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For each category the board reports if residents from the individual program performed in the upper cheap fenofibrate 160mg fast delivery cholesterol levels while pregnant, middle or lower third compared to all residents taking the boards cheap 160mg fenofibrate cholesterol & your eyes. In addition purchase discount fenofibrate on-line cholesterol medication over the counter, the overall pass/fail rate over the past 5 years is provided for the program and compared to the national rate order genuine fenofibrate online cholesterol test no food. This information is used to determine if the program may have specific areas of weakness in training. Program improvements will be investigated for area in which the residents performed in the lower third. The overall program percentile performance compared to the national performance is used to identify areas of training in need of improvement. This provides the department two large objective exams for evaluation of residents. Performance variation within specific areas by the overall group of residents is used to identify potential areas for training improvement. The evaluations are completely anonymous and are reviewed in detail by the Resident Education Committee. These evaluations are initially reviewed by the Program Director on a biannual basis and then a summary is presented to the Resident Education Committee for use in program improvement. The evaluations are reviewed by the Program Director and if any problem is identified it is reported to the Departmental Chair. The Departmental Chair also receives a copy of all evaluations and uses them for annual faculty review. An announcement is made to all faculty members that program improvement suggestions are welcomed. Recommendations from the residents meeting are then taken to the Resident Education Committee. Pathology Resident Manual Page 24 • Ad Hoc Projects and Task Forces – Depending upon need, ad hoc task forces or subcommittees are formed to address specific program improvement questions. The annual review examines and summarizes any needs for improvement in program quality, resident performance, faculty development, or graduate performance. Residents being evaluated will receive an email notification when an evaluation has been completed. Residents are also evaluated by technologists, pathology assistants and autopsy assistants. In addition to rotation evaluations, information from other sources will be considered. These include attendance records for required academic sessions, results of written examinations, and informal reports. Residents are reviewed as to performance by the Residency Director at least twice yearly. Please refer to the Housestaff Policies and Procedure Manual for details of the recommended institutional guidelines pertaining to progress and promotions. A poor grade or unsatisfactory rotation evaluation will result in formal counseling, which may include development of a remediation plan, repetition of the rotation or probation. Very specific guidelines from the School of Medicine govern remediation, probation, and due process/grievance procedures pertaining to any such actions. Please refer to the appropriate section in the Housestaff Policy and Procedure Manual for details. Whenever the Residency Director is informed of significant concern regarding a resident’s performance, the resident involved will be contacted and given the opportunity to provide a response. The resident may provide this response by any or all of the following: in the form of a written document, through verbal communication with the residency director, or by personal appearance before the departmental Residency Review Committee. Questions of capricious, arbitrary, punitive or retaliatory actions or interpretations of the policies governing graduate medical education on the part of any faculty member or officer of the Pathology Residency Program are subject to the grievance process. Complaints of illegal discrimination, including failure to provide reasonable accommodations and sexual harassment, are processed in accordance with the Medical Center policies and procedures that are administered through the Equal Opportunity Office. Should a house officer in the Department of Pathology have a grievance or be dissatisfied with any aspect of the program, he/she is encouraged to initially discuss the issue with his/her attending or the Chief Residents. If this is felt by the resident to be inappropriate or the issue is not satisfactorily resolved, timely discussion with the Program Director is highly recommended. Documentation of the issues and a statement of dissatisfaction by the aggrieved resident may be helpful, and is also