Welcome to the 2024 update on Renew reviews, where we delve into the latest insights surrounding this dietary supplement. In this comprehensive analysis, we explore various facets of Renew, ranging from its effectiveness in promoting weight loss to its impact on overall well-being. With a focus on user experiences and scientific evidence, we aim to provide a nuanced perspective on the efficacy and safety of Renew.
Renew has garnered significant attention for its purported benefits in supporting weight loss, enhancing sleep quality, and promoting overall health. As individuals seek natural solutions to address health concerns, Renew has emerged as a popular choice, drawing interest from consumers seeking to optimize their wellness journey.
​
Renew Reviews : Scam Or Legit (Salt Water Trick) Should You Try This Metabolism Booster?
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!
Among the key areas of interest are Renew's potential effects on liver health, nerve function, and metabolic regulation. Liver Renew reviews and Nerve Renew reviews offer insights into how this supplement may impact vital physiological processes, such as detoxification and nerve signaling. Additionally, scrutiny of Renew's formula and efficacy extends to other formulations, including Naked and Thriving Renew Serum and Renew My Smile.
However, amidst the positive testimonials and endorsements, questions arise regarding the authenticity and reliability of Renew. Liver Renew reviews complaints and inquiries about Renew as a scam prompt critical examination into the product's claims and performance. Is Renew truly a good product, or does it fall short of expectations?
In this exploration of Renew supplement reviews, we aim to provide clarity and transparency, empowering consumers to make informed decisions about their health and wellness journey. Join us as we navigate the landscape of Renew reviews and uncover the truth behind this dietary supplement.
Supplement Name:
Renew
Supplement Form:
Capsules
Supplement Category:
Dietary supplements

Renew Pros and Cons :

Before diving into the key features of Renew, it's essential to understand both its strengths and limitations. Evaluating the pros and cons can provide a balanced perspective on the supplement, allowing individuals to make informed decisions about its suitability for their needs.

Pros:

1. Natural ingredients formulation
2. Supports deep sleep and rejuvenation
3. Promotes healthy weight loss
4. Enhances metabolism and energy levels
5. Vegan-friendly and non-GMO
6. Backed by scientific research and evidence
7. Manufactured in FDA-approved facilities
8. 60-day money-back guarantee

Cons:

1. Limited availability, only sold on official website
2. No option for auto-shipping
3. Potential risk of going out of stock due to popularity

What is Renew?

Renew is a dietary supplement designed to promote deep sleep and support the body's natural regeneration processes. It is formulated using natural ingredients that target sleep quality, metabolism, and overall well-being. By addressing sleep issues, Renew aims to enhance weight loss, increase energy levels, and improve overall health.

Creator of Renew

The creator of Renew remains undisclosed, but the supplement is developed with the collaboration of a team of doctors and health experts. Their collective expertise in health and wellness contributed to the formulation of Renew, aiming to address the growing concern of poor sleep quality and its impact on health. Despite the anonymity of the primary creator, Renew is crafted with careful consideration and adherence to high-quality standards.

Science Behind The Working Of Renew

Renew works by leveraging natural ingredients that have been scientifically studied for their effects on sleep quality and metabolic function. Ingredients such as melatonin, Withania somnifera, and L-Theanine are known to promote relaxation, improve sleep onset, and support overall rejuvenation during rest. By enhancing deep sleep and metabolic processes, Renew facilitates weight loss, boosts energy levels, and contributes to overall well-being. The blend of ingredients in Renew is carefully selected to synergistically support various aspects of health, backed by scientific research and evidence.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Ingredients Used In Renew

Renew is a dietary supplement formulated with a blend of natural ingredients known for their potential to support deep sleep, metabolism, and overall health. Each ingredient plays a unique role in promoting well-being and rejuvenation. Let's delve into the key ingredients of Renew:

1. Withania somnifera (Ashwagandha)

Withania somnifera, commonly known as Ashwagandha, is an adaptogenic herb used in traditional Ayurvedic medicine for centuries. It is revered for its ability to combat stress, enhance vitality, and promote overall well-being. Ashwagandha's adaptogenic properties help the body adapt to stressors, promoting a sense of calm and relaxation conducive to deep sleep.
Benefits:

• Reduces stress and anxiety levels, promoting relaxation.
• Supports healthy adrenal function, aiding in stress management.
• Enhances energy levels and vitality, combating fatigue and promoting overall well-being.

1. Griffonia simplicifolia

Griffonia simplicifolia is a plant native to West Africa, known for its high content of 5-Hydroxytryptophan (5-HTP), a precursor to serotonin. Serotonin is a neurotransmitter involved in regulating mood, sleep, and appetite. By increasing serotonin levels, Griffonia simplicifolia promotes relaxation, improves sleep quality, and supports mood balance.
Benefits:

• Improves sleep quality by enhancing serotonin levels and promoting relaxation.
• Supports mood balance and mental well-being.
• Regulates appetite and may aid in weight management.

1. L-Theanine

L-Theanine is an amino acid found in tea leaves, particularly green tea, known for its calming and relaxing effects. It promotes alpha brain wave production, inducing a state of relaxation without sedation. L-Theanine also modulates neurotransmitter levels, including dopamine and serotonin, which contribute to mood regulation and sleep quality.
Benefits:

• Promotes relaxation and reduces stress and anxiety levels.
• Enhances sleep quality by supporting alpha brain wave production.
• Improves cognitive function and mental clarity.

These ingredients work synergistically to promote deep sleep, enhance metabolism, and support overall health and well-being. By addressing various aspects of sleep and metabolic function, Renew offers a holistic approach to health optimization.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

How Does Renew Work?

Renew works by harnessing the power of its natural ingredients to promote deep sleep, enhance metabolism, and support overall health. Let's explore the mechanisms behind its efficacy:

1. Sleep Promotion

Renew contains ingredients like Ashwagandha, Griffonia simplicifolia, and L-Theanine, known for their calming and relaxing effects. These ingredients promote the production of neurotransmitters like serotonin, which regulates mood and sleep-wake cycles. By increasing serotonin levels, Renew helps induce a state of relaxation conducive to deep sleep. Additionally, L-Theanine promotes alpha brain wave production, facilitating relaxation without sedation, leading to improved sleep quality.

1. Metabolism Enhancement

Certain ingredients in Renew, such as Ashwagandha and L-Theanine, have been shown to support metabolism and energy expenditure. Ashwagandha enhances mitochondrial function in adipose tissue and skeletal muscle, promoting energy expenditure and metabolic wellness. By boosting metabolism, Renew helps the body burn calories more efficiently, aiding in weight management and fat loss. Additionally, improved sleep quality and reduced stress levels contribute to metabolic health by optimizing hormone regulation and energy balance.

1. Stress Reduction

Chronic stress can disrupt sleep patterns and metabolism, leading to weight gain and metabolic dysfunction. Renew contains adaptogenic herbs like Ashwagandha, which help the body adapt to stress and promote relaxation. By reducing stress levels, Renew supports healthy sleep and metabolic function. The calming effects of Ashwagandha and L-Theanine also alleviate anxiety and promote mental well-being, contributing to overall stress reduction and improved sleep quality.

1. Hormone Regulation

Sleep plays a crucial role in hormone regulation, including hormones involved in appetite control, metabolism, and energy balance. Renew promotes deep sleep, which is essential for the release of hormones like growth hormone and leptin, which regulate metabolism and appetite. By optimizing hormone levels, Renew helps maintain energy balance, reduce cravings, and support weight management. Additionally, improved sleep quality enhances insulin sensitivity, reducing the risk of insulin resistance and metabolic disorders.

1. Cellular Repair and Regeneration

During deep sleep, the body undergoes cellular repair and regeneration processes essential for overall health and well-being. Renew supports these processes by promoting uninterrupted deep sleep, allowing the body to repair damaged tissues, detoxify, and regenerate cells. Ingredients like Ashwagandha and Griffonia simplicifolia enhance sleep quality and duration, facilitating optimal cellular repair and regeneration. This promotes overall health and vitality, supporting longevity and wellness.
Renew's holistic approach to health optimization addresses sleep quality, metabolism, stress reduction, hormone regulation, and cellular repair. By targeting multiple aspects of health, Renew offers comprehensive support for overall well-being and vitality.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Renew Health Benefits

Renew offers a range of health benefits attributed to its natural ingredients and their synergistic effects on the body. Let's explore some of the key benefits:

1. Improved Sleep Quality

Renew promotes deep and restful sleep, allowing the body to undergo essential repair and regeneration processes during the night. Ingredients like Melatonin, Griffonia simplicifolia, and L-Theanine help regulate sleep-wake cycles, induce relaxation, and enhance sleep duration and quality. Better sleep quality leads to increased energy levels, improved mood, and overall well-being.

1. Enhanced Metabolism

By supporting metabolism and energy expenditure, Renew aids in weight management and fat loss. Ingredients like Ashwagandha and L-Theanine boost metabolic function, promote energy expenditure, and optimize hormone regulation. This leads to increased calorie burning, reduced fat storage, and improved body composition. Additionally, better sleep quality and stress reduction contribute to metabolic health and overall weight management.

