Some questions//Stroke Risk

[Guest guest]

Hello, everyone,

I am a relatively new member of this group but have had a long

experience with afib as my mother had it for many years before I

developed it. For me, the question of whether to use coumidin or not is

not so much on the odds of having a stroke (for me, they are quite low

as I have afib maybe 3 or 4 times a year and convert in 4 or 5 hours) as

it is on what happens when one has a stroke caused by afib. My mother

took coumidin for years and then needed surgery. She, of course, had to

stop taking coumidin and the result was she had a stroke. She went from

an independent, active, senior citizen, fully enjoying her golden years

to totally dependent with a different personality, luckily for me, as

her caregiver for the next year and half while working full time, a

sweet personality. But she wasn't my mother any more. Taking or not

taking coumidin is a decision most of us have to make but I would NEVER

want in a few minutes to change to someone so dependent on my family for

all of my basic care. I am not willing to take any risk of stroke when

I know first hand the consequences if I lose. I know that for some,

there is danger from a bleed in the brain and the consequences would be

same as a stroke or even bleeding to death (if one's INR is checked

frequently and in good control, there is little danger of a bleed - it

may take a little longer to stop the bleeding but not a significantly

longer time) and there are side effects for all of us who take it, but

for me, having seen the toll that a stroke can take not only on the

individual but on the family, I would think very carefully before I

would refuse coumidin.

, as for new drugs in the pipeline, Ellen sent us a link to a report

about a Canadian company called Cardiome Pharma Corp. that will be

reporting on a Phase III trial of new drug for afib/aflutter tomorrow,

March 14 at the American College of Cardiology Conference Scientific

Sessions 2006 in Atlanta, Georgia. Here is the link to the company:

http://www.cardiome.com/. Of course, it may be years before the drug

ever is ready for use but all the same, I bought 7 shares of stock in

support:-)

Kathy C. from Spokane, WA - Age 60, NSR, Toprol XL, 50 mg once a day

[Guest guest]

I had a mini stroke before being diagnosed with afib, I was put of

warfarin that day, my afib as I understand it is several short episodes

everyday. I think there are several factors that the doctors consider

before anticoagulation such as the frequency and length of afib episodes

and weighing up the risk against the benefits. As everyone is

different, it is important to raise your concerns with the doctor, if

you are not happy with the explanation given, then seek another opinion.

This seems a major issue for many afibbers, I personally found it the

most difficult thing to come to terms with when the answer to my

question on how long I need to be on warfarin? Was that I would need to

be on it for life.

ine

Re: Some questions//Stroke Risk

At what point in time are we at the highest risk of stroke ~~~ during

Afib,

during NSR, converting from Afib to NSR or NSR to Afib? It is my

understanding that the clot issue occurs when returning to NSR. I have

been

on Dofetilide for six years, and although I am in NSR, I have occasional

breakthroughs of Afib.

I read somewhere that cardiologist will down play afib in a young

adults,

but if you ask a nuerologist who treats stroke you will get the

response

that coumadin in Afib at any age is a must.They see the effects of the

Afib-stroke. I have had many inquires as to why, if I'm in NSR, am I

still

on Coumadin/Warfarin. Its because of the conversion period from Afib to

NSR.

As an avid Texas Hold'em Poker and Blackjack player, something else I

read

has always stuck with me ~~~~ when playing Blackjack, hold at 19! Why

take

the chance! I'm holding at 19!

Ellen

*****************************

> (snip) My AF is very intermitent, and self coverting ..sometimes 1

hour

> ...sometimes several hours. If I had permanent or chronic AF ..... or

AF

> that continually lated very long perioda of time, I would most likely

give

> strong consideration to coumadin. But the way things stand for me

right now,

> I honesly agree with my EP, that there is no need, at least at this

point.

>

>

******************************

[Guest guest]

my question is in young adults with lone a-fib does

the risk of being on coumadin outweight the risk o0f

stroke. the leading cause of death in my age group is

automobile accidents, and now i am on coumadin. and

does the research support coumadin is any more

effective than an aspirin a day??

--- E Gilmartin failteg@...> wrote:

> At what point in time are we at the highest risk of

> stroke ~~~ during Afib,

> during NSR, converting from Afib to NSR or NSR to

> Afib? It is my

> understanding that the clot issue occurs when

> returning to NSR. I have been

> on Dofetilide for six years, and although I am in

> NSR, I have occasional

> breakthroughs of Afib.