encouraged, particularly when making an appeal to the Department’s Resident Education Committee. In general, the resident will first discuss any grievance with the Chief Residents. If this fails to provide adequate closure to the grievance, then he/she is directed to speak with one of the Program Director. Issues can best be resolved at this stage and every effort should be made to achieve a mutually agreeable solution. If the grievance is not resolved to the satisfaction of the resident after discussion with the Program Director, the resident has the option to present the grievance, in writing, to the Office of Graduate Medical Education. In situations where the grievance relates to the Chair or Program Director, or where the resident believes that a fair resolution cannot be attained by presenting the grievance to those individuals, he/she may present the grievance in writing directly to the Office of Graduate Medical Education. The Associate Dean for Graduate Medical Education will meet with the resident, the Program Director, the Chair and one or more of the program’s Chief Residents to determine the cause and validity of the complaint and to determine the means of redress. Should the meeting with the Associate Dean fail to resolve the grievance to the satisfaction of the resident, the resident may request that he/she be heard by the Executive Dean. Any action(s) taken in good faith by the Executive Dean addressing the grievance will be final. An appropriate ratio of education to service is ensured by providing a blend of supervised patient care responsibilities, clinical teaching, and didactic education. The Program provides an educational and working environment in which residents may address concerns in a confidential and protected manner. Residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs. Appropriate educational resources are provided including medical information access, faculty supervision, and a wide variety and volume of both anatomic and clinical pathology cases. Graded and progressive clinical responsibility within the supportive educational environment assures resident development of sufficient competence to enter practice without direct supervision upon completion of the program. Therefore, the use of protective equipment to prevent parenteral, mucous membrane and non-intact skin exposures to a healthcare provider is recommended; iii. Such opportunities include, but are not limited to, confidential discussion with the chief residents, program director, program chair, core program director, and/or core program chair. Other intradepartmental avenues to confidentially discuss any resident concern or issue occur during the Annual Program Evaluations completed by each resident and/or through discussion with the resident representative during the required Annual Program Review (Annual Program Outcomes Assessment and Action Plan Report); ii. E*Value “On-The-Fly” praise and concern comments can be sent through E*Value directly and confidentially to those program directors that offer this service. All procedures performed in autopsy, surgical pathology and clinical laboratory medicine are performed under either direct or indirect supervision of an attending faculty member. Resident responsibilities and progression of responsibility is described in each rotation description. More Pathology Resident Manual Page 29 advanced residents are given increased responsibility which will include more time on each procedure or task being indirectly supervised (immediate availability) by the faculty member.
An excess of cold turns on the furnace to bring more heat generic fenofibrate 160 mg otc cholesterol levels chart age, and an excess of heat turns off the fur- nace to lower the temperature buy fenofibrate overnight cholesterol test triglyceride levels. This back-and-forth buy fenofibrate 160mg low price cholesterol vs fatty acid, nip-and-tuck sort of control is active while healing is going on generic fenofibrate 160 mg cholesterol levels uk normal range, but discontinues when the healing job has been completed. Some over-all con- trol then gives anti-growth the upper hand and the forma- tion of scar tissue stops altogether. Thus, there should be more anti-granulation "stuff" present in the final stages of healing—in the scab which has already completed its growth. Anti-Growth Serum Made Wounds Heal Faster My anti-granulation tissue serum was made from the scrapings of newly formed but full grown granulation tis- sue of a healing wound, which, after being suspended in solution, was injected into rabbits, to stimulate them to react against this granulation tissue. The serum, injected into the mouse at the point furthest from the wound, accelerated healing by