1. Stress Reduction

Renew contains adaptogenic herbs like Ashwagandha, known for their stress-relieving properties. These ingredients help the body adapt to stress, reduce anxiety, and promote relaxation. By lowering stress levels, Renew supports better sleep quality, enhances mood, and improves overall mental well-being. Reduced stress also benefits metabolic health by optimizing hormone regulation and energy balance.

1. Hormone Regulation

Optimal sleep is essential for hormone regulation, including hormones involved in appetite control, metabolism, and energy balance. Renew promotes deep sleep, which facilitates the release of hormones like growth hormone and leptin, regulating metabolism and appetite. By balancing hormone levels, Renew helps maintain energy balance, reduce cravings, and support weight management. Improved sleep quality also enhances insulin sensitivity, reducing the risk of metabolic disorders.

1. Cellular Repair and Regeneration

During deep sleep, the body undergoes vital cellular repair and regeneration processes crucial for overall health and longevity. Renew supports these processes by promoting uninterrupted deep sleep, allowing the body to repair damaged tissues, detoxify, and regenerate cells. Ingredients like Ashwagandha and Griffonia simplicifolia enhance sleep quality and duration, facilitating optimal cellular repair and regeneration. This promotes overall health, vitality, and resilience.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

How To Use Renew Effectively?

To maximize the benefits of Renew, follow these guidelines for effective use:

1. Take 3 Renew capsules daily, preferably 30 minutes before bedtime.
2. Consistency is key – take Renew consistently every night to maintain a healthy sleep routine.
3. Pair Renew with a balanced diet and regular exercise for optimal results.
4. Avoid consuming stimulants like caffeine or nicotine close to bedtime, as they may interfere with sleep quality.
5. Create a relaxing bedtime routine to signal to your body that it's time to wind down and prepare for sleep.
6. Consult with a healthcare professional before starting any new supplement regimen, especially if you have underlying health conditions or are taking medication.

By following these recommendations, you can effectively incorporate Renew into your daily routine and experience its full range of health benefits.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Renew Side Effects

While Renew is generally well-tolerated, some users may experience mild digestive discomfort, such as bloating or gas, especially when first starting the supplement. These side effects typically subside as the body adjusts to the ingredients.

Is Renew Safe?

Renew is considered safe for most individuals when taken as directed. It is formulated with natural ingredients and manufactured in FDA-approved facilities following Good Manufacturing Practices (GMP). However, individuals with underlying health conditions, pregnant or nursing women, and those taking medication should consult with a healthcare professional before using Renew.

Who Should Use Renew?

Renew is suitable for individuals looking to improve sleep quality, support weight management, reduce stress, and enhance overall well-being. It is ideal for adults seeking a natural solution for better sleep and metabolism. Additionally, individuals experiencing sleep disturbances, stress-related issues, or weight management challenges may benefit from using Renew.

Who Should Avoid Renew?

While Renew is safe for most adults, certain individuals should avoid using it without consulting a healthcare professional. This includes pregnant or nursing women, individuals with pre-existing health conditions, and those taking medication that may interact with Renew's ingredients. Additionally, children and individuals allergic to any of the ingredients should refrain from using Renew. It's essential to prioritize safety and seek medical advice if unsure about using Renew.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Renew Customer Reviews

1. Sarah from New York: "I was skeptical about trying Renew at first, but I'm so glad I did. After struggling with poor sleep and low energy levels for months, I decided to give it a shot. Within just a few weeks, I noticed a significant improvement in my sleep quality. I wake up feeling refreshed and energized, ready to tackle the day ahead. Plus, the natural ingredients make me feel good about what I'm putting into my body."
2. Michael from Los Angeles: "As someone who's always been conscious of their health, finding a supplement like Renew was a game-changer for me. Not only did it help me shed those stubborn extra pounds, but it also improved my overall well-being. I've noticed a significant increase in my energy levels and mental clarity since starting Renew. Plus, the fact that it's made with natural ingredients is a huge bonus for me."
3. Emily from Chicago: "I've struggled with insomnia for years, trying countless remedies with little success. However, Renew has been a game-changer for me. Not only am I sleeping better than ever before, but I've also noticed improvements in my mood and stress levels. I feel more relaxed and centered throughout the day, thanks to Renew. It's truly been a lifesaver for me."
4. David from Miami: "Renew has exceeded all my expectations. As someone who leads a busy lifestyle, I often find it challenging to unwind and get quality sleep. However, since incorporating Renew into my nightly routine, I've noticed a significant improvement in my sleep quality. I wake up feeling more rested and rejuvenated, ready to take on whatever the day throws at me."
5. Jennifer from San Francisco: "After struggling with weight loss for years, I was hesitant to try yet another supplement. However, Renew has been a game-changer for me. Not only have I lost weight, but I also feel healthier and more vibrant overall. I've noticed improvements in my skin, hair, and energy levels since starting Renew. It's truly been a transformative experience for me."
6. Alex from Seattle: "I've always been a skeptic when it comes to supplements, but Renew has made me a believer. Not only does it help me get a better night's sleep, but it also boosts my energy levels and mood during the day. Plus, the fact that it's made with natural ingredients gives me peace of mind. I can't recommend Renew enough."
7. Natalie from Boston: "Renew has been a game-changer for me. As someone who struggles with anxiety and stress, I've found that Renew helps me relax and unwind at the end of a long day. I sleep better, feel more energized, and have noticed improvements in my overall well-being since starting Renew. It's become an essential part of my self-care routine."
8. Daniel from Houston: "I've tried countless supplements in the past, but none have worked as well as Renew. Not only does it help me sleep better, but it also supports my weight loss goals and boosts my energy levels. I've noticed a significant improvement in my overall health and well-being since starting Renew. It's become a staple in my daily routine."
9. Sophia from Atlanta: "Renew has been a lifesaver for me. As someone who struggles with insomnia, finding a supplement that actually works has been a game-changer. I've noticed a significant improvement in my sleep quality since starting Renew. Plus, the fact that it's made with natural ingredients gives me peace of mind. I can't recommend Renew enough to anyone struggling with sleep issues."
10. Ryan from Dallas: "I was skeptical about trying Renew at first, but I'm so glad I did. Not only does it help me sleep better, but it also supports my weight loss goals and boosts my energy levels. I've noticed a significant improvement in my overall health and well-being since starting Renew. Plus, the fact that it's made with natural ingredients gives me peace of mind. It's become a must-have in my daily routine."

=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Where to Buy Renew?

Renew can be purchased exclusively from its official website. This ensures that customers receive genuine products and have access to any special offers or discounts provided by the manufacturer. Buying directly from the official website also guarantees customer support and assistance with any inquiries or issues.

Renew Pricing

• 1-month supply: $69 per bottle
• 3-month supply: $49 per bottle
• 6-month supply: $39 per bottle

Purchasing larger quantities offers significant savings per bottle, making it a cost-effective option for long-term use.

Refund Policy of Renew

Renew offers a 60-day money-back guarantee on all purchases. If customers are not satisfied with the product for any reason, they can request a full refund within 60 days of purchase, no questions asked. This policy ensures that customers can try Renew risk-free and provides peace of mind when making a purchase.

Bonuses of Renew

In addition to the product itself, Renew may offer bonuses or special deals to customers, especially when purchasing multiple bottles. These bonuses could include free shipping, additional bottles at discounted rates, or complementary health resources such as e-books or guides. Customers should check the official website for any current bonus offers available with their purchase.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

FAQs of Renew

1. Is Renew safe to use? Renew is crafted from natural ingredients in FDA-approved facilities, making it generally safe for consumption. However, individuals with specific health conditions or allergies should consult a healthcare professional before use.
2. How long does it take to see results with Renew? Results may vary, but many users report noticing improvements in sleep quality and overall well-being within a few weeks of consistent use. For optimal results, it's recommended to use Renew as directed for at least a month.
3. Can Renew be used by pregnant or breastfeeding women? Pregnant or breastfeeding women should avoid using Renew without consulting a healthcare provider, as the effects of the supplement on maternal and fetal health are not well-studied.
4. Are there any side effects associated with Renew? While side effects are rare, some users may experience mild digestive discomfort initially. It's essential to follow the recommended dosage and monitor for any adverse reactions.
5. How should I take Renew for best results? The recommended dosage is three capsules daily, taken approximately 30 minutes before bedtime. Consistency is key to experiencing the full benefits of Renew.
6. Can Renew be taken with other medications? Individuals taking prescription medications should consult a healthcare professional before using Renew to avoid potential interactions.
7. Is Renew suitable for vegetarians/vegans? Yes, Renew is formulated with plant-based ingredients and is suitable for vegetarians and vegans.
8. Does Renew contain any stimulants? No, Renew is free from stimulants, artificial preservatives, dairy, and soy, making it a suitable option for those sensitive to stimulants.
9. Is Renew FDA-approved? While individual supplements like Renew are not FDA-approved, the facilities where it is manufactured follow FDA regulations to ensure quality and safety.
10. What is the recommended duration of use for Renew? Renew can be used continuously for as long as desired to support sleep quality and overall well-being. Some individuals may choose to incorporate it into their daily routine long-term for ongoing benefits.