>

> I read somewhere that cardiologist will down play

> afib in a young adults,

> but if you ask a nuerologist who treats stroke you

> will get the response

> that coumadin in Afib at any age is a must.They see

> the effects of the

> Afib-stroke. I have had many inquires as to why, if

> I'm in NSR, am I still

> on Coumadin/Warfarin. Its because of the conversion

> period from Afib to

> NSR.

>

> As an avid Texas Hold'em Poker and Blackjack player,

> something else I read

> has always stuck with me ~~~~ when playing

> Blackjack, hold at 19! Why take

> the chance! I'm holding at 19!

>

> Ellen

> *****************************

> On 3/12/06, george alexander alexgpa@...>

> wrote:

>

> > (snip) My AF is very intermitent, and self

> coverting ..sometimes 1 hour

> > ...sometimes several hours. If I had permanent or

> chronic AF ..... or AF

> > that continually lated very long perioda of time,

> I would most likely give

> > strong consideration to coumadin. But the way

> things stand for me right now,

> > I honesly agree with my EP, that there is no need,

> at least at this point.

> >

> >

> ******************************

>

>

> [Non-text portions of this message have been

> removed]

>

>

__________________________________________________

[Guest guest]

This is a good string. I am 36 years old now and I also worry about

the long term effects of coumadin.

I developed AF around age 30 and was diagnosed at age 35. Long story

short, when my EP diagnosed me he advised me to go on coumadin, but

also mentioned that I could take aspirin instead. Fearing drug side

effects, I opted for aspirin. Two weeks later, I went back into AF and

developed a blood clot in my left atrium.

I spent the next three months in AF, off work, being very sedentary,

and scared to death that the blood clot would break loose and causes a

stroke or heart attach. Also, I was literally being put on the table

for a cardioversion when I told my EP of vision problems that I

experienced the night before. Luckily, he then decided to send me in

for a TEE before cardioversion. I hate to think what might have

happened if I had been cardioverted with a blood clot.

I am not advocating for, or against coumadin. I am just relaying my

story - as a fellow young AFibber. I now take coumadin, but I still

worry about the side effects. I am in and out of AF a lot so I have to

be really careful about blood clots. For me, I think that ablation is

the only way for me to get off the medication. I am having an ablation

at CC in November.

Best of luck to you!

Lori

> >

> > > (snip) My AF is very intermitent, and self

> > coverting ..sometimes 1 hour

> > > ...sometimes several hours. If I had permanent or

> > chronic AF ..... or AF

> > > that continually lated very long perioda of time,

> > I would most likely give

> > > strong consideration to coumadin. But the way

> > things stand for me right now,

> > > I honesly agree with my EP, that there is no need,

> > at least at this point.

> > >

> > >

> > ******************************

> >

> >

> > [Non-text portions of this message have been

> > removed]

> >

> >

>

>

> __________________________________________________

>

[Guest guest]

The clot risk is not only during conversion to NSR. I first found out about

my afib when I got a sharp pain in my side that turned out to be a blood

clot that went to my kidney.

Re: Some questions//Stroke Risk

my question is in young adults with lone a-fib does the risk of being on

coumadin outweight the risk o0f stroke. the leading cause of death in my age

group is automobile accidents, and now i am on coumadin. and does the

research support coumadin is any more effective than an aspirin a day??

--- E Gilmartin failteg@...> wrote:

> At what point in time are we at the highest risk of stroke ~~~ during

> Afib, during NSR, converting from Afib to NSR or NSR to Afib? It is

> my understanding that the clot issue occurs when returning to NSR. I

> have been on Dofetilide for six years, and although I am in NSR, I

> have occasional breakthroughs of Afib.

>

> I read somewhere that cardiologist will down play afib in a young

> adults, but if you ask a nuerologist who treats stroke you will get

> the response that coumadin in Afib at any age is a must.They see the

> effects of the Afib-stroke. I have had many inquires as to why, if

> I'm in NSR, am I still on Coumadin/Warfarin. Its because of the

> conversion period from Afib to NSR.

>

> As an avid Texas Hold'em Poker and Blackjack player, something else I

> read has always stuck with me ~~~~ when playing Blackjack, hold at 19!

