Biomarkers show little help in predicting heart disease

A study suggests that researchers will have to find a better way to identify who is more likely to develop heart disease.

This is the VOA Special English Health Report.

Cardiovascular disease is the world’s leading cause of death. It includes heart attack, stroke and high blood pressure.

Over the years, researchers have identified several substances in the blood that can serve as what they call cardiac biomarkers. These are used to measure the presence and development of cardiovascular disease.

Biomarkers show little help in predicting heart disease

Researchers have increasingly tried to use these biomarkers to identify people who are at high risk of developing heart disease. But a new study has found that they offer little help in this way.

A team from Massachusetts General Hospital and Sweden’s Lund University studied how effective the biomarkers are as predictors. Thomas Wang at the Mass General Heart Center was the senior author of the study.

THOMAS WANG: “What we found is that, in fact, even after measuring those additional biomarkers that there wasn’t a great deal of benefit in terms of understanding who was more likely to develop heart disease.”

Doctor Wang says they did identify some combinations of biomarkers that improved predictions of heart attacks and strokes. But, he says, there is not enough evidence to justify measuring these in everybody.

THOMAS WANG: “It’s still possible that in certain patients, measuring these biomarkers would be helpful. There are some patients for whom physicians are really on the fence about whether to give one therapy or another. And in those cases having the biomarker which adds a little bit of information may be helpful in terms of decision making. But for the majority of patients, having the information of the biomarker probably wouldn’t make a difference.”

Doctor Wang hopes future research will discover biomarkers that are better able to predict the risk of cardiovascular disease. But for now, he says, doctors should depend on traditional risk factors. These include a history of high blood pressure, high cholesterol, tobacco use, diabetes, obesity, physical inactivity or poor nutrition.

A separate study found no support for a theory that a biomarker called C-reactive protein causes heart disease. Earlier research suggested that the more of the protein in people’s blood, the more likely they are to develop heart disease. The new study confirmed a link, but did not find evidence that the C-reactive protein causes the disease.

Both studies appeared in the July 1st issue of Journal of the American Medical Association.

The World Health Organization estimates that cardiovascular disease killed seventeen and a half million people in 2005. That was 30 percent of all deaths. Eight out of ten happened in low and middle income countries. At current growth rates, the W.H.O. expects the number to reach 20 million by 2015.

And that’s the VOA Special English Health Report, written by June Simms. I’m Steve Ember

What’s the link between smoking and heart disease?

Answer:

 

About 30% of all deaths from heart disease in the U.S. are directly related to cigarette smoking. Smoking is a major cause of atherosclerosis.

Among other things, the nicotine present in smoke causes:

  • Decreased oxygen to the heart.

  • Increased blood pressure and heart rate.

  • Increase in blood clotting.

  • Damage to cells that line coronary arteries and other blood vessels, triggering atherosclerosis and heart disease.

Angina incentives – heat and humidity
      As we all know, in the cold winter, the onset of coronary heart disease high frequency. Then in the hot summer whether the onset of angina seldom do?

     In fact, the thermal environment is likely to cause angina, especially in hot and wet circumstances, the angina attack rate, as if winter was the peak value of the state. This is due to heat and humidity makes the heart rate increased rapidly, stroke output is reduced, combined with hot and humid environment can increase ventricular volume, causing an increase in myocardial oxygen consumption, so that myocardial ischemia and hypoxia, and induce angina.

   To this end, coronary heart disease in the hot summer months should pay attention to the following points.

First, exercise training should be conducted in the early morning cooler, avoid exercising in the hot sun. Thunderstorm prior to the arrival of the hot and humid in the circumstances, should pay attention to the appropriate state of rest or keep quiet.

Second, pay attention to summer cooling, the outdoor activities or work should be wearing a visor and supply thereafter, water, and prevent expansion of peripheral blood vessels, blood volume makes the lack of coronary blood flow reduction induced by myocardial ischemia and angina.

Third, there is a history of angina pectoris in patients with preventable medication, such as propranolol, isosorbide dinitrate Danshen tablets and so on, if the travel required to carry nitroglycerin or amyl nitrite and other anti-angina drugs.

Color depends on heart medication?

心脏病用药还要看肤色?