Renew Reviews - Final Word

Renew has garnered positive feedback from users, highlighting its efficacy in promoting deep sleep, enhancing overall well-being, and supporting weight loss efforts. The natural ingredients in Renew have been carefully selected to address sleep issues and metabolic function, leading to improved energy levels, mood, and physical health.
Users have reported experiencing better sleep patterns, increased energy during the day, and noticeable improvements in weight management. The supplement's formulation, free from stimulants and artificial additives, appeals to those seeking a natural approach to health and wellness.
While individual experiences may vary, Renew has generally been well-received by customers seeking a holistic solution to sleep and weight management. With its 100% money-back guarantee and positive user testimonials, Renew emerges as a promising option for individuals looking to improve their sleep quality and overall health.
In summary, Renew offers a safe and effective way to address sleep-related issues and support weight loss goals, making it a valuable addition to a healthy lifestyle regimen.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Welcome to the 2024 update on Renew reviews, where we delve into the latest insights surrounding this dietary supplement. In this comprehensive analysis, we explore various facets of Renew, ranging from its effectiveness in promoting weight loss to its impact on overall well-being. With a focus on user experiences and scientific evidence, we aim to provide a nuanced perspective on the efficacy and safety of Renew.
Renew has garnered significant attention for its purported benefits in supporting weight loss, enhancing sleep quality, and promoting overall health. As individuals seek natural solutions to address health concerns, Renew has emerged as a popular choice, drawing interest from consumers seeking to optimize their wellness journey.
​
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!
Posted 2 days ago by Renew Reviews: Pros, Cons, Ingredients, Pricing and Results Revealed!
Among the key areas of interest are Renew's potential effects on liver health, nerve function, and metabolic regulation. Liver Renew reviews and Nerve Renew reviews offer insights into how this supplement may impact vital physiological processes, such as detoxification and nerve signaling. Additionally, scrutiny of Renew's formula and efficacy extends to other formulations, including Naked and Thriving Renew Serum and Renew My Smile.
However, amidst the positive testimonials and endorsements, questions arise regarding the authenticity and reliability of Renew. Liver Renew reviews complaints and inquiries about Renew as a scam prompt critical examination into the product's claims and performance. Is Renew truly a good product, or does it fall short of expectations?
In this exploration of Renew supplement reviews, we aim to provide clarity and transparency, empowering consumers to make informed decisions about their health and wellness journey. Join us as we navigate the landscape of Renew reviews and uncover the truth behind this dietary supplement.
Supplement Name:
Renew
Supplement Form:
Capsules
Supplement Category:
Dietary supplements

Renew Pros and Cons :

Before diving into the key features of Renew, it's essential to understand both its strengths and limitations. Evaluating the pros and cons can provide a balanced perspective on the supplement, allowing individuals to make informed decisions about its suitability for their needs.

Pros:

1. Natural ingredients formulation
2. Supports deep sleep and rejuvenation
3. Promotes healthy weight loss
4. Enhances metabolism and energy levels
5. Vegan-friendly and non-GMO
6. Backed by scientific research and evidence
7. Manufactured in FDA-approved facilities
8. 60-day money-back guarantee

Cons:

1. Limited availability, only sold on official website
2. No option for auto-shipping
3. Potential risk of going out of stock due to popularity

What is Renew?

Renew is a dietary supplement designed to promote deep sleep and support the body's natural regeneration processes. It is formulated using natural ingredients that target sleep quality, metabolism, and overall well-being. By addressing sleep issues, Renew aims to enhance weight loss, increase energy levels, and improve overall health.

Creator of Renew

The creator of Renew remains undisclosed, but the supplement is developed with the collaboration of a team of doctors and health experts. Their collective expertise in health and wellness contributed to the formulation of Renew, aiming to address the growing concern of poor sleep quality and its impact on health. Despite the anonymity of the primary creator, Renew is crafted with careful consideration and adherence to high-quality standards.

Science Behind The Working Of Renew

Renew works by leveraging natural ingredients that have been scientifically studied for their effects on sleep quality and metabolic function. Ingredients such as melatonin, Withania somnifera, and L-Theanine are known to promote relaxation, improve sleep onset, and support overall rejuvenation during rest. By enhancing deep sleep and metabolic processes, Renew facilitates weight loss, boosts energy levels, and contributes to overall well-being. The blend of ingredients in Renew is carefully selected to synergistically support various aspects of health, backed by scientific research and evidence.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Ingredients Used In Renew

Renew is a dietary supplement formulated with a blend of natural ingredients known for their potential to support deep sleep, metabolism, and overall health. Each ingredient plays a unique role in promoting well-being and rejuvenation. Let's delve into the key ingredients of Renew:

1. Withania somnifera (Ashwagandha)

Withania somnifera, commonly known as Ashwagandha, is an adaptogenic herb used in traditional Ayurvedic medicine for centuries. It is revered for its ability to combat stress, enhance vitality, and promote overall well-being. Ashwagandha's adaptogenic properties help the body adapt to stressors, promoting a sense of calm and relaxation conducive to deep sleep.
Benefits:

• Reduces stress and anxiety levels, promoting relaxation.
• Supports healthy adrenal function, aiding in stress management.
• Enhances energy levels and vitality, combating fatigue and promoting overall well-being.

1. Griffonia simplicifolia

Griffonia simplicifolia is a plant native to West Africa, known for its high content of 5-Hydroxytryptophan (5-HTP), a precursor to serotonin. Serotonin is a neurotransmitter involved in regulating mood, sleep, and appetite. By increasing serotonin levels, Griffonia simplicifolia promotes relaxation, improves sleep quality, and supports mood balance.
Benefits:

• Improves sleep quality by enhancing serotonin levels and promoting relaxation.
• Supports mood balance and mental well-being.
• Regulates appetite and may aid in weight management.

1. L-Theanine

L-Theanine is an amino acid found in tea leaves, particularly green tea, known for its calming and relaxing effects. It promotes alpha brain wave production, inducing a state of relaxation without sedation. L-Theanine also modulates neurotransmitter levels, including dopamine and serotonin, which contribute to mood regulation and sleep quality.
Benefits:

• Promotes relaxation and reduces stress and anxiety levels.
• Enhances sleep quality by supporting alpha brain wave production.
• Improves cognitive function and mental clarity.

These ingredients work synergistically to promote deep sleep, enhance metabolism, and support overall health and well-being. By addressing various aspects of sleep and metabolic function, Renew offers a holistic approach to health optimization.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

How Does Renew Work?

Renew works by harnessing the power of its natural ingredients to promote deep sleep, enhance metabolism, and support overall health. Let's explore the mechanisms behind its efficacy:

1. Sleep Promotion

Renew contains ingredients like Ashwagandha, Griffonia simplicifolia, and L-Theanine, known for their calming and relaxing effects. These ingredients promote the production of neurotransmitters like serotonin, which regulates mood and sleep-wake cycles. By increasing serotonin levels, Renew helps induce a state of relaxation conducive to deep sleep. Additionally, L-Theanine promotes alpha brain wave production, facilitating relaxation without sedation, leading to improved sleep quality.

1. Metabolism Enhancement

Certain ingredients in Renew, such as Ashwagandha and L-Theanine, have been shown to support metabolism and energy expenditure. Ashwagandha enhances mitochondrial function in adipose tissue and skeletal muscle, promoting energy expenditure and metabolic wellness. By boosting metabolism, Renew helps the body burn calories more efficiently, aiding in weight management and fat loss. Additionally, improved sleep quality and reduced stress levels contribute to metabolic health by optimizing hormone regulation and energy balance.

1. Stress Reduction

Chronic stress can disrupt sleep patterns and metabolism, leading to weight gain and metabolic dysfunction. Renew contains adaptogenic herbs like Ashwagandha, which help the body adapt to stress and promote relaxation. By reducing stress levels, Renew supports healthy sleep and metabolic function. The calming effects of Ashwagandha and L-Theanine also alleviate anxiety and promote mental well-being, contributing to overall stress reduction and improved sleep quality.

1. Hormone Regulation

Sleep plays a crucial role in hormone regulation, including hormones involved in appetite control, metabolism, and energy balance. Renew promotes deep sleep, which is essential for the release of hormones like growth hormone and leptin, which regulate metabolism and appetite. By optimizing hormone levels, Renew helps maintain energy balance, reduce cravings, and support weight management. Additionally, improved sleep quality enhances insulin sensitivity, reducing the risk of insulin resistance and metabolic disorders.

1. Cellular Repair and Regeneration

During deep sleep, the body undergoes cellular repair and regeneration processes essential for overall health and well-being. Renew supports these processes by promoting uninterrupted deep sleep, allowing the body to repair damaged tissues, detoxify, and regenerate cells. Ingredients like Ashwagandha and Griffonia simplicifolia enhance sleep quality and duration, facilitating optimal cellular repair and regeneration. This promotes overall health and vitality, supporting longevity and wellness.
Renew's holistic approach to health optimization addresses sleep quality, metabolism, stress reduction, hormone regulation, and cellular repair. By targeting multiple aspects of health, Renew offers comprehensive support for overall well-being and vitality.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Renew Health Benefits

Renew offers a range of health benefits attributed to its natural ingredients and their synergistic effects on the body. Let's explore some of the key benefits:

1. Improved Sleep Quality

Renew promotes deep and restful sleep, allowing the body to undergo essential repair and regeneration processes during the night. Ingredients like Melatonin, Griffonia simplicifolia, and L-Theanine help regulate sleep-wake cycles, induce relaxation, and enhance sleep duration and quality. Better sleep quality leads to increased energy levels, improved mood, and overall well-being.