> Why take the chance! I'm holding at 19!

>

> Ellen

> *****************************

> On 3/12/06, george alexander alexgpa@...>

> wrote:

>

> > (snip) My AF is very intermitent, and self

> coverting ..sometimes 1 hour

> > ...sometimes several hours. If I had permanent or

> chronic AF ..... or AF

> > that continually lated very long perioda of time,

> I would most likely give

> > strong consideration to coumadin. But the way

> things stand for me right now,

> > I honesly agree with my EP, that there is no need,

> at least at this point.

> >

> >

> ******************************

>

>

>

[Guest guest]

Hi all, I have left this story intact really as a warning on what can

happen.

Women have a tough time on Wafarin for oblivious reasons, I ma not sure how

this or will it affect the baby making for the future but I suspect it will.

If you go down the road of suffering and then have a PVA you want to feel

well. Alas if you have a stroke then you may have a bit of a problems trying

to get over that as this is life threatening.

C Uk On a dark winters night and only next week we change to summer

time where has global warming gone, Get out in those cars a pollute a bit

more. LOL

This is a good string. I am 36 years old now and I also worry about

the long term effects of coumadin.

I developed AF around age 30 and was diagnosed at age 35. Long story

short, when my EP diagnosed me he advised me to go on coumadin, but

also mentioned that I could take aspirin instead. Fearing drug side

effects, I opted for aspirin. Two weeks later, I went back into AF and

developed a blood clot in my left atrium.

I spent the next three months in AF, off work, being very sedentary,

and scared to death that the blood clot would break loose and causes a

stroke or heart attach. Also, I was literally being put on the table

for a cardioversion when I told my EP of vision problems that I

experienced the night before. Luckily, he then decided to send me in

for a TEE before cardioversion. I hate to think what might have

happened if I had been cardioverted with a blood clot.

I am not advocating for, or against coumadin. I am just relaying my

story - as a fellow young AFibber. I now take coumadin, but I still

worry about the side effects. I am in and out of AF a lot so I have to

be really careful about blood clots. For me, I think that ablation is

the only way for me to get off the medication. I am having an ablation

at CC in November.

Best of luck to you!

Lori

[Guest guest]

Hi john

Women do have a tough time, especially with long term anticoagulation.

It is not impossible to have a baby but there are risks, firstly the

advice is to come off warfarin before getting pregnant, secondly to

arrange with your doctor as heprin injections may be necessary.

Again it is about weighing up the benefits against the risks. For

myself after suffering a TIA I would not consider stopping the warfarn.

ine

RE: Re: Some questions//Stroke Risk

Hi all, I have left this story intact really as a warning on what can

happen.

Women have a tough time on Wafarin for oblivious reasons, I ma not sure

how

this or will it affect the baby making for the future but I suspect it

will.

If you go down the road of suffering and then have a PVA you want to

feel

well. Alas if you have a stroke then you may have a bit of a problems

trying

to get over that as this is life threatening.

C Uk On a dark winters night and only next week we change to summer

time where has global warming gone, Get out in those cars a pollute a

bit

more. LOL

This is a good string. I am 36 years old now and I also worry about

the long term effects of coumadin.

I developed AF around age 30 and was diagnosed at age 35. Long story

short, when my EP diagnosed me he advised me to go on coumadin, but

also mentioned that I could take aspirin instead. Fearing drug side

effects, I opted for aspirin. Two weeks later, I went back into AF and

developed a blood clot in my left atrium.

I spent the next three months in AF, off work, being very sedentary,

and scared to death that the blood clot would break loose and causes a

stroke or heart attach. Also, I was literally being put on the table

for a cardioversion when I told my EP of vision problems that I

experienced the night before. Luckily, he then decided to send me in

for a TEE before cardioversion. I hate to think what might have

happened if I had been cardioverted with a blood clot.

I am not advocating for, or against coumadin. I am just relaying my

story - as a fellow young AFibber. I now take coumadin, but I still

worry about the side effects. I am in and out of AF a lot so I have to

be really careful about blood clots. For me, I think that ablation is

the only way for me to get off the medication. I am having an ablation

at CC in November.

Best of luck to you!

Lori

Web Page - http://www.afibsupport.com

List owner: AFIBsupport-owner

For help on how to use the group, including how to drive it via email,

send a blank email to AFIBsupport-help

Nothing in this message should be considered as medical advice, or

should be acted upon without consultation with one's physician.