The inventor of BiDil tablets are the University of Minnesota cardiologist Keenboshi. As early as 80 years in the last century, he would try the original two kinds of heart disease in general efficacy of drugs mixed with a certain percentage of patients taking, we found a mixture of taking any of the efficacy of a drug than to be alone a lot better. However, in 1997, FDA rejected this called “BiDil” mix of drugs, because Keenboshi under the auspices of a clinical trial showed the drug on the general sense, the efficacy of mass is not significant in statistical no distinction between science and in placebo.
Keenboshi did not give up, through his analysis of the racial distribution of subjects and found that black patients respond to this drug in patients with significantly better than whites. In June 2001, he again BiDil for a new round of clinical trials, and only in black patients has been conducted. He found a total of 1050 black patients with heart disease, and give half of them were taking BiDil. The results of black patients taking BiDil reduced deaths by nearly half! Out of humanitarian considerations, Keenboshi in the July 2004 initiative to stop the comparative experiment, he let the other half of the original placebo patients taking into worship Dir.
Significant effect in the year after to make BiDil received FDA approval.

If BiDil is aimed at women or children, perhaps no problem, but BiDil is aimed at a particular race happens. Although different people eat different medicine is already a very common medical knowledge, but previously have only been made an issue of gender and age, no one would dare touch the race in this restricted area for fear of being labeled “racial discrimination” label.

The emergence of BiDil in the United States caused an uproar, opponents argue that the emergence of the drug will trigger a new round of discrimination against minorities, as this will prove to be black at the gene level are different from other races, and this point It is the theoretical basis for racist discrimination against blacks.

Racial issues in the United States is a very sensitive topic, any studies on racial issues must first be clear: What is the purpose of the study? There are some scientists working on the intellectual differences between different races, so there is little research to a practical meaning, and secondly, some people with ulterior motives can easily be used as a basis for racial discrimination. There are some scientists working on different race on the prevalence of different diseases, or the same treatment of the different reactions. Although the purpose of such research is to better saving lives, but still met with some opposition. Grounds for objection are: the concept of race is not a science, there is no biological basis.

Computer, these were divided into four large groups

To find out this problem, you must first take a look at the definition of race. Biological taxonomy of all life on the earth was divided into 6 – doors, the key link, eyes, family and genus, species, where “species” is a clear definition of the smallest one. “Planted” Here there are sub-species, varieties, species, and so different sub-groups, but in biology are not very clear on the definition of “race” is one of them. From an evolutionary perspective, the geographical environment factors such as gene flow among different groups, blocking is the main reason for sub-groups, produced, because a group of internally generated variability can not go to another group, so that constant, daily, variation piled up many different groups in the shape and structure will produce measurable differences. This definition in most animals is easy to implement, such as gorillas, can according to the length of body hair and color depth is divided into different sub-species, taxonomists In such a classification will not carry any emotional.

To a human here, the situation becomes complicated. First of all, the ability of movement of animals were stronger than a lot of genetic exchange between human beings but also much broader than the animals. The same exchange within the continent is not said that in recent centuries, Asia, Africa, the Americas and the exchange of genes between the Europeans are becoming increasingly easy, it is becoming increasingly popular, which generated a lot of communication between black people, between the white and yellow of the “hybrid”, such as the North African people, both Africans and Europeans on many of the features, while the Indians is both the characteristics of the three Asia, Africa and Europe, this phenomenon indicates that the human race division no longer clearly divided, but rather form a relatively continuous band, which gives the study of race has brought some difficulties.

Due to the existence of racial discrimination, this historical phenomenon, so that humanity in the face of their own race issues is hard not to somewhat emotional, and even with the demand for the interests of blatant prejudice. The history of the United States there had been such a provision: any point in the blood of black components are classified as black, but as long as blood is not 100% pure, you can not go under the name of the Indians. For whites, the blacks are slaves, of course, the better; while American Indians are indigenous people, had the right to take back their own land, is naturally little as possible. So with an obvious racial divide is clearly discriminatory inequalities, let alone science. In fact, precisely because of ethnicity, the problems arising from making sociologists prefer to use with the language and customs and other cultural factors, including “national (EthnicGroup)” to replace the concept of “race” is a pure biological concepts.