1. Enhanced Metabolism

By supporting metabolism and energy expenditure, Renew aids in weight management and fat loss. Ingredients like Ashwagandha and L-Theanine boost metabolic function, promote energy expenditure, and optimize hormone regulation. This leads to increased calorie burning, reduced fat storage, and improved body composition. Additionally, better sleep quality and stress reduction contribute to metabolic health and overall weight management.

1. Stress Reduction

Renew contains adaptogenic herbs like Ashwagandha, known for their stress-relieving properties. These ingredients help the body adapt to stress, reduce anxiety, and promote relaxation. By lowering stress levels, Renew supports better sleep quality, enhances mood, and improves overall mental well-being. Reduced stress also benefits metabolic health by optimizing hormone regulation and energy balance.

1. Hormone Regulation

Optimal sleep is essential for hormone regulation, including hormones involved in appetite control, metabolism, and energy balance. Renew promotes deep sleep, which facilitates the release of hormones like growth hormone and leptin, regulating metabolism and appetite. By balancing hormone levels, Renew helps maintain energy balance, reduce cravings, and support weight management. Improved sleep quality also enhances insulin sensitivity, reducing the risk of metabolic disorders.

1. Cellular Repair and Regeneration

During deep sleep, the body undergoes vital cellular repair and regeneration processes crucial for overall health and longevity. Renew supports these processes by promoting uninterrupted deep sleep, allowing the body to repair damaged tissues, detoxify, and regenerate cells. Ingredients like Ashwagandha and Griffonia simplicifolia enhance sleep quality and duration, facilitating optimal cellular repair and regeneration. This promotes overall health, vitality, and resilience.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

How To Use Renew Effectively?

To maximize the benefits of Renew, follow these guidelines for effective use:

1. Take 3 Renew capsules daily, preferably 30 minutes before bedtime.
2. Consistency is key – take Renew consistently every night to maintain a healthy sleep routine.
3. Pair Renew with a balanced diet and regular exercise for optimal results.
4. Avoid consuming stimulants like caffeine or nicotine close to bedtime, as they may interfere with sleep quality.
5. Create a relaxing bedtime routine to signal to your body that it's time to wind down and prepare for sleep.
6. Consult with a healthcare professional before starting any new supplement regimen, especially if you have underlying health conditions or are taking medication.

By following these recommendations, you can effectively incorporate Renew into your daily routine and experience its full range of health benefits.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Renew Side Effects

While Renew is generally well-tolerated, some users may experience mild digestive discomfort, such as bloating or gas, especially when first starting the supplement. These side effects typically subside as the body adjusts to the ingredients.

Is Renew Safe?

Renew is considered safe for most individuals when taken as directed. It is formulated with natural ingredients and manufactured in FDA-approved facilities following Good Manufacturing Practices (GMP). However, individuals with underlying health conditions, pregnant or nursing women, and those taking medication should consult with a healthcare professional before using Renew.

Who Should Use Renew?

Renew is suitable for individuals looking to improve sleep quality, support weight management, reduce stress, and enhance overall well-being. It is ideal for adults seeking a natural solution for better sleep and metabolism. Additionally, individuals experiencing sleep disturbances, stress-related issues, or weight management challenges may benefit from using Renew.

Who Should Avoid Renew?

While Renew is safe for most adults, certain individuals should avoid using it without consulting a healthcare professional. This includes pregnant or nursing women, individuals with pre-existing health conditions, and those taking medication that may interact with Renew's ingredients. Additionally, children and individuals allergic to any of the ingredients should refrain from using Renew. It's essential to prioritize safety and seek medical advice if unsure about using Renew.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Renew Customer Reviews

1. Sarah from New York: "I was skeptical about trying Renew at first, but I'm so glad I did. After struggling with poor sleep and low energy levels for months, I decided to give it a shot. Within just a few weeks, I noticed a significant improvement in my sleep quality. I wake up feeling refreshed and energized, ready to tackle the day ahead. Plus, the natural ingredients make me feel good about what I'm putting into my body."
2. Michael from Los Angeles: "As someone who's always been conscious of their health, finding a supplement like Renew was a game-changer for me. Not only did it help me shed those stubborn extra pounds, but it also improved my overall well-being. I've noticed a significant increase in my energy levels and mental clarity since starting Renew. Plus, the fact that it's made with natural ingredients is a huge bonus for me."
3. Emily from Chicago: "I've struggled with insomnia for years, trying countless remedies with little success. However, Renew has been a game-changer for me. Not only am I sleeping better than ever before, but I've also noticed improvements in my mood and stress levels. I feel more relaxed and centered throughout the day, thanks to Renew. It's truly been a lifesaver for me."
4. David from Miami: "Renew has exceeded all my expectations. As someone who leads a busy lifestyle, I often find it challenging to unwind and get quality sleep. However, since incorporating Renew into my nightly routine, I've noticed a significant improvement in my sleep quality. I wake up feeling more rested and rejuvenated, ready to take on whatever the day throws at me."
5. Jennifer from San Francisco: "After struggling with weight loss for years, I was hesitant to try yet another supplement. However, Renew has been a game-changer for me. Not only have I lost weight, but I also feel healthier and more vibrant overall. I've noticed improvements in my skin, hair, and energy levels since starting Renew. It's truly been a transformative experience for me."
6. Alex from Seattle: "I've always been a skeptic when it comes to supplements, but Renew has made me a believer. Not only does it help me get a better night's sleep, but it also boosts my energy levels and mood during the day. Plus, the fact that it's made with natural ingredients gives me peace of mind. I can't recommend Renew enough."
7. Natalie from Boston: "Renew has been a game-changer for me. As someone who struggles with anxiety and stress, I've found that Renew helps me relax and unwind at the end of a long day. I sleep better, feel more energized, and have noticed improvements in my overall well-being since starting Renew. It's become an essential part of my self-care routine."
8. Daniel from Houston: "I've tried countless supplements in the past, but none have worked as well as Renew. Not only does it help me sleep better, but it also supports my weight loss goals and boosts my energy levels. I've noticed a significant improvement in my overall health and well-being since starting Renew. It's become a staple in my daily routine."
9. Sophia from Atlanta: "Renew has been a lifesaver for me. As someone who struggles with insomnia, finding a supplement that actually works has been a game-changer. I've noticed a significant improvement in my sleep quality since starting Renew. Plus, the fact that it's made with natural ingredients gives me peace of mind. I can't recommend Renew enough to anyone struggling with sleep issues."
10. Ryan from Dallas: "I was skeptical about trying Renew at first, but I'm so glad I did. Not only does it help me sleep better, but it also supports my weight loss goals and boosts my energy levels. I've noticed a significant improvement in my overall health and well-being since starting Renew. Plus, the fact that it's made with natural ingredients gives me peace of mind. It's become a must-have in my daily routine."

=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Where to Buy Renew?

Renew can be purchased exclusively from its official website. This ensures that customers receive genuine products and have access to any special offers or discounts provided by the manufacturer. Buying directly from the official website also guarantees customer support and assistance with any inquiries or issues.

Renew Pricing

• 1-month supply: $69 per bottle
• 3-month supply: $49 per bottle
• 6-month supply: $39 per bottle

Purchasing larger quantities offers significant savings per bottle, making it a cost-effective option for long-term use.

Refund Policy of Renew

Renew offers a 60-day money-back guarantee on all purchases. If customers are not satisfied with the product for any reason, they can request a full refund within 60 days of purchase, no questions asked. This policy ensures that customers can try Renew risk-free and provides peace of mind when making a purchase.

Bonuses of Renew

In addition to the product itself, Renew may offer bonuses or special deals to customers, especially when purchasing multiple bottles. These bonuses could include free shipping, additional bottles at discounted rates, or complementary health resources such as e-books or guides. Customers should check the official website for any current bonus offers available with their purchase.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

FAQs of Renew

1. Is Renew safe to use? Renew is crafted from natural ingredients in FDA-approved facilities, making it generally safe for consumption. However, individuals with specific health conditions or allergies should consult a healthcare professional before use.
2. How long does it take to see results with Renew? Results may vary, but many users report noticing improvements in sleep quality and overall well-being within a few weeks of consistent use. For optimal results, it's recommended to use Renew as directed for at least a month.
3. Can Renew be used by pregnant or breastfeeding women? Pregnant or breastfeeding women should avoid using Renew without consulting a healthcare provider, as the effects of the supplement on maternal and fetal health are not well-studied.
4. Are there any side effects associated with Renew? While side effects are rare, some users may experience mild digestive discomfort initially. It's essential to follow the recommended dosage and monitor for any adverse reactions.
5. How should I take Renew for best results? The recommended dosage is three capsules daily, taken approximately 30 minutes before bedtime. Consistency is key to experiencing the full benefits of Renew.
6. Can Renew be taken with other medications? Individuals taking prescription medications should consult a healthcare professional before using Renew to avoid potential interactions.
7. Is Renew suitable for vegetarians/vegans? Yes, Renew is formulated with plant-based ingredients and is suitable for vegetarians and vegans.
8. Does Renew contain any stimulants? No, Renew is free from stimulants, artificial preservatives, dairy, and soy, making it a suitable option for those sensitive to stimulants.
9. Is Renew FDA-approved? While individual supplements like Renew are not FDA-approved, the facilities where it is manufactured follow FDA regulations to ensure quality and safety.
10. What is the recommended duration of use for Renew? Renew can be used continuously for as long as desired to support sleep quality and overall well-being. Some individuals may choose to incorporate it into their daily routine long-term for ongoing benefits.