[Guest guest]

Hello:

Except on another website dedicated to Polycythemia Vera/other

blood diseases.....no one ever talks on afib websites about how we

can reduce our chances of having a blood clot, in addition to taking

Coumadin or some other blood thinner. .

So, if we reduce our hematocrit, we lessen the problems caused by

more viscous or thicker blood. The higher our

hemoglobin/hematocrit, the thicker or more viscous our blood is, and

this increases problems with blood flow, inappropriate clotting,

difficulties in cell function....etc.......author:

LeClair..Phd.

In my opinion, the clot risk is almost always there, especially, if

we don't hydrate well, or we don't consume at least 85mcg daily of

dietary vitamin K (about 1.5 cups of raw spinach or romaine is a

portion other wise it is usually 1/2 cup of cooked green leafy

veggies) or our hemoglobin is above 14 and our hematocrit is

above 42 (men or women)..... (the average ratio of hgb to hmt is

about 1:3)

Some of us may have a hypercoagulable blood....and we are totally

unaware of this factor......Also, if we eat fatty foods like:

cheese, butter, meat often, and we never watch the GI of the food

consumed....the above indulgences of fat and sugar floating in our

blood vessels, could also be a contributing cause of clots.

So, I believe the clot risk is not only there during conversion to

NSR but it is there much of the time.....

Isabelle

I first found out about

> my afib when I got a sharp pain in my side that turned out to be a

blood

> clot that went to my kidney.

>

>

>

>

[Guest guest]

Isabelle,

You've said in several posts that those of us on warfarin need to

take in at least 85 mcg of Vitamin K to avoid blood clots. I'm

having trouble following your logic here - if Vitamin K causes

clotting in the blood, why do we need at least 85 mcg of it daily? I

thought we were trying to avoid clotting.

Mike from Minnesota

>

> Hello:

>

> Except on another website dedicated to Polycythemia Vera/other

> blood diseases.....no one ever talks on afib websites about how we

> can reduce our chances of having a blood clot, in addition to

taking

> Coumadin or some other blood thinner. .

> >

> In my opinion, the clot risk is almost always there, especially,

if

> we don't hydrate well, or we don't consume at least 85mcg daily of

> dietary vitamin K (about 1.5 cups of raw spinach or romaine is a

> portion other wise it is usually 1/2 cup of cooked green leafy

> veggies)

> Isabelle

>

>

> I first found out about

> > my afib when I got a sharp pain in my side that turned out to be

a

> blood

> > clot that went to my kidney.

> >

> >

[Guest guest]

Ditto Mike's message.

Re: Some questions//Stroke Risk

Isabelle,

You've said in several posts that those of us on warfarin need to take in

at least 85 mcg of Vitamin K to avoid blood clots. I'm having trouble

following your logic here - if Vitamin K causes clotting in the blood, why

do we need at least 85 mcg of it daily? I thought we were trying to avoid

clotting.

Mike from Minnesota

>

> Hello:

>

> Except on another website dedicated to Polycythemia Vera/other blood

> diseases.....no one ever talks on afib websites about how we can

> reduce our chances of having a blood clot, in addition to

taking

> Coumadin or some other blood thinner. .

> >

> In my opinion, the clot risk is almost always there, especially,

if

> we don't hydrate well, or we don't consume at least 85mcg daily of

> dietary vitamin K (about 1.5 cups of raw spinach or romaine is a

> portion other wise it is usually 1/2 cup of cooked green leafy

> veggies)

> Isabelle

>

>

> I first found out about

> > my afib when I got a sharp pain in my side that turned out to be

a

> blood

> > clot that went to my kidney.

> >

> >

Web Page - http://www.afibsupport.com

List owner: AFIBsupport-owner

For help on how to use the group, including how to drive it via email,

send a blank email to AFIBsupport-help

Nothing in this message should be considered as medical advice, or should be

acted upon without consultation with one's physician.

