Who Should Be Tested For COVID-19

As a physician working for one of the big local healthcare systems, starting Monday I will have the ability to order outpatient testing for the coronavirus. University Hospitals of Cleveland and the Cleveland Clinic are both offering drive-through swab testing with a doctor’s order.

Credit: bangordailynews.com

I’m anticipating a LOT of phone calls on Monday. Before you call, I want to go over the guidelines for who should be tested for COVID-19.

The very first question that will be asked when someone calls is “ARE YOU SICK.” This sounds silly but the worried well are going to want to be tested. I was at Costco Friday morning, am I at risk? I work in healthcare, am I at risk? Yes, of course. But I do NOT need to be tested because I am NOT sick.

The symptoms of COVID-19 include fever, cough, and shortness of breath. If you have a runny nose and cough, but no fever, you have a cold and do NOT need to be tested. And you don’t need to go to the doctor, urgent care or emergency room either! Stay home, drink fluids, rest and wash your hands until you are feeling better.

Suppose you do have a fever and a cough. If so, I guarantee that anxiety is going to make you feel short of breath! The next question is, have you been exposed? At this point, if you have not traveled and have not been in contact with a known or suspected case of COVID-19, and are well enough to stay home, you do NOT need to be tested. The exceptions are healthcare workers and those at high risk (like cancer patients and those 65 and older with multiple medical problems).

If you or a family member have any of THESE symptoms, you need to call 911.

  • Shortness of breath
  • Chest pain, pressure or discomfort
  • Bluish discoloration around the lips or fingernails
  • Confusion or difficulty waking up

If you need to call 911, let the dispatcher know what’s going on so they can give the paramedics and ER a heads-up and be prepared.

Social distancing, closing schools, avoiding large groups, good handwashing and sanitizing surfaces will help slow the spread of the virus. It’s inevitable that some people will be infected, and knowing who needs tested is important. We don’t have unlimited ability to test the general population. Just because you are scared and MIGHT have been exposed is not a reason to get tested.

If you need more information about this infection, here are some good resources for facts, not hype or hysteria:

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How To Wash Your Hands

I was browsing the health news reports to get an idea of a topic for this weekend’s post. Literally every post is about the coronavirus outbreak and its spread to numerous countries.

While this is very important, unfortunately I’ve already written about this topic. I have seen a number of posts this week on social media about proper hand washing, and decided this was a good time to review the right way to wash your hands.

Everyone from Mayo Clinic to the CDC has put out guidelines about how to wash hands correctly. I have included a video at the end but here are the steps:

  • Wet hands with warm water
  • Use regular soap. Antibacterial soap actually increases the risk of staph infections and is not recommended.
  • Lather the hands thoroughly and rub them together. Get between the fingers, the tips, and the thumb.
  • Continue to rub the hands for 20 seconds. This is the time it takes to sing the Happy Birthday song or the Yankee Doodle song through twice.
  • Rinse the hands thoroughly under warm water.
  • Turn off the tap with a paper towel, NOT your clean hands
  • Open the bathroom door with a paper towel, NOT your clean hands

Studies have shown over and over that good hand hygiene is critical in preventing infection. This is true not only in hospitals and doctors’ offices but in the general public as well. Especially with the growing concern about coronavirus infection, proper hand washing is a critical measure everyone can and should take to reduce their risk of illness.

QUESTION: Are you washing your hands correctly?

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Wuhan Coronavirus

OK, everyone is talking about the Coronavirus infection that started in Wuhan, China and is spreading throughout the world. What do you need to know about it?

This infection was first reported in late 2019 in Wuhan, China. A number of the first cases were reported in people who had connections to a large seafood and animal market, but later cases seemed to clearly show person-to-person transmission.

The infection is now here in the United States, and not everyone who has tested positive for the virus has been to China. Clearly the virus can pass from person to person. As of Friday, 1/31, there have been seven cases in the United States.

Wuhan Coronavirus is a respiratory illness that causes fever, cough and shortness of breath. Serious cases can involve pneumonia. Symptoms can be mild to severe. There is no vaccine, although scientists are working to develop one, and as of now there is no widely available treatment. A combination of medications designed for influenza and HIV seems to be helpful though.