about 40%. These results were encouraging and led to further re- finement of the serum for human use. At the time I began using this serum on human patients, I had no other hope than that it might accelerate the healing of surgical wounds. There are millions of women in the middle age group who have held down jobs for twenty years or more who suddenly meet the competition of younger people despite their experience and competence. Many of them have come for surgical help to remove the signs of age from their eyelids and face to make them look younger and hold onto their jobs for another ten years. What I had not anticipated, however, was the number of patients who received the serum and returned several months later to report that they felt younger, had more pep and energy, and that some of their aches and pains had disappeared. To prove anything, numerous experiments would have to be made under control conditions and scientific obser- vation. How Your Thoughts, Attitudes and Emotions Act as Nonspecific Therapy I began to look for other factors, or common denomina- tors, which might explain why the surgical wounds of • some patients heal faster than others. Frustration and emotional stress can be induced in mice, however, by immobilizing them so that they cannot have freedom of movement. Laboratory experiments have shown that under the emotional stress of frustration, very minor wounds may heal faster, but any real injury is made worse, and healing sometimes made impossible. How the Failure Mechanism Injures You Thus it might be said that frustration, and emotional stress (those factors we have previously described as the "failure mechanism") literally "add insult to injury" whenever the physical body suffers damage. If the physi- cal damage is very slight, some emotional stress may stimulate the defense mechanism into activity, but if there is any real or actual physical injury, emotional stress "adds to" and makes it worse. If "aging" is brought about by a "using up" of our adaptation energy, as most experts in the field seem to think, then our indulging ourselves in the negative components of the "Failure Mechanism" can literally make us old before our time. Philosophers have long told us, and now medical researchers confirm, that resentment and hatred hurt us more than the person we direct them against. There was, however, one easily recognizable characteristic which all the "rapid- healers" had in common. They were optimistic, cheerful "positive thinkers" who not only expected to "get well" in a hurry, but invari- ably had some compelling reason or need to get well quick. They had "something to look forward to" and not only "something to live for" but "something to get well for. In short, they epitomized those characteristics and atti- tudes which I have previously described as the "Success Mechanism. Lieb adds, "Tests have been made of the effect of personality disturbances on convalescence: one hospital showed that the average duration of hospitalization was increased by forty per cent from this cause. Is our Success Mechanism a sort of built-in youth serum which we can use for more life, more energy? Placebos, or "sugar pills" (capsules containing inert ingredients) have long been a medical mystery. Yet, when placebos are given to a control group in order to test the effectiveness bf a new drug, the group receiving the phony pills nearly always shows some improvement, and quite often as much as the group receiving the medicine. In 1946 the New York Journal of Medicine carried an account of a round-table discussion of placebos by mem- bers of the Department of Pharmacology and Medicine of Cornell University Medical College. Group 2 received sugar pills, and only 13 per cent suffered from seasickness, while 30 per cent of Group 3, which received nothing, got sick. Many doctors now believe that a similar type of "sug- gestive treatment" is the best form of therapy for warts. The warts are painted with methalene blue, red ink, or any other color, and a colored light is used to "treat" them. The Journal of the American Medical Association has said, "The facts of the suggestive therapy of warts seem to make a strong case in favor of the reality of such a process. They believe they are receiving legitimate medi- cine which will "bring about a cure. We may do something very similar, but in reverse, when we unconsciously "expect to get old" at a certain age. It is a matter of common observation that some people between the ages of 40 and 50 begin to both look and act "old," while others continue to act and look "young. At least two ways suggest themselves as to how we may think ourselves into old age. In expecting to grow "old" at a given age we may unconsciously set up