But studied only those who have years of living in one place, the “aboriginal”, their differences at the DNA level is certainly there. This year in February, an anthropologist at Stanford University conducted an anthropological history of the biggest experiment big changes in 326 gene loci on the 3636 volunteers of different races had DNA sequence analysis. They get the data entered into the computer, does not require a computer in advance of these data into several categories, but let the computer based on these data the difference between their own decisions. A result, the computer put them into four major groups, corresponding to blacks, whites, Asians and Hispanics (Hispanics, the United States as a unique refer to all Spaniards and South Americans), accuracy rate of 99.86%! This key experimental results show that the human race is the difference between the level of DNA. Whether called “race” or “ethnic” or, if you do not consider “hybrid” phenomenon, the difference has nothing to do with the strengths and weaknesses.

A point worth noting is that the experimental analysis of the 326 gene loci. If only a few analysis of the case, would not have such an outcome. In fact, as early as 2003, there were several American scientists studied the genetic polymorphism of Alu, they found that if a comprehensive 60 Alu loci polymorphism data, can be 90% accuracy rate in sub-Saharan Africans, Europeans and Asians to distinguish. However, if the study of 100 such Alu polymorphic loci, then the resolution accuracy rate can reach 100%. The study also found that there is no one there is only a particular Alu variation within a race, that is, the distinction between different ethnic groups is not reflected in a number of genes, but several allele frequency differences , that is, inter-ethnic differences are not across the board, but a probability. Many studies have shown that DNA variation within races accounted for the total variation Jiucheng the human race is only one difference between the into.

But even this into a difference enough to cause people of different races have different reactions to certain drugs. 2 Pennsylvania State University professor of anthropology, published in the United States in 2003, “Human Genome Science” magazine on the paper provided by the data show that different ethnic groups the probability of suffering from different diseases are different. For example, the HbS causing hemochromatosis gene, common in sub-Saharan Africans; cause cystic fibrosis, a variant of the CFTR gene ΔF508, is more common in the Nordic populations. Black prostate cancer, breast cancer, the incidence of heart disease and high blood pressure than whites, while the multiple sclerosis, skin cancer, osteoporosis and dementia are more common in white. Asians also have their own “Gate of Life”, coronary heart disease, obesity and non-insulin diabetes mellitus is Asians, “enemies.”

These differences enough to make more and more medical professionals to consider the development of different races for different drugs, which is leading to BiDil came out a reason. In this exploration process, a lot of sober scientists believe that the current classification of different ethnic groups according to treatment is temporary, and only in a deeper level understanding of why people of different races are different and better to do to prescribe the right remedy. For example, there is no BiDil find out why blacks would be good results. Some scientists believe that BiDil increases levels of nitric oxide in the human body, while Nitric oxide is an important molecule to maintain blood vessel elasticity. One study showed that can promote the body produce more nitric oxide in the share of alleles in whites was 60% in blacks, only 30%. Does this mean, precisely for this reason, so that the efficacy of BiDil in black body is more prominent? If this mechanism ultimately proved to be correct, then we need not rely on race and color can be used to determine whether the BiDil, measuring different patients in the blood of nitric oxide on the list.

This shows that the pill’s color really is a question of the right medicine. If you do not register the patient did Keenboshi race, BiDil for black patients may be impossible to show efficacy, there is no apparent efficacy in black patients, also do not cause medical research on this phenomenon more in-depth exploration of a new round of . This may be reflected from one side of the richness of human beings, has nothing to do with the merits of race.

What are the performance of coronary heart disease and how to diagnose?
A clinical-like syndrome:

    According to their clinical coronary heart disease-like disease can be divided into five types:

   1 angina type: performance as a sternum pressing a sense of nausea after the swelling sense of anxiety associated with significant sustained 3-5 minutes often diverge to the left arm shoulder lower jaw and throat can also radiate into the back of his right arm. Sometimes involving these areas After the area without affecting the breastbone. forcefully emotional catch cold meal such as increase in myocardial oxygen consumption under attack is called angina pectoris with nitroglycerin for rest and ease the sometimes atypical angina pectoris can be expressed as gas-tight syncope Weakness belch, especially in the elderly according to the frequency and severity of attacks are divided into stable angina and unstable angina. stable angina refers to the onset of angina pectoris in January over parts of the frequency of their seizure severity continued to time to onset of labor-inducing size can ease the pain of nitroglycerin dosage is basically stable unstable angina refers to the original stable angina attack frequency increase in the duration of the severity or new onset of exertional angina pectoris ( occurred within 1 month) or when the onset of resting angina with unstable angina pectoris is a precursor of acute myocardial infarction is why, once discovered should be immediately to the hospital.

