumming event in New Hampshire. Cultures from the site and two of the animal skin drums grew out anthrax. Presumably drumming of the anthrax-contaminated hides produced an aerosol of anthrax particles which she swallowed. (7)

1.Scientific American, October 2010, p.98, Michael Shermer
2. Internat Jour of Epidemiology, “Brain tumor Risk in Relation to Mobile Telephone Use”
3. Am Heart Assoc conference, reported in Boston Globe, Nov 15, 2010
4. MASBIRT, reported in Boston Globe , Nov. 15, 2010
.Findings, Harper’s Magazine, December 2010, p.84
6. Scientific American, August 2010, p. 24
7. New Eng Jour Med, August 19, 2010, p. 766

Vol. 31 October 15, 2010 Medical Astrology

October 15, 2010

The gravitational influence of the obstetrician is
much greater [on the baby]
than the gravitational influence of Mars.

– Carl Sagan, On the Pseudoscience of Astrology, 2008

The birth of my sixth grandchild on October 10, 2010 ( time of birth was 10:18 so he just missed a perfect “pentafecta”, 10:10-10/10/10) caused me to notice all the hoopla about 10/10/10 and to do a bit of web surfing among astrology and numerology sites. I was disappointed that I didn’t find anything too exciting or illuminating. One of the more popular sites (according to Google) noted that one of three things could happen on 10/10/10:  1) something really good, 2) nothing, or 3) something really bad, and that #2 was the most likely.

I did discover, believe it or not, a site devoted to Medical Astrology or “Iatromathematics” that, among other things, postulated that Carl Sagan’s death in 1996 was predicted by the alignment of the planets in 1994.

Number of E-cigarette distributors recently cited by the FDA for false health claims and for delivering liquid pharmaceuticals not yet approved in the U.S.: 5  (1)

Types of liquid drugs delivered by E-cigarettes: erectile dysfunction and weight loss

  • I guess that is the kind of cigarette you should light up BEFORE having sex.

Whatever happened to the swine flu epidemic and that H1N1 vaccine we heard so much about? (2)

  • Among 483,276 recipients of the vaccine in one study there were NO cases of Guillain-Barre Syndrome (GBS) and NO deaths.
  • Another study showed that receiving the H1N1 (swine flu) vaccine increased the chance of getting GBS by 0.7/100,000 person-years which is tiny and IDENTICAL to the rate of the usual seasonal flu vaccine.
  • Number of 10 patients with swine flu admitted to a Michigan ICU for ventilator support who were obese: 9 (3)
  • Number of the same 10 who were extremely obese: 7

Funny Graphs - How bad they thought it would be How bad it was

Per cent of people in the U.S. with antibody levels high enough to protect them from getting mumps:  90%

Per cent of immune people necessary to provide “herd immunity” (the protection of unimmunized people) :  92%  (4)

Per cent increase in risk of seizures in 400,000 children within 3 days after a diptheria-tetanus immunization:  ZERO (5)

1. Pediatric News, Clinical Rounds, September 2010, p.42
2. Adriana Weinberg, MD, Report given at 2010 Pediatric Infectious Disease Conference, Pediatric News, September 2010, p.11
3. http://www.cdc.gov/mmwr July 7, 2009
4. J Infect Dis 2010 Sept 1; 202:667
5. Pediatrics 2010 Aug; 126:263

Vol. 30 October 1 ,2010 Fake Pharma and Terror Pharma

October 1, 2010

If, by chance, you are one of those people who ordered some excellently priced prescription drugs from a slick, clean, multi-colored Canadian website (without having to submit a prescription, of course), and then received, a number of days later, a plain brown package postmarked from India, you MAY have received counterfeit drugs.
You may never know.
Neither may the FDA.

The FDA did discover in June of 2010 that some Tamiflu (an anti-flu drug in great demand at the time) postmarked from India was really cloxacillin (an anti-staph drug unrelated to influenza).

  • Estimate of the world market for all types of counterfeit drugs: $75 Billion annually

The yearly appropriation to the FDA is $2.5 billion, or $8 per person per year. That is what the FDA has to safeguard us from harmful or ineffectual prescription drugs. Congress never actually authorizes (“allows the checks to be written”) that much money and a shortfall of about $600 million each year is made up by collecting “user fees” from pharmaceutical companies making new applications for drug approval. Before you jump to the conclusion that this is too cozy a situation, “the hens are paying the fox”, you should know that Big Pharma complains that “sponsors of new applications have had to triple the time taken to respond to FDA inquiries.”