a negative goal image for our creative mechanism to accomplish. Or, in expecting "old age" and fearing its onset, we may unwit- tingly do those very things necessary to bring it about. Cutting out practically all vigorous physical activity, we tend to lose some of the flexibility of our joints. Lack of exercise causes our capillaries to constrict and virtually disappear, and the supply of life-giving blood through our tissues is drastically curtailed. Vigorous exercise is necessary to dilate the capillaries which feed all body tis- sues and remove waste products. For some unknown reason bio- logically new and "young" cells form inside this tube. Selye suggests that this may be the mechanism of aging, and that if so, "old age" can be postponed by slowing down the rate of waste production, or by help- ing the system to get rid of waste. In the human body the capillaries are the channels through which waste is removed. It has definitely been established that lack of exercise and inactivity literally "dries up" the capillaries. Activity Means Life When we decide to curtail mental and social activities, we stultify ourselves. If you could induce him to sit in a rock- ing chair all day, give up all his dreams for the future, give up all interest in new ideas, and regard himself as "washed up," "worthless," unimportant and non-produc- tive, I am sure that you could experimentally create an old man. John Schindler, in his famous book, How to Live 365 Days a Year (Prentice-Hall, Inc.
In an a c tu a l a ssa y buy fenofibrate with american express grapefruit cholesterol medication interaction, the p o in ts are s h ifte d to l e f t or rig h t of th is v e r tic a l f it t e d curve by an amount p ro p o rtio n a l to th e fr a c tio n a l error in th e ir apparent d ose generic fenofibrate 160 mg with amex cholesterol medication downside, and th is error can be read at a glan ce to 0 purchase 160mg fenofibrate overnight delivery cholesterol spinach. If the p o in ts depart from the v e r tic a l lin e in some system atic p a ttern generic fenofibrate 160 mg line definition of cholesterol level, the model i s revealed to be not f u lly a p p lica b le; in t h is c a se , an adjustm ent of the curve shape can be made by e ith e r of 2 reasonably sim ple procedures. Straight line fitted to data points by weighted linear least-squares procedures is used as standard curve. Aln X is Inofapparent dose (read offstandard curve) minus Inof true dose (known from dilution ofstandard). Discrepancies between data points, their errors, and standard curve are more easily appreciated than in Fig. This approach s a c r ific e s a good f i t at the extrem es of the curve (where i t is le s s im portant) in order to ob tain a b e tte r f i t elsew h ere. The second a lte r n a tiv e a llo w s a sim ple manual adjustm ent of the shape of the p lo tted curve; th is procedure i s presumably seldom n ecessary, but is a u n iv ersa l fa ll-b a c k op tion that perm its subsequent autom atic a n a ly sis o f unknowns under any circum stances. The o b je c tiv e of error accounting is to deduce and to d isp la y the stru ctu re of random errors in the assay: to attach r e a lis t ic confidence lim its to the derived an alyte co n cen tra tio n s, to provide w eigh tin g fo r the c u r v e -fittin g c a lc u la tio n s , to id e n tify o u t lie r s , and to reveal whether the magnitude of random errors i s c o n siste n t w ith past exp erien ce. The programs handle random errors in 2 separate c a te g o r ie s: c o u n tin g -s ta tis tic s erro rs and n o n -c o u n tin g -s ta tis tic s errors (nam ely, a l l o th e r s). The former are sim ply c a lc u la te d for each tube from the raw counting d ata. The la t t e r can be deduced only from exp erien ce on many specim ens analyzed in r e p lic a te. This exp erien ce can be taken from the ensem ble of r e p lic a te s in the current assay batch i f 2 p asses are made through the data: f i r s t to decipher the error stru ctu re, second to use and d isp la y i t. However, a sin g le batch may co n ta in too few specim ens to d efin e the error stru ctu re c le a r ly. Each assay batch i s f i r s t analyzed using a stru ctu re of n o n -c o u n tin g -s ta tis tic s errors assumed from exp erien ce on p reviou s b atch es. C oncurrently w ith the a n a ly s is , however, the error stru ctu re of the p resen t batch i s assem bled for fu tu re use and te ste d by ch i-sq u are t e s t s fo r co n sisten cy w ith the assumed stru ctu re. If co n sisten cy i s not observed (showing th at the a n a ly st does not have h is assay system under c o n tr o l), then the stored counting data can be au tom atically reanalyzed a fte r providing the error stru