    Type 2 myocardial infarction: infarction often occurs about a week before the prodromal symptoms such as resting and mild physical activity during the onset of angina pectoris with obvious discomfort and fatigue infarction presenting with persistent severe oppressive sense of boredom or even a knife-like plug After the pain in the sternum often affect the entire chest to the left as the most important part of the patient can extend his left arm caused by radiation down the left side of the wrist ulnar palm and fingers, tingling and some patients may be radiation to the upper jaw to the left shoulder and neck pain-based site location consistent with previous angina pain, but continued much longer with more emphasis on rest and nitroglycerin does not relieve the performance of upper abdominal pain is sometimes easy to be confused with abdominal disease, irritability accompanied by low-heat, and cold sweat, nausea, sweating vomiting, dizziness, palpitations very weak sense of difficulty in breathing for 30 minutes or more near-death for several hours often find this situation should seek medical attention immediately

How the early detection of coronary artery disease?

  Coronary heart disease is the common diseases and frequently-occurring disease in the elderly in this age group phase of the people in their daily lives if the following conditions must be promptly for medical treatment early detection of coronary artery disease

(1) fatigue or mental stress or after sternum when precordial Mentong or contraction-like pain in left shoulder and left upper arm to the radiation lasting 3-5 minutes after the break on their own remission

(2) physical activity, chest tightness, palpitation and shortness of breath when at rest on their own remission

(3) The emergence and exercise-related leg pain such as headache, toothache

(4) eat too much cold or watching a movie thriller palpitations chest pain who

(5) night of sleep to feel chest tightness, low pillow suffocating pillow lying side require a high comfort persons; sleeping supine position during the day when a sudden chest pain or palpitations shortness of breath requiring immediate sit or stand can be reduced by

(6) sexual life or forceful defecation flustered when shortness of breath or chest pains, chest discomfort

(7) heard the noise they were chest tightness caused by flustered

(8) recurring pulse arrhythmia of unknown causes too fast or too slow heart rate were

  For the early detection of coronary heart disease over 40 years of age who regularly do the following test:

       If the test results are not normal or have other risk factors for susceptibility to coronary heart disease should be one or more times every five years for blood cholesterol tests

    Blood pressure checks every year to make a

    A year to make a blood glucose testing

     If it is a high risk of coronary heart disease should ask the doctor to see if you need to receive ECG if you need further examination will be arranged for a doctor to do an exercise test to measure a fixed pin in the foot car or foot treadmill ECG machine

    Coronary angiography is the surest method of diagnosis of coronary heart disease

    3 silent myocardial ischemic: Many patients have a wide range of coronary artery occlusion did not feel that some patients who had angina pectoris or even myocardial infarction angina when some patients did not feel that the occurrence of sudden cardiac death in heart attack routine physical examination found that before being discovered. some patients with ischemic ECG manifestations because the arrhythmia occurred or because the exercise test positive for coronary angiography being done only to find that such patients are sudden cardiac death and myocardial infarction and angina patients the opportunity to, like it should be Note that usually the heart of the health-care

   4 heart failure and arrhythmia type: some patients with angina pectoris after the original lesion due to extensive myocardial fibrosis in a wide range gradually reduced to the disappearance of angina heart failure have occurred in the performance such as air-tight edema, fatigue, etc. There are a variety of arrhythmias manifested as palpitations. There are some patients with angina pectoris has never directly expressed as heart failure and arrhythmias

   5 sudden death type: that due to coronary heart disease caused by unpredictable sudden death in patients with acute onset of symptoms occurred within 6 hours after cardiac arrest due to mainly due to myocardial ischemia caused by abnormal electrophysiological activity lead to serious arrhythmia

2. Signs:

   In general no clear positive signs of early heavy can determined to expand the sector to the left under the first heart sound can be heard when the weakened with arrhythmias such as atrial fibrillation with heart failure, and premature beats when the two can be heard under the lungs and wet rales can be heard and the apical gallop, etc.