Renew Reviews - Final Word

Renew has garnered positive feedback from users, highlighting its efficacy in promoting deep sleep, enhancing overall well-being, and supporting weight loss efforts. The natural ingredients in Renew have been carefully selected to address sleep issues and metabolic function, leading to improved energy levels, mood, and physical health.
Users have reported experiencing better sleep patterns, increased energy during the day, and noticeable improvements in weight management. The supplement's formulation, free from stimulants and artificial additives, appeals to those seeking a natural approach to health and wellness.
While individual experiences may vary, Renew has generally been well-received by customers seeking a holistic solution to sleep and weight management. With its 100% money-back guarantee and positive user testimonials, Renew emerges as a promising option for individuals looking to improve their sleep quality and overall health.
In summary, Renew offers a safe and effective way to address sleep-related issues and support weight loss goals, making it a valuable addition to a healthy lifestyle regimen.
=> Order Your “Renew Premium” =>From The Official Website => Before Stock Runs Out!

Good evening all /r Healthcare_anon readers
This post is dedicated to our healthcare professional colleagues, be it in nursing, MD, pharmacist, or any other healthcare field colleagues. Today I thought I would discuss the subject of AI in healthcare. I know Rainy probably already went through the subject of AI in healthcare in different posts within our subreddit, which I will provide the links:
https://new.reddit.com/Healthcare_Anon/comments/1brjar1/pivotal_junction_in_healthcare_ai_and_machine/
https://new.reddit.com/Healthcare_Anon/comments/1bpnf5p/clover_healths_diamond_mine_irb_hipaa_p4_and_ai/
https://new.reddit.com/Healthcare_Anon/comments/1bmzwiq/they_are_making_kind_of_a_big_deal_out_of_chatgtp/
https://new.reddit.com/Healthcare_Anon/comments/1bx5qas/clover_assistant_vs_merative_vizai_enlitic_regard/
My post will instead deal with the role of clinical practice application, and how the potential of AI is the integration of the human providephysician with a LLM AI partner that can leverage the intuition of a human with the ability of AI processing speed for diagnosis, treatment, and decision making for each individual patient.
*** Please do not use the content of this post without author authorization ***
Although generative AI is creating a lot of buzz with OpenAI's creation of chatgpt4, Sora, and other products, I am personally leery of using generative AI due to the potential of "hallucinations", and I have personally directed students to not use OpenAI products for their work submissions. After all, the individual provider is the sole responsible individual in care of the patient, and data that is "hallucinated" should not be trusted. AI data must therefore be vetted, proven, and have value prior to its insertion into practice. That being said, there are now some studies that show chatgpt4 may have some value in identification of drug interactions and provide recommendations after additional specific question prompt by dedicated healthcare professionals. With time, these concerns may subside.
Let us first provide the references for our discussion today:
Alowais, S.A., Alghamdi, S.S., Alsuhebany, N. et al. Revolutionizing healthcare: the role of artificial intelligence in clinical practice. BMC Med Educ 23, 689 (2023). https://doi.org/10.1186/s12909-023-04698-z (accessed 4/17/24)
Damiani G, Altamura G, Zedda M, Nurchis MC, Aulino G, Heidar Alizadeh A, Cazzato F, Della Morte G, Caputo M, Grassi S, Oliva A; D.3.2 group. Potentiality of algorithms and artificial intelligence adoption to improve medication management in primary care: a systematic review. BMJ Open. 2023 Mar 23;13(3):e065301. doi: 10.1136/bmjopen-2022-065301. PMID: 36958780; PMCID: PMC10040015. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10040015/ (accessed 4/17/24)
Silva P, Jacobs D, Kriak J, Abu-Baker A, Udeani G, Neal G, Ramos K. Implementation of Pharmacogenomics and Artificial Intelligence Tools for Chronic Disease Management in Primary Care Setting. J Pers Med. 2021 May 21;11(6):443. doi: 10.3390/jpm11060443. PMID: 34063850; PMCID: PMC8224063. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8224063/ (accessed 4/17/24)
AI assistance in diagnostics
Rainy mentioned it within his past post on IBM using AI to power their SonoSAMTrack and show potential in removing variability and intrinsic noise via foundational modeling, improving accuracy in imaging, and may even be used in a resource constrained environment via the SonoSAMLite version. This touches on an important aspect in AI: the ability to help providers in early diagnostics and improve disease state management.

1. Cancer detection: study in UK and South Korea showed that if an AI model is fed mammograms, it can detect breast cancers with improved sensitivity, reduce false positives and false negatives
2. Microorganism detection, gene sequencing, and antibiotic resistance detection potential for providing PCPs with adequate data for antibiotic prescriptions and/or notification that a switch of regimen is necessary once new data comes through.
3. Other areas include skin cancer, diabetic retinopathy, arrhythmia detection via ECG and prediction of new onset atrial fibrillation, detection of pneumonia from CXR, etc
   AI in genomic medicine - Truly exciting if you are into genetics and disease state management
   
4. In the field of oncology, categorizing cancers into clinically relevant molecular subtypes can be accomplished using transcriptomic profiling. Such molecular classifications, first developed for breast cancer and later extended to other cancers like colorectal, ovarian, and sarcomas, hold substantial implications for diagnosis, prognosis, and treatment selection. For those of you who are not in the field, this has now huge implications in the treatment modality of patients. Never thought Herceptin can be used for gastric cancer (HER2+ only), but by golly we were wrong, and its perfect!
   
5. In the field of medication management, to utilize AI and pharmacogenomics to predict drug-drug interactions, drug-gene interactions (poor CYP2D6 or CYP2C19 metabolizer and effect in substrate metabolism with patient medication list), and potential identification of either on patient presentation as part of HPI gathering.
   

AI assistance in treatment - Personalized medicine
Personalized treatment, also known as precision medicine or personalized medicine, is an approach that tailors medical care to individual patients based on their unique characteristics, such as genetics, environment, lifestyle, and biomarkers. This individualized approach aims to improve patient outcomes by providing targeted interventions that are more effective, efficient, and safe.
AI has emerged as a valuable tool in advancing personalized treatment, offering the potential to analyze complex datasets, predict outcomes, and optimize treatment strategies. There is some note for caution, as more data gathering is necessary to create the comprehensive data to train algorithms correctly and develop AI based Clinical Decision support tools for providers.
Dose optimization and therapeutic drug monitoring

1. Who hates warfarin? We all do. Don't let that Anticoagulation Clinic pharmacist fool you, the patient is one weekend away from having his/her INR to be out of range, and that pharmacist will have to take a whole week trying to tune it back and they will pretend to like it, and some may actually truly like it. Even worse, what if you don't even have an AC clinic pharmacist? Well, AI can help! In a study that aimed to develop an AI-based prediction model for prothrombin time international normalized ratio (PT/INR) and a decision support system for warfarin maintenance dose optimization. The authors analyzed data from 19,719 inpatients across three institutions, and the algorithm outperformed expert physicians with significant differences in predicting future PT/INRs and the generated individualized warfarin dose was reliable. Hoooray, now you can have AI help your warfarin dosing! Or just use Eliquis. I am not paid by BMS/Pfizer for that last statement, and I hope to god you don't need a prior auth for that.
2. AI is also starting to show publications within the oncology dosing field, which is quite exciting.
   AI assistance in population health management - what our insurance colleagues need it seems
   

https://preview.redd.it/pr5gzf8nr5vc1.jpg?width=1489&format=pjpg&auto=webp&s=a3536e0adf0f7c740c458e40c7c59bcfcc3430fa
Population health management increasingly uses predictive analytics to identify and guide health initiatives. In data analytics, predictive analytics is a discipline that significantly utilizes modeling, data mining, AI, and ML. In order to anticipate the future, it analyzes historical and current data

1. AI algorithms can analyze large amounts of data and identify patterns and relationships that may not be obvious to human analysts; this can help improve the accuracy of predictive models and ensure that patients receive the most appropriate interventions.
2. It is pivotal to note that the success of predictive analytics in public health management depends on the quality of data and the technological infrastructure used to develop and implement predictive models. In addition, human supervision is vital to ensure the appropriateness and effectiveness of interventions for at-risk patients. AI needs to be partnered with trusted healthcare providers to have maximum benefit to the patient.