ctu re ju st found during the f i r s t p a ss, or perhaps some w eighted average of the p resen t and p reviou s error stru ctu re. As d efin ed in th ese programs, they are concerned only w ith n o n -c o u n tin g -sta tistic s e r r o r s. In the case o f unknowns, the r e s u lts and errors are fo r a n a ly te co n cen tra tio n. In the case of the ch i-sq u are d a ta , each cum ulation i s again fla g g e d , i f ap p rop riate, according to the same 3 ranges of p as fo r in d iv id u a l specim ens; from the cum ulations, d iscrep a n cies between observed s c a tte r and expected s c a tte r can be d etected w ith g rea ter s e n s it iv it y than from in d iv id u a l specim ens. If past and p resen t s c a tte r are not c o n s is te n t, candidate o u tlie r s must be reexam ined. Presumed o u tlie r s are never discarded a u to m a tica lly ; operator in it ia t iv e is required to accom plish t h is. As a con ven ien ce, the p a r tia lly p rocessed r e s u lts from each batch, or from up to 20 com posited b atch es, can be stored on m agnetic card s. F in a lly , the d r if t (w ith confidence lim its and fla g g in g ) i s c a lc u la te d fo r the com posite of a l l p o o ls. The o f f - lin e programs already d istr ib u te d d if f e r in the fo llo w in g main r e sp ects from those described in S ectio n 3. F ir s t, a n a ly sis fo llo w in g each input of counts extends the time during which the operator must atten d the c a lc u la to r. Second, should i t be d esired to reanalyze a batch of data (fo r exam ple, a fte r d isco v erin g th at the assumed error stru ctu re i s in a p p lica b le to th is b a tch ), a l l the data would have to be keyed in again. In p a r tic u la r , they ad ju st counting tim e on each tube so as to a ch ieve a c o u n tin g -s ta tis tic s error s lig h t ly lower than the n o n -c o u n tin g -s ta tis tic s component of the random error (or la r g e r i f d esired ) [8 ]. T his perm its maximum e f fic ie n c y in the u t iliz a t io n of a v a ila b le counting tim e, and in p r in c ip le reduces the number of counters required to cope w ith the w orkload. Very few were fa m ilia r w ith the philosophy of error a n a ly s is a t the heart of th ese programs. Each lab oratory was provided a c a lc u la to r w ith e s s e n tia l a c c e s s o r ie s , the programs, and d e ta ile d docum entation on the op era tio n and str a te g y o f the programs. In a d d itio n , they were prom ised answers to q u estio n s sent to Vienna, a p o s s ib ilit y of a tr ip to atten d th is Symposium i f they did w e ll, and withdrawal o f th e ir c a lc u la to r s i f they did n o t. This e sta b lis h e s that the whole system can in fa c t be used, and w ithout the requirem ent of a tra in in g cou rse. From the e a r ly ex p erien ce, the most common "abuse” of the system appears to be o u tlie r r e je c tio n. However, th is ex h o rta tio n has been commonly ignored, and o v ero p tim istic hypotheses about co n sisten cy among r e p lic a te s have been perpetuated. The new v ersio n of the programs rev erses the stra teg y : nothing i s discarded u n less the a n a ly st manually in terv en es. Many of the la b o r a to r ie s are now ro u tin ely p rocessin g th e ir data on th is system , but some are apparently n o t. There i s a n atu ral in e r tia in s h iftin g to a new system whose advantages may not be f u lly recognized. Another b a rrier may be the com paratively low speed o f c a lc u la tio n : 1 d u p lica te specimen in about 40-50 seconds. This would reduce enthusiasm in la b o r a to r ie s having la rg e numbers of assays (fo r which the system was however not in ten d ed ). Using the new v ersio n of the programs (S e c tio n 3 ), i t should become p o ssib le to en ter counting data a u to m a tica lly from counters ap p rop riately equipped, or to key in data rap id ly ( i f manual en try i s ch o sen ), w ith a n a ly sis accom plished au tom atically th e r e a fte r. In part t h is sig n ific a n c e can be h ig h lig h ted by improved docum entation, in part i t w ill become more com pelling as fa m ilia r ity w ith the system grows. Im precision p r o f ile s , response error r e la tio n sh ip s, v a ria n ce-ra tio t e s t s , ch i-sq u are t e s t s , and perhaps even con fid en ce lim its are new concepts in most of th ese la b o r a to r ie s. However, as the la b o r a to r ie s come to r e a liz e th a t th ese p ercep tio n s are a v a ila b le a t no c o st to the a n a ly st in time or e f f o r t , and that they allow not only the a n a ly st but a lso h is su p ervisor to d etect anom alies in the assay a t a gla n ce, they should be accorded grea ter a tte n tio n. Although