[Guest guest]

I am having problems believing that you need to take Vit K, I was told

not to take it, the only thing taking Vit k will do will increase the

amount of warfarin. The only time I had vit K was when my INR was way

to high and was give by IV under hospital supervision. Warfarin is

essentially Rat Poison and Vit K is the antidote, therefore my taking

Vit K you are essentially stopping the anticoagulation process.

ine

Re: Some questions//Stroke Risk

Isabelle,

You've said in several posts that those of us on warfarin need to take

in

at least 85 mcg of Vitamin K to avoid blood clots. I'm having trouble

following your logic here - if Vitamin K causes clotting in the blood,

why

do we need at least 85 mcg of it daily? I thought we were trying to

avoid

clotting.

Mike from Minnesota

>

> Hello:

>

> Except on another website dedicated to Polycythemia Vera/other blood

> diseases.....no one ever talks on afib websites about how we can

> reduce our chances of having a blood clot, in addition to

taking

> Coumadin or some other blood thinner. .

> >

> In my opinion, the clot risk is almost always there, especially,

if

> we don't hydrate well, or we don't consume at least 85mcg daily of

> dietary vitamin K (about 1.5 cups of raw spinach or romaine is a

> portion other wise it is usually 1/2 cup of cooked green leafy

> veggies)

> Isabelle

>

>

> I first found out about

> > my afib when I got a sharp pain in my side that turned out to be

a

> blood

> > clot that went to my kidney.

> >

> >

Web Page - http://www.afibsupport.com

List owner: AFIBsupport-owner

For help on how to use the group, including how to drive it via email,

send a blank email to AFIBsupport-help

Nothing in this message should be considered as medical advice, or

should be

acted upon without consultation with one's physician.

[Guest guest]

>

> I am having problems believing that you need to take Vit K, I was

told

> not to take it, the only thing taking Vit k will do will increase the

> amount of warfarin. The only time I had vit K was when my INR was

way

> to high and was give by IV under hospital supervision. Warfarin is

> essentially Rat Poison and Vit K is the antidote, therefore my taking

> Vit K you are essentially stopping the anticoagulation process.

>

> ine

ine: Vitamin K does a lot of things other than inhibit warfarin

and your body needs a certain amount of it, which you're probably

getting from food unless you're intentionally omitting those foods

with Vitamin K.

There's a great discussion of that in the Life Extension April

Magazine which is not yet posted to their URL www.lef.org.

Gordon

[Guest guest]

ine: Vitamin K does a lot of things other than inhibit warfarin

and your body needs a certain amount of it, which you're probably

getting from food unless you're intentionally omitting those foods

with Vitamin K.

There's a great discussion of that in the Life Extension April

Magazine which is not yet posted to their URL www.lef.org.

Yes I agree and it is important to maintain a healthy diet with things

such as green leafy veggies and nuts whole meal bread etc, the important

thing is to get this vitamin this way and not turn to taking it in

tablet form. When I had my induction session for warfarin this was

explained to me, and the important of maintaining a regular intake of

foods that contain Vit K, if for example you eat lots of vit K foods

prior to PT testing and do not continue to do so after testing then your

INR will be to low. And vice versa. I personally tend to stick to one

healthy portion of green leafy veggies a day.

ine

Web Page - http://www.afibsupport.com

List owner: AFIBsupport-owner

For help on how to use the group, including how to drive it via email,

send a blank email to AFIBsupport-help

Nothing in this message should be considered as medical advice, or

should be acted upon without consultation with one's physician.

[Guest guest]

Hello and Mike:

You are both negating as so many other persons are, all the medical

and nutritional literature on vitamin K and the need for at least

85mcg daily whether you are on Coumadin or not. What is important

about it is that it needs to be taken in the same consistent amount

daily when on Coumadin.

Dietary vitamin K is, as I have mentioned before, a regulator of

blood viscosity, it helps to make blood flow better and may prevent

internal bleeding. In addition, it plays a role in calcium

metabolism and in forming strong bones. It also may prevent

osteoporosis

By the way, those green leafy veggies also provide anti-oxidents as

well as fiber, which help our bodies to function better and the

other nutrients also help in preventing drusen and possibly age-

related macular degeneration in our eyes. As we get older 1 in 3

persons may have significant vision loss due to AMD.

These green leafy veggies and avocado are needed daily, because very

little of vitamin K is stored in our bodies. Yes, it is a fat-

soluble vitamin but, it acts like a water soluble vitamin in that it

has to be consumed daily.

I hope this clarifies my previous posts discussing this vital

vitamin....Whether you are on Coumadin or not, if you avoid vitamin

K veggies, you will be more susceptible to both clots and bleeding

as well as osteoporosis later in life.