The risk of chest pain can not be ignored warning

胸痛 不容忽视的危险警示

      “Squeezing chest suddenly appeared a large area of pain, this is a very dangerous warning, suggesting that there may be acute cardiovascular events such as acute myocardial infarction there needs to immediately go to the hospital!” Well of Cardiology, Medical Hospitals, deputy director of the Wo-dong Wu stressed that the Chest pain is often a precursor of acute myocardial infarction, but there are many patients clinically this “warning” does not pay sufficient attention to a delay of several hours to the hospital and lost the best treatment time.

The greater the scope the more intense chest pain and myocardial infarction

     Myocardial infarction is the most common cardiac emergency, most patients when the disease is the most common symptoms of chest pain. Acute myocardial infarction due to chest pain and general pain, not the same, chest pain concentrated in the upper abdomen, often expressed as squeezing kind of pain, but persistent pain in a large area of the entire piece. Pain, patients are often cold sweats, sudden change in his face. Wu Wo-dong, said the event of such a chest pain, and patients themselves have diabetes, hypertension, family history of coronary heart disease, age above 40 years old, must not be taken lightly, the need immediately to the hospital for treatment.

    In general, the extent of chest pain and myocardial infarction scope, location is proportional to the relationship. Larger infarct size, location more chest pain will be more intense. If the patient began to show mild chest pain, then pain can not tolerate even more severe, indicating the scope of more and more extensive myocardial infarction, or infarction of the area increased, more dangerous.

   The longer the delay the higher mortality rate

        “Chest pain, within two minutes if we can realize that this may be a harbinger of acute cardiovascular events, immediately go to the hospital, we will have to secure the best time for treatment. But in fact we have encountered many patients, chest pain, after its snack drug or rub points, oil, dragged on for two or three hours or even 56 hours before go to the hospital, a number of patients to the hospital has been shock. “Wo-Wu Dong said, myocardial infarction for too long will lead to myocardial necrosis, high mortality rate. Studies have shown that acute myocardial infarction during the 1 minute’s delay, the success rate of CPR will be declined 7% to 10%.

    Therefore, Wu Wo-dong proposal, a major area of crushing chest pain and I have a heart attack in patients with risk factors, they should first call 120 emergency call. Before the arrival of the medical staff, patients, oral administration of nitroglycerin tablets or amyl nitrite vasodilators such as quick at the same time you can take a deep breath and then forced coughing, which are effective for self-rescue.

Chongqing heart disease deaths on the rise
    
heart disease

heart disease

 

       DragonSoft at 12:45 on September 27 am hearing (digital journalist Wang Sen, correspondents Wu Jia Liu) Today is World Heart Day, this year’s theme is “to improve the working environment and promote heart health.” According to Xinqiao Hospital, PLA Institute of Cardiovascular Diseases, Associate Professor, deputy director of the Shanxi introduced, Chongqing in recent years, the number of deaths due to heart disease on the rise. Clinical statistics show that at present by the high position, high pressure, high salary, the new “three high” staff accounted for a significant proportion of sudden death is expected to reach its peak in 2020, and the sudden death of “three high” males than females in the crowd.

      This morning, the reporter learned from the Cardiology, Xinqiao Hospital, this year the proportion of admissions for cardiovascular death in patients with 20% more than last year, according to Professor Jin cardiovascular disease is also a way of life to some extent, disease, unhealthy lifestyle, first of all is the high-risk populations crowd. My heart disease are younger, the incidence is the highest risk 40-year-old to 50-year-old prime-age adult. He said that the prevention of heart disease should first be a reasonable diet, the National Day is coming to remind the public not to excessive alcohol consumption, more attention to the rest. Secondly, we must maintain a healthy lifestyle.
     
      Professor Jin said, there are many occurs when the patient’s chest pain, or activity emerged after palpitation, shortness of breath, once when the above-mentioned symptoms should be as early as possible to the regular hospital examination and treatment. Young people in the event of the above-mentioned symptoms, they are more vulnerable to sudden death than the elderly, so more should be alert. Because the young people in the very fast pace of work, which often occur when the aura symptoms ignored, thought it was work tired or no rest at all, so if the above symptoms, then the proposed middle-aged, especially the “three-high white-collar workers” should be as soon as possible to a regular hospital checks timely treatment.
Heart attack symptoms in women who are less likely to be found in
     BERLIN, September 28 Ta Kung Pao recent study found, and for females than males when the symptoms of a heart attack are less easily noticed.