su p rlsin g ly l i t t l e evidence of such support has yet emerged, there i s hope th a t i t w ill do so. N ev erth eless, a d d itio n a l tim e w ill be required to meet the f u l l g o a ls of th is p r o je c t. The introduction of immunoassay to laboratories where environmental changes and limited equipment are likely to limit reliability and precision have emphasized the need for routine evaluation of assay performance. The aim has been to provide both an accurate calibration of the immunoassay response and an assessment of assay error which will allow the assayist to monitor and improve assay performance. As models of immunoassay error are used at all stages of processing they are described in some detail. Analysis of sources of error associated with counting, small perturbation “experimental” errors and assay “drift” is explicitly embraced by the program and is used to screen out untypical assay errors or “outliers”. This is a statistically more reliable estimate of precision than the observed replication for an individual result and when calculated for doses over the working range of the assay yields the precision profile as an important indicator of assay performance.
In regard to the geographic distribution of the disease order fenofibrate on line cholesterol levels fasting, areas with the highest prevalence are located in higher latitudes in both the northern and southern hemispheres purchase fenofibrate cholesterol medication causing organ failure. A number of viruses have been isolated from cultures of material in patients with multiple sclerosis buy fenofibrate 160 mg line cholesterol levels uk chart, including herpes simplex virus discount fenofibrate 160mg overnight delivery cholesterol levels range normal, scrapie virus, parainﬂuenza virus, subacute myelo-opticoneuropathy virus, measles virus, Epstein-Barr virus, and coronavirus. At present, the available data do not appear to support a common virus as the cause for the increased antibody levels, which are more likely the result of an autoimmune reaction. It was discovered that the diets of the farmers were much higher in animal and dairy products than the diets of the coastal dwellers, whose diet featured more cold-water ﬁsh. Therapeutic Considerations From a natural medicine standpoint, the primary approach is to utilize dietary therapy and nutritional supplements shown to be helpful in arresting the disease process, along with exercise and effective stress management. Although red meat consumption is signiﬁcantly restricted on the Swank Diet, ﬁsh is highly recommended because of its excellent protein content and, perhaps more important, its high omega-3 fatty acid content. In addition, because optimal neuronal functioning depends on cell membrane ﬂuidity, which in turn depends on lipid composition, optimal essential fatty acid levels may have an important neuroprotective effect. Diet was monitored over two years by dietary record, and plasma fatty acid levels were noted at baseline, year one, and year two. Patients on the diet showed a signiﬁcant increase in plasma levels of omega-3 fatty acids and a signiﬁcant decrease in plasma omega-6 fatty acids. The group on the low-fat diet plus fish oil had better quality-of-life scores (as measured on a questionnaire) for physical well-being than the group taking olive oil supplementation, although the result was not statistically signiﬁcant. The olive oil group reported an improvement in fatigue as compared with the ﬁsh oil group. For both intervention groups, relapse rates were reduced as compared with the year prior to their entering the study. After three and six months of ﬁsh oil supplementation, a signiﬁcant decrease in the levels of inﬂammatory cytokines was noted. Cytokine levels returned to baseline values when fish oil supplementation was discontinued for three months. Although the results did not achieve statistical signiﬁcance, both groups in the study were advised to follow a diet low in animal fat, and this may have affected the results. These enzymes include chymotrypsin and trypsin from pancreatin (from hog pancreas), bromelain (pineapple enzyme), papain (papaya enzyme), and fungal and bacterial proteases. In the treatment of multiple sclerosis, pancreatic enzyme preparations have been shown to reduce the severity and frequency of symptom ﬂare-ups. Especially good results were noted in cases of visual disturbance, bladder and intestinal malfunction, and sensory disturbances. Ginkgo biloba was shown to signiﬁcantly improve performance on several tests that measured attention and executive function. However, these reports were largely anecdotal or from uncontrolled clinical trials. This encouraging preliminary study led to further trials