Future directions and considerations for clinical implementation
AI has the potential to revolutionize clinical practice, but several challenges must be addressed to realize its full potential.

1. Lack of quality medical data which can lead to inaccurate outcomes. Large patient database is needed to produce high quality medical data to train appropriate LLM/ML algorithms for the proper outcomes.
2. Data privacy, availability, and security are also potential limitations to applying AI in clinical practice. HIPAA regulations also limit the transmission of healthcare data, which implies that there needs to be a HIPAA compliant database that contains large amount of patient data will be necessary for LLM/ML training.
3. The AI-generated data and/or analysis could be realistic and convincing; however, hallucination could also be a major issue which is the tendency to fabricate and create false information that cannot be supported by existing evidence. Therefore the LLM/ML model must be selected carefully to prevent such occurrences.

Human expertise and involvement are essential to ensure the appropriate and practical application of AI to meet clinical needs and the lack of this expertise could be a drawback for the practical application of AI.
I hope this proves informational, educational, and has some entertainment value, and I hope this illustrates some of the potential of AI in the medical setting. I thank all of you super nerds wonderful healthcare providers on taking the time to read this on your very busy day.
Sincerely
Moocao

Bazopril Reviews (Advanced BioHealth Legit Or Fake) Ingredients, Side Effects, What Do Customers Say?

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Bazopril Review Bazopril Reviews 2024
Bazopril is an advanced blood pressure support formula intended to help regulate blood flow and blood vessel health. This dietary supplement, when used as directed, has the ability to improve kidney function, enhance nitric oxide levels for healthy blood flow, boost circulation, regulate cholesterol levels, and, ultimately, maintain healthy blood pressure levels.

Were you aware that roughly half (or some 120 million) of the American population aged 20 and up suffers from hypertension?

High blood pressure can cause various health problems, including heart disease, stroke, and kidney problems. Chronic kidney disease is a genuine and frightening health problem because they are essential to our well-being. They detoxify, support, protect, and prevent the risk of disease, which prompted our team to scour the marketplaces for kidney-supporting products. In so doing, we came across one particular supplement that takes an entirely holistic approach to maintaining kidney function and blood pressure levels. Without any further delay, here's what we were able to gather on Bazopril.

What is Bazopril?

Bazopril is an advanced blood pressure support formula intended to help regulate blood flow and blood vessel health. This dietary supplement, when used as directed, has the ability to improve kidney function, enhance nitric oxide levels for healthy blood flow, boost circulation, regulate cholesterol levels, and, ultimately, maintain healthy blood pressure levels. We were startled to see that this formula primarily targets the kidneys, given that most researchers focus on the heart. But as it turns out, ensuring proper kidney function is imperative; maintaining blood pressure levels becomes impossible without it. Next, we'll look closer into the effects of kidney function on blood pressure levels.

How does Bazopril work?

Bazopril works twofold. It primarily aims to improve kidney function, but it also affects secondary factors that influence blood pressure levels. The kidney is in charge of purifying the bloodstream. Additionally, as mentioned in one source, other processes are part of its list, including blood pressure. Specifically, your kidneys can help raise or lower blood pressure by producing a hormone called Renin. When released, this hormone activates critical components of the Renin-Angiotensin-Aldosterone System (RAAS), causing blood vessels to constrict (essential for maintaining warmth).
Renin is typically released when the kidneys sense decreased blood flow, usually experienced by people with chronic kidney disease (CKD). In the case of CKD, filters that clean out the bloodstream are depleted, contributing to elevated blood pressure over time. To make matters worse, high blood pressure can also trigger a loss in these filters, but this is considered a rare event. Bearing everything in mind, Bazopril might effectively lower blood pressure by increasing kidney protection.
Regarding secondary factors, the selected ingredients might positively influence resistance, blood viscosity, and blood vessel functioning. Now that the foundation of this dietary supplement is out of the way, it's time to take a closer look at the key drivers: the ingredients.
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What are the main ingredients in Bazopril?

Each Bazopril serving comprises a 620mg-proprietary blend of:

Hawthorn (Leaf & Fruit)

Hawthorn is a berry that grows on trees and shrubs belonging to the Crataegus genus. These berries are high in nutrients that remedy digestion issues, heart problems, and high blood pressure. The hawthorn can be used in its whole, as its leaves and fruits contain health-friendly compounds. Its antioxidant nature may also protect and prevent kidney damage caused by toxins. A study conducted on diabetic rats showed that hawthorn extract lowered cell damage in the kidneys by reducing inflammation.
Regarding its impact on heart health, one source highlighted two main substances: flavonoids and oligomeric procyanidins. In particular, the rhynchophylline alkaloid is trusted to prevent strokes and reduce the risk of heart attack by lowering blood pressure, increasing circulation, and preventing plaque formation on arterial walls and blood clot formation in the brain, heart, and arteries. Another point worth highlighting is its hypotensive activity, which has been linked to vasorelaxation, thereby boosting nitric oxide availability.

Garlic (Bulb)

Garlic is a plant in the onion family, scientifically known as allium. It is a popular element used in cuisines worldwide due to its potent fragrance and taste. Most people don't know that garlic is widely used for its health and medicinal effects. Garlic antibacterial properties make it a viable ingredient to treat kidney infections, whereas its antioxidant properties are trusted to fight free radicals, consequently protecting the kidneys. According to a study conducted in 2021, garlic might reduce inflammation in people with CKD. In the context of heart health, this ingredient has been repeatedly shown to increase nitric oxide production, which relaxes the muscles and promotes vasodilation. The latter might only hold true in people with increased systolic pressure.

Olive Leaf

Olive leaf refers to the leaves of an olive plant. It comprises an active ingredient called oleuropein, known for its anti-inflammatory and antioxidant properties. A 2017 study found that taking olive leaf extract may lower blood pressure. Another study linked its antioxidant properties to a reduction in structural changes in kidney tissue. 🔵 Click Here to Get Bazopril At Discounted Price!!!🔵

Hibiscus Flower

Hibiscus, known as hibiscus sabdariffa, is a plant used for centuries both decoratively and medicinally. Precisely, individuals can find this ingredient in the form of extracts, teas, and supplements. Traditionally, hibiscus has been used to treat liver problems and high blood pressure. The latter stems from its rich source of antioxidants, which are reckoned to restore blood pressure levels and relaxation in blood vessels, damaged kidneys, and their overall functioning.

Buchu Leaf

Buchu is a small, green, woody plant primarily found in western South Africa. It is widely known for its natural anti-inflammatory and antiseptic properties. The leaf of this particular plant contains potent compounds used to treat urinary issues, inflammations, and irritation of the bladder. Its anti-inflammatory properties have been demonstrated to increase water flow through the kidneys for maximum detoxification. Interestingly, ingesting buchu might also lower and stabilize initial rises in blood pressure as well.

Uva Ursi Leaf

Uva Ursi is an herbal extract from bearberry leaves, a small shrub originally found in North America. It is a long-known staple in Native American medicine as a treatment for urinary tract infections, painful urination, and kidney stones. This particular ingredients abundant arbutin source supposedly promotes urinary tract benefits. Once absorbed, arbutin is converted to hydroquinone and passes through the kidneys, relieving pain and inflammation.

Juniper Berry

Juniper berries are seed cones from the juniper tree, also known as Juniperus communis, grown in North America, Europe, and Asia.. Used in culinary and medicinal spaces, this respective berry is liked for its diuretic activity, which increases the flow of urine, and ultimately cleanses the body of excess fluids while restoring the kidneys. It is one of the few ingredients to comprise a significant concentration of vitamin C, which is essential for immune health, collagen synthesis, and blood vessel function (not to mention its role in eradicating free radicals).

Green Tea

Green tea is made from the Camellia sinensis plant leaves, traditionally used in China and Japan. It contains naturally occurring nutrients and antioxidants that can help the body eliminate free radicals. Its antioxidant nature is beneficial in reducing inflammation and oxidative stress, two major factors influencing CKD.
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Besides those above, each serving has also been equipped with supporting ingredients such as:
· Vitamin C (60mg): May act as a diuretic and promote blood vessel function, thereby lowering blood pressure;
· Niacin (2.5mg): May release chemicals shown to improve blood flow and reduce blood pressure;
· Vitamin B6 (5mg): Might prevent heart and blood vessel diseases by lowering homocysteine levels;
· Folate (100mcg): May reduce homocysteine levels and heart disease in people with kidney disease, especially when paired with Vitamin B6;
· Vitamin B12 (100mcg): Might prevent heart and blood vessel diseases by reducing homocysteine levels.

Purchasing Bazopril

Bazopril is available on the official website in several money-saving bundles. As the number of bottles purchased in one order increases, the price per unit decreases significantly! Here are the offers available right now:
· Order one bottle of Bazopril for $69 each & shipping
· Order three bottles of Bazopril bottles for $59 each & free shipping
· Order six bottles of Bazopril bottles for $49 each & free shipping People who place orders of six bottles and more will also gain access to a free bonus guide called The Heart's Kitchen. Inside this cookbook, individuals will find desserts and superfoods that strengthen the heart.