Right now the best way to stay safe from this virus is to avoid infection. Travel to China has been restricted by the State Department. People returning from the Wuhan region of China are being quarantined.

If you have been to China and are sick with a respiratory illness, please see the doctor right away and tell the doctor immediately that you were in China. Follow sensible precautions like washing hands, covering coughs and disinfecting surfaces in your home.

The Wuhan Coronavirus can be deadly. About 2% of cases in China have been fatal. Compared to influenza, which kills about 1 in 1000 people who catch it, this is much more dangerous but also much more rare. 360 people have died in China from Coronavirus, compared to over 34,000 people who died in the United States in the 2018-2019 flu season.

Be aware of Wuhan Coronavirus. Don’t travel to China until the State Department announces it is safe. If you have traveled and get sick, see the doctor and make sure they know your travel history. Take sensible precautions. And don’t panic.

QUESTION: Are you worried about Wuhan Coronavirus?

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Cardiac Rehab After Heart Attack

If I tried to make a list of all my patients who have had a heart attack in the past year, unfortunately I probably would be here awhile. We are NOT good at identifying patients at risk, and many patients refuse treatments and lifestyle changes that are proven to reduce their risk of a heart attack.

AFTER a heart attack, though, we have a very good idea what will reduce the risk of having another one. Sadly, only a very small number of patients take advantage of one of the best measures to reduce the risk of an encore performance: cardiac rehab.

Cardiac rehab consists of 36 one-hour sessions which are covered by Medicare and most if not all commercial insurance. The sessions include

  • supervised exercise training
  • counseling on diet
  • counseling on stress management
  • smoking cessation (if needed)
  • guidance on other measures for heart-healthy living

Researchers at the CDC in Atlanta looked at heart attack and heart failure patients covered by Medicare and found that only 24% of the patients even started cardiac rehab. Of those, on average patients completed only 25 sessions, with only 27% attending the recommended 36 sessions.

Older patients, patients of color, sicker patients and women were less likely to go to cardiac rehab. The study wasn’t designed to figure out why this was seen. However, I can imagine transportation and family support may have been a problem with the older and sicker patients. Access to care is always a problem with patients of color and in this instance doesn’t surprise me. Women in general put their own needs last, and I can definitely see female patients being less likely to attend an extended series of rehab sessions. I can’t even get them to go to 12 physical therapy sessions to address an excruciating musculoskeletal injury!

Cardiac rehab reduces the risk of death in the period after a heart attack. It improves quality of life, mood and functional status. It also reduces the risk of hospital readmission. Every patient with a heart-related hospital stay should be offered (and should take advantage of) cardiac rehab.

If you or a family member find yourself diagnosed with a heart condition, ask your cardiologist or family doctor whether you qualify for cardiac rehab. If you do, GO. Go to ALL the sessions, go until they tell you not to come back anymore. Your heart will thank you!

QUESTION: Did you know about cardiac rehab? Do you know anyone who would benefit from it?

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Measles Outbreaks In The Pacific

Fever, rash, cough and congestion. These are the hallmarks of measles. Before the beginning of the measles vaccination program in the 1960s, there were 3-4 million cases of measles annually in the United States, almost 40,000 people were hospitalized, over 1000 people developed permanent disability from measles encephalopathy, and almost 500 people died. Every year. Most of these cases happened in children.

Now with vaccination rates falling, we are again seeing outbreaks of measles. Right now, there are measles outbreaks occurring in the South Pacific. It’s estimated that only 30% of the population of Samoa, for instance, have been vaccinated against measles, and they are in the midst of a terrible outbreak right now. Other countries are sending medical supplies, doses of vaccine and health care personnel to help deal with this outbreak.

Samoa is a country with about 200,000 people. 3,149 cases of measles have been reported, 197 people are hospitalized and 42 have died. To give some idea of the magnitude of this outbreak, we can compare to the United States, which has a population of 327.2 million people. This size of an outbreak in the US would result in 5.2 million cases, 322,000 people hospitalized, and 68,712 deaths. Most of Samoa’s deaths have been in children under 4 years of age.