     According to the German media reports, according to the German Federal Association of Pharmacists, men, when a heart attack, there will be sudden, prolonged chest pain, pain may spread to the arms, back, stomach and throat and other parts of the same time, male face has also become pale, and sweating. In addition, the men will appear difficulty breathing, dizziness, loss of consciousness and other symptoms.

     However, for women, the symptoms of a heart disease  is not so remarkable, sometimes only upper abdominal pain, nausea, vomiting, back pain and so on.

      The German Federal Association of Pharmacists suggested that all women in the above-mentioned symptoms should be timely to the hospital for medical treatment, suffering from high blood pressure, diabetes or high blood lipids in female patients, as well as smoking and very little movement of women more in need of special attention.

Early symptoms of heart disease
     Goes speakers, disease-free as early as defense and prevention opportunities; sick as early as governance is not to late to remedy the situation. Heart disease prevention and treatment of the key is “early.”

     So how does the early detection of heart disease? That is the concept of police Yan color: In addition to the common heart palpitations, chest pain and other symptoms of well-known, and often there are some superficial signs. To observe the aura symptoms, can be early detection and early treatment.

These surface symptoms include:

◆ breathing made some minor events, or in a quiet state, experiencing shortness of breath phenomenon, but not accompanied by cough, sputum. This situation is likely to be the performance of left ventricular dysfunction.

◆ face if the face was gray and purple, expression apathy, which is in critical condition late heart face. If the face Chenganhongse, which is rheumatic heart disease, mitral stenosis characteristics. If the color was pale, there may be signs of mitral regurgitation.

◆ nose if the nose and no air conditioning, which indicates accumulation of too much fat, the heart. If the swollen nose, indicating that enlargement of the heart or heart fat may also change is growing. In addition, the red nose, often indicates that the heart is sick.

◆ skin with chronic heart failure, pulmonary heart disease in patients with advanced skin may be dark brown or dark purple, this is a long-term hypoxic tissues, a decline in adrenocortical function. Skin and mucous membranes, and extremities was black and blue, indicating the heart of oxygen in the blood to restore the blood protein increased.

◆ ears heart disease at an early performance of varying degrees of tinnitus, it is because the inner ear of the micro-motor dysfunction in blood vessels, the disease has not caused systemic reactions, the inner ear has been the harbinger of the signal. If your earlobe there a coherent fold, most likely due to coronary artery disease.

◆ If the clavicle on the head and neck extended to the lobe direction of ribs protruding one table, such as the little finger thick, and is likely to be of right heart dysfunction.

◆ shoulder the weather obviously very good, the left shoulder, left arm and inside there are bursts of pain, which may be coronary heart disease.

◆ fingers, hands and feet clear thick end or toe, and a convex surface such as the drumstick-like, is common in chronic pulmonary heart disease or congenital cyanotic heart disease.

◆ lower limbs of the elderly lower extremity edema, cardiac dysfunction, often leading to venous return blocked performance. In addition, if frequent heart palpitations, asthma, and only the squat was able to ease, which is the unique purple heart clamp performance.

Emphasis on chest tightness and palpitation

      I have found that many elderly people for their lack of understanding of some of the symptoms, while some young people for the occurrence of chest tightness, palpitation and other symptoms is not very great importance, tend to believe that no relationship between tolerance and forbearance on the one passed. It is these ideas the best treatment time delays. A 40-year-old leader of colleges and universities, usually the heart is not conscious, but not seriously, the results of sudden death, and premature death is very unfortunate. If he is a timely treatment, prompt treatment, the results will differ materially. So, as long as the active treatment, cure and mitigation of heart disease is still very optimistic.

About heart disease symptom From China
Patients:
This year I have just over 19 years old, I myself have long been aware of my heart from time to time will be a sudden jump quickly, I do not know why, like tonight, my friends and one to go out to dinner, is eating when the heart suddenly speed up, when feeling really fast No pulling, jump out to pull the heart feeling that I usually have no major illness, the heart has never been hurt before, but often I just said that state, a sudden rapid heart beat, I do not understand what the reasons are, but also somewhat worried about the hope that good-hearted people can help me to answer what, thank you pull
Doctor
First diagnosed! I thought you have a pre-excitation syndrome caused by paroxysmal tachycardia. To be a first hospital ECG, to find the heart specialist doctor to see.
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