on a larger number of subjects, with longer periods of follow- up. The results showed no signiﬁcant improvement, apart from a subjective improvement in bowel and bladder function in one of the studies. Detailed reviews and analysis of the 14 controlled trials of hyperbaric oxygen treatment showed that only one of the trials produced a signiﬁcant positive effect. Simple steatosis is associated with obesity, occurring in 70% of patients who are 10% above ideal body weight and nearly 100% of those who are obese. In addition, special foods rich in factors that help protect the liver from damage and improve liver function include high-sulfur foods such as garlic, legumes, onions, and eggs; good sources of soluble ﬁber such as pears, oat bran, apples, and legumes; vegetables in the brassica family, especially broccoli, brussels sprouts, and cabbage; artichokes, beets, carrots, and dandelion; many herbs and spices such as turmeric, cinnamon, and cilantro; and green leafy vegetables that enhance detoxification processes in the liver. Nutritional Supplements Betaine and Other Lipotropic Factors Betaine, choline, methionine, vitamin B6, folic acid, and vitamin B12 are important lipotropic agents, compounds that promote the ﬂow of fat and bile to and from the liver. Lipotropic agents have a long history of use in naturopathic medicine; in essence, they produce a “decongesting” effect on the liver and promote improved liver function and fat metabolism. The important thing in taking a lipotropic formula is to take enough to provide a daily dose of 1,000 mg betaine, 1,000 mg choline, and 1,000 mg methionine and/or cysteine. Carnitine plays an extremely important role in the utilization and metabolism of fatty acids in the liver as well as in the function of mitochondria, the energy-producing part of cells. Carnitine supplementation has been shown to signiﬁcantly inhibit and even reverse alcohol-induced fatty liver disease. Since carnitine normally facilitates fatty acid transport and oxidation in the mitochondria, a high carnitine level may be needed to handle the increased fatty acid load produced by alcohol consumption or other liver injury. Results demonstrated signiﬁcant improvements in the carnitine group, including improvement in liver function and evidence of improved mitochondrial function. Bile Acids Bile acids are naturally occurring compounds such as ursodeoxycholic acid and tauroursodeoxycholic acid that, like the liptropic agents described above, are effective in promoting the ﬂow of bile and fat to and from the liver. Bile acid preparations are available by prescription, but mixtures of bile acids from ox bile are available in health food stores and may prove to be suitable alternatives. Botanical Medicines There is a long list of plants that have beneﬁcial effects on liver function. However, the most impressive research is with the extract of milk thistle (Silybum marianum) known as silymarin. For more information on silymarin, see the chapter “Detoxification and Internal Cleansing. Certain foods are particularly helpful because they contain the nutrients the liver needs to produce and activate the dozens of enzymes involved in the various phases of detoxification or aid in the effective elimination of toxins. Such foods include: • Garlic, legumes, onions, eggs, and other foods with a high sulfur content. Osteoarthritis • Mild early-morning stiffness, stiffness following periods of rest, pain that worsens on joint use, loss of joint function • Local tenderness, soft tissue swelling, joint crepitus (crackling sound), bony swelling, and restricted mobility • X-ray findings (narrowed joint spaces, cartilage erosion, bone spurs, etc. The most common form of arthritis is osteoarthritis, which is also known as degenerative joint disease because it is characterized by joint degeneration and loss of cartilage, the shock-absorbing gel-like material between joints. Surveys have indicated that more than 40 million Americans have osteoarthritis, including 80% of those over the age of 50. Under age 45, osteoarthritis is much more common in men; after 45, it is a little more common in women. In primary osteoarthritis, the degenerative wear-and-tear process occurs after the ﬁfth or sixth decade of life, with no apparent predisposing abnormalities. The cumulative effects of decades of use leads to the degenerative changes by stressing the collagen matrix, the support structure of the cartilage. Damage to the cartilage results in the release of enzymes that destroy cartilage components. With aging, the ability to restore and synthesize normal cartilage structures decreases. The incidence of osteoarthritis increases dramatically with age and body mass index for weight-bearing joints.