Think about that. Imagine a United States in which almost 70,000 infants, toddlers and preschoolers were killed within a month’s time. Bearing in mind that those deaths are preventable, this outbreak in Samoa is a heartbreaking tragedy.

The good news for the USA is that vaccine coverage overall is still above 90%. However, there are 11 states in which coverage is under 90% and there are pockets where vaccine coverage is much, much lower. Amish people reject most modern medical innovations (including vaccines). Many California communities have vaccine coverage rates at about 50%. This is much lower than what is required to prevent outbreaks of measles.

Measles is the most contagious illness we know. It is a serious illness and potentially fatal. The vaccine is safe, so safe that in 1.5 million people vaccinated in Finland from 1982-1992 no deaths or serious permanent adverse reactions were reported.

If you are not immune to measles and are exposed, you have a 90% chance of getting sick. This is in comparison to influenza, which has about a 50% transmission rate. Parents who choose not to vaccinate their children are making a choice to leave them unprotected against a serious, possibly fatal, horribly contagious illness that is still endemic in parts of the world.

No vaccine is perfectly effective, but the MMR vaccine is pretty close. It eradicated measles, mumps and rubella in Finland in the 1980s with a 12-year, 2-dose vaccination schedule.

Measles is still present in the world. The MMR vaccine is the most effective weapon we have against this illness. Please be sure to vaccinate your children.

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Mental Health Professional Shortage

Tiffany came to see me as a new patient this week. She is a very nice young woman with a number of very big problems. She is a single mother to two daughters, one of whom is autistic. As a working mom, she has to juggle childcare and all the other household tasks. Her ex-husband is behind on child support and only rarely takes the girls for weekends. He has trouble managing their autistic child’s behaviors.

It probably won’t surprise you that Tiffany is REALLY stressed. She isn’t sleeping, and her anxiety is becoming harder to manage. She came in this week asking for a referral to a psychiatrist.

If you’ve been following me for a while, you probably know part of me started to do a quiet little happy dance on the inside as I was listening to my new friend. She was in the absolute perfect place because I have so many tools to help her. The one that I DON’T use often (and just sits dusty on the shelf almost all the time) is a psychiatry referral. I don’t need it except in rare cases.

It’s a good thing, too, because psychiatrists aren’t exactly thick on the ground in northern Ohio. In fact, most of the country has a severe mental health professional shortage.

Researchers found that this shortage is impacting how people get care for mental health problems in a big way. They looked at claims for mental health vs. physical health problems. The researchers found that people chose to go out of network and pay a larger share of the cost of treatment for their mental health problems.

While the researchers didn’t speak to patients directly and didn’t ask why they went out of network, it’s pretty obvious to me. Those of us in primary care know it takes months to get an appointment with a psychiatrist. Insurance companies often have only a handful of choices for in-network care, and many psychiatrists don’t take insurance at all because reimbursement is very low. If someone is severely sick or a danger to themselves or others, they are directed to the ER where they may be hospitalized. Otherwise they wait.

Here is my prescription for fixing our mental health care shortage:

  • Every single person needs to have an established relationship with a primary care doctor. This means a family doctor, general internal medicine doctor (NOT A SPECIALIST) or pediatrician for little kids. If you are reading this and don’t have a primary doctor, GET ONE. See him or her annually for your physical at a minimum. If you don’t like your primary doctor, get a new one!
  • Be aware of your lifestyle and its impact on your mood. Sleep, exercise, your spiritual practice, diet, ALL will impact your mood. Take small steps to improve your lifestyle before your mood starts to suffer!
  • If you start to feel stress is getting to you, see your primary doctor before things get bad. Don’t wait until you’re so sick you can’t function at all!
  • Consider seeing a counselor. Cognitive behavior therapy (CBT) is as effective as medication for mild-to-moderate depression and anxiety symptoms. It’s hard work, and requires a special kind of courage to unpack what’s going on in your life, but so worth it!
  • Psychiatrists need to send patients with depression and anxiety who are improved and in remission BACK TO THEIR PRIMARY DOCTOR for management. There is no excuse for psychiatrists to continue seeing patients who don’t need them. This will free up space in their schedule for patients who are truly in need of specialty care.