About Advanced Biohealth

Advanced Biohealth is a supplement company on a mission to help people on the path to the best possible version of themselves. As a company, the team prides itself on its success in offering cutting-edge supplements that have been carefully formulated. They claim to work with accredited suppliers and manufacturers to ensure high-quality ingredients and establish proper protocols in the manufacturing stage. For more on Advanced Biohealth and its processes, visit their website.

Frequently Asked Questions (FAQ)

Q: Who is Bazopril best suited for? A: Bazopril is meant for anyone who wishes to maintain their blood pressure levels within a normal range. To date, this solution is said to have helped most adults of all ages combat blood pressure issues.
Q: Is Bazopril safe? A: There are few safety concerns as a dietary supplement, as the main ingredients are combined in a reasonably dosed proprietary blend. The elements themselves either have scientific or alternative medicine backing with promising evidence. This supplement is not suitable for children, pregnant or nursing mothers, and people with hypotension or cardiovascular disorders. Finally, people with an existing medical condition must do their own research to avoid the risk of medication interaction and other unwanted side effects. If you have any concerns, you should consult your physician before using Bazopril.
🔵 Read what others are saying and decide for yourself >>> 🔵
Q: Where is Bazopril manufactured? A: Bazopril is manufactured at a GMP-certified and FDA-inspected facility in the United States. On top of this, a third-party lab was hired to perform tests to ensure the ingredients' quality, purity, and bioavailability, further emphasizing safe uses.
Q: What is the best way to take Bazopril? A: The manufacturer recommends taking one Bazopril capsule twice daily for safe yet optimal uses.
Q: Is Bazopril a subscription service? A: Bazopril is not offered as a subscription service; therefore, individuals should not see recurring payments unless additional orders are placed.
Q: How long does it take to ship an order of Bazopril? A: Bazopril orders are processed as soon as they are received. Shipping typically takes anywhere between 3 and 5 business days within the continental USA. Once the order is received and shipped, an email containing more information will be sent out.
Q: Is Bazopril backed by a guarantee? A: Bazopril is protected by a 365-day money-back guarantee on every order. If desired results are not reached within the allotted timeframe, individuals are encouraged to contact the support team for a full purchase price refund. To familiarize oneself with the refund policy and processes, the support team must be contacted via email at contact@bazopril.com.
Q: Will Bazopril always be available? A: The team at Bazopril works tirelessly to ensure it remains available all the time for consumers. However, given that the ingredients are sourced from different parts of the world, supplies might eventually dwindle, and restocks might only arrive months later. Therefore, the manufacturer recommends purchasing in bulk.
Final Thoughts
From the analysis above, it should be evident that Bazopril enhances kidney functioning while targeting key facets that determine whether blood pressure levels fall within acceptable ranges. Kidney function is crucial because it produces the renin hormone required for optimal blood vessel activity and flow. Is this to say that Bazopril directly stimulates the renin hormone? Not exactly. It is only triggered when the kidneys detect a substantial deficiency of blood flow, but for the kidneys to notice them, they must be operating at peak efficiency. The latter could potentially be reached considering the blend of ingredients at hand. Most of the listed ingredients either have scientific backing or support from traditional medicine, all of which are considered promising evidence for improving blood pressure levels. All-in-all, we believe it is worthwhile to include Bazopril. As with any dietary supplement, we encourage everyone to do their homework before starting.
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Establishing a Supportive Sleep Routine
Creating a Sleep-Friendly Environment
Establishing a supportive sleep routine is essential for postpartum moms aiming for weight loss. Creating a sleep-friendly environment involves minimizing disruptions, such as dimming lights and reducing noise, to promote a restful atmosphere conducive to quality sleep.
Prioritizing Self-Care for Better Sleep
Encouraging new moms to prioritize self-care is integral to promoting better sleep. This involves setting aside time for relaxation activities before bedtime, such as reading a book or taking a warm bath. Additionally, delegating tasks and seeking support from family members can alleviate the demands that often contribute to sleep disruptions.
For a personalized approach to postpartum weight loss, explore a customized keto diet plan designed for new moms. Discover how tailored nutrition can enhance your weight loss journey here.
Breastfeeding and Weight Loss
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https://preview.redd.it/ns6klo1xad4c1.png?width=1280&format=png&auto=webp&s=636d057dda8117fdd1b5b971f336085b3b2bfb46
How Breastfeeding Affects Metabolism
Breastfeeding plays a pivotal role in postpartum weight loss by actively engaging a mother's metabolism. During lactation, the body expends additional energy to produce milk, leading to increased calorie burning. Prolactin, a hormone responsible for milk production, stimulates the metabolism, aiding in the breakdown of fat stores. Studies have shown that breastfeeding mothers tend to lose weight more efficiently than those who do not breastfeed, making it a natural ally in the postpartum weight loss journey.
To maximize the metabolic benefits of breastfeeding, it's crucial to establish a consistent feeding schedule. Frequent, on-demand nursing not only supports the baby's nutritional needs but also helps the mother maintain an elevated metabolic rate. Incorporating skin-to-skin contact during breastfeeding can further enhance the hormonal response, promoting a healthier metabolism.
Nutrition Tips for Breastfeeding Moms
Maintaining a balanced and nutrient-rich diet is paramount for breastfeeding mothers aiming for postpartum weight loss. Adequate nutrition is vital to support both the mother's well-being and the nutritional needs of the baby through breast milk. Key nutrients include:

• Protein: Incorporate lean protein sources such as poultry, fish, legumes, and dairy to support muscle recovery and milk production.
• Omega-3 Fatty Acids: Include sources like salmon, chia seeds, and walnuts to aid in brain development for both the mother and the baby.
• Calcium and Vitamin D: Ensure sufficient intake to support bone health, especially important during postpartum recovery.
• Fiber-rich Foods: Opt for whole grains, fruits, and vegetables to promote digestive health and help control appetite.