Did you see Dr House's TV program (6-8 months ago) about the patient

who never ate veggies? It was fascinating, she first was admitted

to the hospital for blood clots in her legs and was also observed to

have a mental condition....and as she spent time there, she suddenly

had severe internal bleeding.

Dr House felt she was too young to have blood clots in her legs

and sent his colleagues to the patient's house. Well, what they

found was a refrigerator full of frozen brand name,pre-packaged

hamburgers...Her 14 years son was taking care of her and he said

that was the only thing she would eat, he indulged her. He took

copious notes daily on her condition and was a really good son.

Dr. House also felt that she was not delusional and he checked her

eyes and found a big orange ring around her irises and diagnosed it

as some problem with copper metabolism, which he cured (never found

how) as well as her mental condition (apparently these two condition

were interrelated).

It was this program that propelled me, from that very evening on, to

do ongoing extensive research on this often overlooked vitamin, and

thus I found out, how important dietary vitamin K is to our health,

whether on Coumadin or not.

Please remember that vitamin K is not absorbed easily and we need to

take a little oil with it...to enhance absorption.

Thank you, for putting up with my dissertation on one of my favorite

topics....The need for dietary vitamin K is crucial.

Isabelle Bedell.,MPH

> >

> > Hello:

> >

> > Except on another website dedicated to Polycythemia Vera/other

blood

> > diseases.....no one ever talks on afib websites about how we can

> > reduce our chances of having a blood clot, in addition to

> taking

> > Coumadin or some other blood thinner. .

> > >

> > In my opinion, the clot risk is almost always there, especially,

> if

> > we don't hydrate well, or we don't consume at least 85mcg daily

of

> > dietary vitamin K (about 1.5 cups of raw spinach or romaine is

a

> > portion other wise it is usually 1/2 cup of cooked green leafy

> > veggies)

> > Isabelle

> >

> >

> > I first found out about

> > > my afib when I got a sharp pain in my side that turned out to

be

> a

> > blood

> > > clot that went to my kidney.

> > >

> > > a

>

>

>

>

>

>

> Web Page - http://www.afibsupport.com

> List owner: AFIBsupport-owner

> For help on how to use the group, including how to drive it via

email,

> send a blank email to AFIBsupport-help

>

> Nothing in this message should be considered as medical advice, or

should be

> acted upon without consultation with one's physician.

>

[Guest guest]

ine,

I think you mean just the opposite. If you eat lots of Vitamin K

foods prior to testing and do not continue to do so after testing,

then your INR will be too high, not too low. And vice versa.

Mike from Minnesota

When I had my induction session for warfarin this was

> explained to me, and the important of maintaining a regular intake

of

> foods that contain Vit K, if for example you eat lots of vit K foods

> prior to PT testing and do not continue to do so after testing then

your

> INR will be to low. And vice versa. I personally tend to stick to

one

> healthy portion of green leafy veggies a day.

> ine

>

>

>

>

>

>

> Web Page - http://www.afibsupport.com

> List owner: AFIBsupport-owner

> For help on how to use the group, including how to drive it via

email,

> send a blank email to AFIBsupport-help

>

> Nothing in this message should be considered as medical advice, or

> should be acted upon without consultation with one's physician.

>

[Guest guest]

Yes, sorry I meant too high

My apologies if I confused anyone

ine

Re: Some questions//Stroke Risk

ine,

I think you mean just the opposite. If you eat lots of Vitamin K

foods prior to testing and do not continue to do so after testing,

then your INR will be too high, not too low. And vice versa.

Mike from Minnesota

When I had my induction session for warfarin this was

> explained to me, and the important of maintaining a regular intake

of

> foods that contain Vit K, if for example you eat lots of vit K foods

> prior to PT testing and do not continue to do so after testing then

your

> INR will be to low. And vice versa. I personally tend to stick to

one

> healthy portion of green leafy veggies a day.

> ine

>

>

>

>

>

>

> Web Page - http://www.afibsupport.com

> List owner: AFIBsupport-owner

> For help on how to use the group, including how to drive it via

email,

> send a blank email to AFIBsupport-help

>

> Nothing in this message should be considered as medical advice, or

> should be acted upon without consultation with one's physician.

>