So what did I do for Tiffany? First I asked her to make an appointment with a counselor. I also asked her to start some nutrition therapy with a good multivitamin, B complex and magnesium supplements. Because she was really struggling I started her also on a low dose of an antidepressant and a gentle non-habit-forming sleeping pill.

As food for thought, we discussed the recent research showing diet’s impact on depression and anxiety and I gave her some suggestions. We’ll continue to discuss this in the future. I’m sure when I see her back in a few weeks she will be feeling better and much more in control.

I can’t fix the things going on in Tiffany’s life that are difficult for her. Divorce, single motherhood, working motherhood, and a child with a chronic illness are real stressors. However, depression and anxiety make hard things just that much harder. Treatment is effective, and doesn’t require a visit to a psychiatrist.

QUESTION: Did you know there is a mental health professional shortage?

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Go Green: Greens Are Good For You!

How many servings of leafy green vegetables did you eat today?  There are so many to choose from, it’s easy to get some every day.  They are soooo good for you and tasty too!  At the end of the post I’ll share my favorite kale recipe 🙂

Why are green vegetables so good for you?  Pound for pound they have the most nutrition of any food on our planet.  They are low-carb, low-calorie and full of good stuff!

1.  Vitamins and minerals:  Vitamins K, E, C, and many of the B vitamins, as well as potassium, magnesium, calcium and iron.

2.  Powerful plant pigments that function as precursors to other vitamins and as antioxidants.  Beta-carotene, chlorophyll, zeaxanthin and lutein are some of the phytonutrients found in dark leafy green veggies.  The brightly-colored pigments in plants help fight cancer by acting as antioxidants.

3.  Green veggies don’t contain as much fiber as, say, beans or lentils or whole grains but they have SOME.  Kale, for instance, has 2.6 grams fiber per 1-cup serving.  They also have a small amount of omega-3 fatty acids.

Nutrition experts estimate that our ancestors ate five pounds of green leaves every day!  They were hunter-gatherers and hunting green leaves was a lot easier than hunting animals.  They didn’t get up and run away, after all!  When game was scarce they simply ate the plants all around them.

So what is the best way to eat your greens?  The same way our ancestors did!  Raw 🙂  You can also lightly steam or saute them.  DON’T boil them (it leaches away the cancer-fighting phytonutrients) and don’t overcook them because that begins to destroy the nutrition.

Try adding a big salad of leafy greens every day.  Mix up your leaves or combine them to take advantage of different flavors.  Use just a little dressing and it’s best to make your own dressings fresh.  If you have a food processor it’s easy to whip up a small amount of fresh dressing for your salad.  Combining different oils (like olive, sesame or walnut) with different vinegars (such as balsamic, red wine, rice wine, or apple cider) and different spices is much healthier than using mass-produced bottled dressings.

One of the most nutritious leafy green vegetables is kale.  Kale is bitter and many people don’t like eating it raw (including me).  I much prefer it sauteed.  Here’s my recipe!

Dr. Jen’s Sauteed Kale

Ingredients

  • 1 tablespoon extra-virgin olive oil or sesame oil
  • 1/2 onion, peeled and chopped
  • 2 cloves garlic, minced
  • 1 large bunch kale, washed, stems removed, and coarsely chopped
  • golden raisins soaked in hot water to plump them
  • Handful of pecans, chopped

Directions

  1. Drizzle a large shallow pan with oil and heat over medium heat. Add the onion and garlic and saute about 5 minutes, until starting to soften.
  2. Add a little water to the pan (for steam) then add the kale.  Cover and steam for about 5 minutes, then drain the oily water out.  Transfer the kale to a bowl and top with plumped golden raisins and pecans.  Enjoy!

Please feel free to play with this recipe.  There are so many fruits that you could use to add a little sweet to balance the bitter kale.  Toasted almonds, walnuts or sesame seeds could also be used for variety.

Want another easy way to get your greens?  Shaklee’s Organic Greens Booster has kale, spinach and broccoli in a form that’s easy to add to soups and smoothies.

For more information, check out 13 easy ways to eat more greens and Fitness Magazine’s guide to leafy greens.

QUESTION:  What is your favorite leafy green vegetable, and how do you like to eat it?