Counterfeit hypertension drugs might make themselves known eventually as your blood pressure climbs, assuming that someone is checking it regularly. Counterfeit diabetes control drugs might declare themselves sooner than that. A kilogram of Viagra can be bought in China for about $60 which when converted into 25 mg. tablets of Viagra is worth $200,000 in the U.S. Counterfeit Viagra, Levitra, Cialis, and the like would probably be the quickest to be unmasked as fake. Maybe they should add an additional warning to the drug ads,

. “If your erection lasts more than four hours, call your physician.
. If it lasts less than four minutes, call the FDA.”

Of course, that may not be true since the literature is now full of papers about the powerful effects of placebo. “If you think you took Viagra, you may be able to act like you did.” That would be a fun study for T. Kaptchuk to do; “Placebo Effect on Penile Erection Compared to Viagra and Fake Viagra; a survey of 100 middle-aged Boston academics”.

There are six pharmacies that are approved by the National Association of Boards of Pharmacy to provide drugs on the internet. One way to make sure you are getting what you have asked for on the Web is to use one of those.

Botox is an apparent favorite for counterfeit drug sellers. In 2006 a “naturopathic” doctor in Colorado pleaded guilty and was sentenced to 9 years in prison for selling $1.5 million of “fake Botox” to doctors across the U.S. There are no less than 20 companies from China selling “botox” on the web. Russia and India are the two next largest suppliers.

Botox is made from botulinum toxin , a powerful neurotoxic agent that was actually developed as an “orphan drug” in 1959. “Orphan drugs” are agents developed for patients with rare or unusual conditions and are subsidized by incentives from the U.S. government. It was approved for a small number of patients suffering from neck and facial muscle diseases in 1989. Its use soon extended to helping control spastic muscles in patients with cerebral palsy.

When its effect of erasing facial wrinkles by paralyzing the underlying muscles was discovered in 1992, its use literally exploded, first by plastic and ENT surgeons for “non-surgical” facelifts, and now, by just about anyone who wants to throw a living room”botox party”. In 2007 use of injectable botox was the most common cosmetic procedure (4.2 million/yr.) according to the American Society of Plastic Surgeons.

As a potent muscle paralytic in very small doses , and a lethal agent in larger doses, Botox is a potentially effective terrorist weapon due to its relatively easy manufacturing and availability through the internet.

Vol. 22 June 1, 2010 Drugs, Tobacco, and Insurance

June 1, 2010

Tobacco is a drug.

Date that the Family Smoking Prevention and Tobacco Control Act gave the FDA extensive authority to regulate tobacco products: June 22, 2009

Date that the FDA regulated use of “modified-risk” words like “light”and “low tar” in cigarette advertising and banned candy- or fruit-flavored (but not menthol-flavored) cigarettes: June 22, 2010 (1)

Value of stocks in tobacco companies held by 7 health and life insurance companies: $ 4.5 Billion  (2)

Amount the drug company making Flomax (for prostate symptoms) spent in 2008 on direct advertising to consumers: $116 Million (3)

Per cent increase in price for Flomax in 2009 “anticipating health care reform”: 20% (4)

Year that the FDA was given authority to approve generic drugs (Waxman-Hatch Act): 1984

Per cent of prescriptions dispensed in U.S. in 2009 that are generic and per cent of total dollars spent on generic medications: 70% / 20% (5)

Number of years of patent protection and market exclusivity for new drugs under the 1984 Act:  5 and 5 years

Number of years of market exclusivity for biologics (like Herceptin, Epogen, Humira) under Health Care Reform Bill of 2010: 12

Number of registered drug-company lobbyists in Washington, D.C. for every member of Congress: 2 (6)

Per cent of U.S. military stockpiled drugs found in a FDA study to be perfectly safe and effective after their expired date: 90% (7)

Per cent of 17,000 retirees with a new diagnosis of hypertension and a higher co-pay ($15-20) that failed to fill their antihypertensive prescriptions: 55%

Per cent of the same group with a lower co-pay ($5) that failed to fill their prescription: 40% (8)

Per cent of patients in health plans that had NO co-pay for medications that did not adhere to their lipid-lowering prescription instructions: 40% (9)

Per cent increase in “abandoned prescriptions” (prescriptions submitted but never picked up) from 2006 to 2008: +34% (10)


1. NEJM 362:19, May 13, 2010, p.1753
2. NEJM 360:23, p.2483
3. Consumer Reports, Dec. 2009 (from Nielson Media Research)
4. AARP Bulletin, Jan-Feb 2010, Patricia Berry
5 .NEJM 361;20, p.1917
6. Harper’s Index, November 2009, (from Open Secrets. com)
7.Wired, December 2009, p. 46
8. Arch Int Med 169:740, Apr 27, 2009
9. Circulation 2009;119:390-7
10. Wolters Kluwer Health 2009 survey in Philadelphia, AARP Bulletin, Oct 2009, p.10

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