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Soy and Breast Cancer

I have a lovely patient who suffers terribly with menopausal hot flushes.  It’s been years and they show no signs of stopping.  The problem is, she also has a condition that increases her risk of breast cancer.  Hormone replacement with estrogen, while it would help her hot flushes, would be dangerous for her.  Some time ago her oncologist told her she also should avoid soy because it has estrogen effects and may increase her breast cancer risk as well.

You probably know I hate to see anyone suffer.  I hate it even more when the reason for the suffering is based on faulty or outdated logic.  I know newer research has shown that soy foods and soy isoflavone supplements do not increase the risk of breast cancer, but I didn’t have the research to back that claim up.  Off to the research database!

First, some background info.  The reason so many doctors and scientists assumed soy was dangerous for breast cancer patients is because soy contains substances, called isoflavones, that are structured like estrogens.  There’s evidence they can bind to estrogen receptors in cells.

It was assumed that, since most breast cancer tumors are responsive to estrogen, that any estrogen activity would stimulate the cells to grow.  In fact, highly successful treatments for breast cancer like Tamoxifen and Arimidex act by blocking ALL estrogen activity.  As you can imagine, these medications cause a lot of side effects like hot flushes, vaginal dryness and other symptoms that mimic menopause.

You know what happens when we assume, right?  More recently, scientists have decided to question that assumption and look to see if soy intake (both soy foods and soy supplements) actually does increase the risk of breast cancer.

What did they find?  LOTS of studies are out there, but I just want to mention a few.  There was a review article published in late 2013 that looked at 131 different studies on soy foods and soy and red clover isoflavones.  There was evidence that eating soy foods was protective against breast cancer.  Even stronger evidence is that breast cancer patients taking Tamoxifen had no increased risk of recurrence when they used soy.

Another study published in February of 2014 analyzed 35 studies looking at associations between breast cancer risk and soy intake.  The study concluded that in Asia, soy intake reduced the risk of breast cancer in women both before and after menopause.  However, there was no change in breast cancer risk demonstrated in women in Western countries with soy intake.  There was certainly no evidence of an INCREASED risk of breast cancer in women using soy.

A very large study published in 2013 asked over 3800 women about their dietary patterns, including soy intake, when they enrolled in the study.  Over 14 years the authors tracked several variables in study participants, particularly breast cancer diagnosis, breast cancer mortality and all-cause mortality.  There was no difference in breast cancer risk or mortality (from breast cancer or other causes) in women with the highest soy intake vs. those with the lowest soy intake.

A review article published in Germany in 2016 also concluded that soy did not increase the risk of breast cancer and increases survival after breast cancer diagnosis.

It is pretty clear that soy intake does not increase the risk of breast cancer and may actually be protective in some populations.  Why is this?  There is a theory that soy isoflavones, while mimicking estrogens in structure, do not actually behave like estrogens.  Therefore, when they bind to estrogen receptors in cells, they block the actions of the person’s own estrogen molecules.  This theory could explain why soy isoflavones do not increase breast cancer recurrence in patients taking Tamoxifen for estrogen-sensitive breast cancer.  The soy actually behaves a bit LIKE Tamoxifen without the side effects.

If you have considered trying soy isoflavones to reduce hot flashes or using soy as a good source of complete dietary protein, there is plenty of good evidence that it won’t hurt you.  Even if you have a higher-than-normal risk of breast cancer, or have actually developed breast cancer, there’s no evidence that soy is harmful.  As always, you should always discuss supplementation with your doctor to make sure any supplements won’t interfere with your treatment plan.

QUESTION:  Do you have menopausal hot flashes?  Have you considered trying soy?  Have you been told it could be harmful?

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Diet Change And Depression

Depression and anxiety are incredibly common symptoms that we see in primary care. It is estimated that 75-90% of visits to doctors are related to problems caused or made worse by stress. I was so excited to see a new study published showing a link between diet change and depression symptoms!

We all have to eat. Most people recognize that our diet has a huge impact on our health. Heart attacks, strokes, cancers, obesity and many other illnesses are impacted by what we eat. Doctors spend a lot of time advising people to eat less sugar, less saturated fat, and more fresh fruits and vegetables.

Many people don’t realize what you eat affects your mood, too! I’ve had great success with nutritional supplements in helping people with depression and anxiety feel better. A new research study has shown a very clear association between diet change and depression as well.

Researchers in Australia studied 76 young adults with depression and anxiety symptoms. They were randomly assigned to two groups – one group got no intervention, and one group got instructions to improve their diet via a 13-minute video they could re-watch whenever they wanted to.

They were instructed to increase their intake of

  • vegetables to 5 servings per day
  • fruits to 2-3 servings per day
  • whole grains to 3 servings per day
  • lean protein (lean meat, poultry, eggs, tofu, legumes) to 3 servings per day (Remember, plant sources are healthier than animal)
  • unsweetened dairy to 3 servings per day
  • fish to 3 servings per week
  • nuts and seeds to 3 tablespoons per day
  • olive oil to 2 tablespoons per day

They were also instructed to take 1 teaspoon of turmeric and 1 teaspoon of cinnamon most days. They were to DECREASE their intake of refined carbohydrates, sugar, fatty or processed meats and soft drinks. They were given sample menus and handouts answering common questions as well.

After 3 weeks the average depression questionnaire scores had not changed in the control group, not surprisingly. However, in the diet-change group the scores had returned to normal! And the improvement was maintained when they were rechecked after 3 months.

This study supports what I’ve said for a long time. Depression and anxiety are not just related to stress or genetics. Our nutrition strongly impacts our brains’ ability to manage and cope with stress. A crappy diet predisposes us to depression and anxiety, and we can improve our mood by improving our diet.

If you struggle with stress, depression and/or anxiety, improving your diet is something you can do TODAY. Improving your diet is as effective as medication, and works just as quickly. It also has no side effects! What are you waiting for?!

QUESTION: Do you see a link between how you eat and how you feel?

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Gout Risk And Lifestyle Factors

Do you know anyone with gout? I do, unfortunately, quite a few people. It is one of the few illnesses I am willing to treat sight-unseen. It is on my top-five list of illnesses I NEVER want to have, right up there with kidney stones and cluster headaches.

We’ve known for a long time that gout risk is tied to lifestyle factors. It used to be known as the “disease of kings” and was associated with a rich diet, obesity, and alcohol intake. Recent research suggests that a huge percentage of gout risk is related to four risk factors: overweight and obesity, not eating a heart-healthy diet, alcohol intake and taking a diuretic medication.

First of all, what is gout? Gout is the most common inflammatory joint disease in the US. It is related to high blood levels of a substance called uric acid. When levels of this substance get high, it creates crystals in the joints that look like tiny needles under the microscope. Just looking at the crystals hurts! No wonder this illness is so painful!

A patient’s gout risk is directly related to serum uric acid levels. What makes uric acid go up? You got it – overweight or obesity, alcohol, a diet rich in meat, saturated fat and sugar, and diuretic medications.

Researchers at Harvard Medical School analyzed NHANES survey data and found that the most important risk factor for high uric acid levels was weight. People with a body mass index (BMI) over 35 were 3.5 times more likely to have high uric acid levels (and therefore increased gout risk) compared to people with a BMI less than 25. The higher the BMI, the higher the risk.

The closer people stuck to the DASH diet (the standard heart-healthy diet rich in fruits and vegetables and low in sodium, sugar and saturated fat) the better, too. Alcohol use increased the risk, and so did taking diuretics (water pills) for blood pressure and water retention.

If you or someone you love has gout, there are real things you can start to do TODAY to lower your uric acid levels and reduce your risk of gout attacks. You DO NOT want gout attacks. Trust me, I’ve seen them, it’s not pretty, and it is VERY painful. It will destroy your joints.

  • Stop drinking alcohol
  • Download a guide to the DASH diet and start following it. Reduce your intake of soda, sugar, processed foods, meat, dairy, eggs and shellfish. Add more fruits, veggies, beans, whole grains, nuts, seeds and fatty fish.
  • Over time, work on bringing your weight down. It won’t happen overnight but you CAN do it!
  • Talk to your doctor if you take water pills. The risk of causing gout isn’t huge, but it is there.

QUESTION: Do you know someone who has gout?

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