Balancing nutrient intake is crucial, considering the additional demands of breastfeeding. Consulting with a registered dietitian can provide personalized guidance tailored to individual needs, ensuring optimal nutrition for both the mother and the baby.
Balancing Weight Loss Goals with Breastfeeding Needs
Finding the right equilibrium between postpartum weight loss goals and the nutritional needs of breastfeeding is a delicate process. It's essential to prioritize gradual, sustainable weight loss rather than opting for drastic measures. Extreme diets can compromise milk production and the overall well-being of both the mother and the baby.
Focus on a holistic approach that includes a well-balanced diet, regular exercise, and ample hydration. Aim for a gradual weight loss of about 1-2 pounds per week to avoid potential negative effects on milk supply. Additionally, monitoring the baby's growth and consulting with a healthcare professional can provide valuable insights into whether the weight loss journey is harmonizing with the breastfeeding journey.
In conclusion, breastfeeding is a natural contributor to postpartum weight loss, leveraging the body's metabolism to shed excess pounds. By embracing a nutrient-dense diet and striking a balance between weight loss goals and breastfeeding needs, mothers can embark on a healthy and sustainable postpartum weight loss journey.
Ready to personalize your postpartum weight loss plan? Check out this custom keto diet program here. Your journey to a healthier you begins now!
Time Management for Moms
Finding Time for Self-Care
In the whirlwind of new motherhood, carving out time for self-care is crucial for postpartum weight loss. Prioritize moments for relaxation and personal rejuvenation. Studies suggest that self-care positively impacts mental health, which, in turn, can influence weight management. This can include short breaks for meditation, deep breathing exercises, or even a quick skincare routine. Online platforms like WebMD emphasize the significance of self-care in managing stress and maintaining overall well-being.
Incorporating Quick and Effective Workouts
For busy moms, integrating time-efficient workouts is essential. High-Intensity Interval Training (HIIT) has gained popularity for its effectiveness in burning calories in shorter durations. Explore home-based HIIT routines tailored for postpartum fitness. Online fitness communities and apps like MyFitnessPal offer a variety of short, effective workout plans suitable for new moms. These workouts not only aid in weight loss but also provide a quick energy boost.
Creating a Supportive Schedule
Crafting a well-organized schedule is key to balancing motherhood and postpartum weight loss. Prioritize tasks, allocate specific time slots for meals and workouts, and enlist support when needed. According to the American Heart Association, having a structured routine can contribute to better time management and stress reduction, ultimately aiding in weight management. Leverage scheduling apps and tools to streamline your daily activities, ensuring dedicated time for self-care and fitness.
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Building a Support System
Importance of Emotional Support
Emotional support is a cornerstone of successful postpartum weight loss. The journey after childbirth is filled with physical and emotional changes, and having a strong support system can significantly impact a mother's well-being. Studies have shown that emotional well-being plays a crucial role in weight management, with stress and anxiety potentially hindering weight loss progress.
Sources: According to the American Psychological Association, emotional well-being is linked to healthier lifestyle choices, including diet and exercise. Moreover, a study published in the International Journal of Behavioral Nutrition and Physical Activity emphasizes the role of emotional support in postpartum weight management.
Partner Involvement in Postpartum Weight Loss
Encouraging partner involvement is vital for sustainable postpartum weight loss. Partners can provide not only practical assistance but also emotional encouragement. Shared responsibilities in meal planning, exercise routines, and childcare allow for a more balanced and supportive environment.
Sources: The Journal of Behavioral Medicine highlights the positive impact of partner involvement on weight loss outcomes. Additionally, the Centers for Disease Control and Prevention (CDC) recommends partner support as a key element in postpartum weight management.
Connecting with Other Moms for Encouragement
Building connections with other moms can create a sense of community and shared experiences. Joining local or online support groups provides a platform to exchange tips, share successes, and seek advice from those going through similar postpartum weight loss journeys.
Sources: A study in the Journal of Women's Health indicates that women who engage in social support networks are more likely to adhere to healthy behaviors, including weight management. Furthermore, the Mayo Clinic emphasizes the positive impact of social support on postpartum mental health.
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Professional Guidance
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Consulting with Healthcare Professionals
In the quest for postpartum weight loss, it's crucial to prioritize your health. A key step is seeking advice from healthcare professionals who can provide personalized guidance based on your unique circumstances. These experts, often including obstetricians, gynecologists, or general practitioners, possess in-depth knowledge of postpartum physiology and can help tailor a weight loss plan that aligns with your overall well-being.
Begin by scheduling a postpartum checkup to discuss your weight loss goals with your healthcare provider. They can assess any potential health concerns, address hormonal imbalances, and offer insights into safe and effective weight loss strategies. Online resources, such as reputable medical websites and journals, can supplement this information, ensuring that your approach is evidence-based and medically sound.
Seeking Guidance from Nutritionists or Trainers
Embarking on a postpartum weight loss journey requires more than just good intentions; it demands a holistic approach. Nutritionists and trainers are valuable allies in this endeavor. These professionals specialize in tailoring nutrition and exercise plans to individual needs, taking into account factors such as breastfeeding, nutritional deficiencies, and postpartum recovery.
A certified nutritionist can assist in developing a well-balanced diet that supports weight loss while ensuring you receive essential nutrients. Similarly, a personal trainer with expertise in postpartum fitness can create a customized exercise regimen that aligns with your fitness level and post-baby body.
Leverage online platforms to explore credible sources on nutrition and fitness, reinforcing the guidance you receive from professionals. Look for peer-reviewed articles, expert blogs, and reputable fitness websites to gain additional insights into the science behind postpartum weight loss.
Knowing When to Ask for Help
Recognizing when you need support is a sign of strength, especially in the postpartum period. Weight loss journeys can be challenging, both physically and emotionally. Knowing when to ask for help, whether from friends, family, or support groups, is a crucial aspect of maintaining mental well-being during this transformative time.
Online communities and forums can be excellent resources for connecting with other moms who share similar postpartum weight loss goals. Engaging in discussions, sharing experiences, and seeking advice from those who have been through similar journeys can provide valuable emotional support.
When faced with challenges or uncertainties, don't hesitate to seek help. Online counseling platforms or mental health resources can offer professional guidance to navigate the emotional aspects of postpartum weight loss.
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Dealing with Plateaus
Understanding Plateaus in Postpartum Weight Loss
Postpartum plateaus are common and can be disheartening, but they're a natural part of the weight loss journey. Hormonal fluctuations, metabolic adjustments, and changes in physical activity can contribute to reaching a weight loss plateau. It's crucial to recognize that plateaus are temporary obstacles and not indicators of failure.
Strategies to Break Through Plateaus

1. Diversify Your Workouts: Introduce new exercises to challenge your body and stimulate different muscle groups. High-intensity interval training (HIIT) and strength training can be particularly effective.
2. Reassess Your Caloric Intake: As your body changes, so do its nutritional needs. Reevaluate your calorie intake and ensure you're still in a slight calorie deficit. Consider consulting with a nutritionist to fine-tune your diet plan.
3. Stay Hydrated: Dehydration can mimic the effects of a plateau. Adequate water intake supports metabolism and can help break through stagnant weight loss. Aim for at least eight glasses of water per day.
4. Prioritize Sleep: Lack of sleep can impact your body's ability to burn fat efficiently. Ensure you're getting quality rest, as it plays a crucial role in overall health and weight management.
5. Manage Stress: Chronic stress can contribute to plateaus. Incorporate stress-reducing activities like meditation, yoga, or deep breathing exercises into your routine.
6. Monitor Non-Scale Victories: Plateaus might not always reflect in the numbers on the scale. Celebrate non-scale victories, such as improved energy levels, increased stamina, or changes in clothing fit.

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Handling Cravings and Emotional Eating
Understanding Cravings and Emotional Eating
Postpartum hormonal shifts and the demands of motherhood can trigger cravings and emotional eating. Recognizing the difference between genuine hunger and emotional triggers is essential for maintaining a healthy relationship with food.
Strategies to Manage Cravings

1. Choose Nutrient-Dense Foods: Opt for snacks rich in nutrients to satisfy cravings while providing essential vitamins and minerals. Incorporate fruits, vegetables, and lean proteins into your diet.
2. Practice Mindful Eating: Pay attention to hunger and fullness cues. Slow down during meals, savor each bite, and listen to your body's signals. Mindful eating can reduce the likelihood of overeating.
3. Plan Healthy Snacks: Prepare nutritious snacks in advance to avoid reaching for less healthy options when cravings strike. Having readily available options can help you make better choices.
4. Stay Hydrated: Sometimes, dehydration is mistaken for hunger. Drink water throughout the day to stay hydrated and curb unnecessary snacking.
5. Address Emotional Triggers: Identify the emotional factors contributing to cravings. Whether it's stress, fatigue, or boredom, finding alternative coping mechanisms, such as exercise or journaling, can be beneficial.

Strategies to Manage Emotional Eating

1. Build a Support System: Share your feelings with a friend, family member, or a support group. Having someone to talk to can provide emotional relief without resorting to food.
2. Seek Professional Help: If emotional eating becomes a persistent challenge, consider consulting with a mental health professional. They can offer guidance and strategies to address underlying emotional issues.
3. Develop Healthy Coping Mechanisms: Replace emotional eating with healthier coping mechanisms, such as deep breathing exercises, meditation, or engaging in a hobby you enjoy.

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Adapting to Lifestyle Changes
Understanding the Need for Lifestyle Adaptations
Postpartum life involves significant adjustments, and adapting your lifestyle to support weight loss is crucial. Balancing childcare, work, and personal time requires strategic planning and flexibility.
Strategies for Successful Lifestyle Changes

1. Create Realistic Schedules: Develop a realistic daily schedule that accommodates both your weight loss goals and the demands of motherhood. Prioritize self-care activities, including exercise and meal preparation.
2. Involve Your Support System: Seek support from your partner, family, or friends. Communicate your goals and enlist their help in childcare or household tasks to free up time for healthy habits.
3. Meal Prep and Planning: Plan meals in advance and consider batch cooking to ensure nutritious options are readily available. This reduces reliance on convenience foods, which may be less healthy.
4. Incorporate Family-Friendly Activities: Include your family in physical activities. Whether it's a family walk, bike ride, or a home workout, making fitness a family affair promotes a healthy lifestyle for everyone.
5. Set Realistic Expectations: Understand that your weight loss journey may progress at a different pace than before motherhood. Set realistic goals and be patient with the process.

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Embracing Body Positivity
In the journey of postpartum weight loss, it's crucial to foster a positive relationship with your changing body. Embracing body positivity involves appreciating the incredible feat your body has accomplished during pregnancy and childbirth. Recognize that these changes are not imperfections but rather symbols of strength and resilience.
Body positivity isn't about conforming to societal ideals but rather about accepting and loving your body as it is. Numerous studies have shown that a positive body image contributes to better mental health and can positively impact weight loss efforts. According to research from the National Eating Disorders Association (NEDA), individuals with a positive body image are more likely to adopt healthy eating habits and engage in regular physical activity.
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Recognizing the Achievements of Motherhood
Amidst the pursuit of postpartum weight loss, it's crucial to celebrate the incredible achievements that come with motherhood. Acknowledge the strength and resilience it takes to bring a new life into the world. Research published in the Journal of Behavioral Medicine emphasizes the positive impact of recognizing and celebrating personal achievements on mental well-being, a factor closely linked to successful weight management.
As a new mom, your achievements extend beyond the scale. Every sleepless night, every comforting cuddle, and every milestone witnessed are triumphs worth celebrating. Recognizing these accomplishments not only boosts your self-esteem but also reinforces a positive mindset, essential for sustainable weight loss.
Celebrate your achievements and nourish your body with a personalized approach. Discover more here.
Focusing on Overall Well-Being
Postpartum weight loss is not solely about shedding pounds; it's about prioritizing your overall well-being. Research from the American Journal of Clinical Nutrition suggests that a holistic approach to health, encompassing physical, mental, and emotional well-being, is more effective in achieving long-term weight management.
Instead of fixating solely on the number on the scale, focus on building a healthy lifestyle. Incorporate nutrient-dense foods, engage in enjoyable physical activities, and prioritize self-care. This approach not only aids in weight loss but also contributes to increased energy levels, improved mood, and enhanced overall quality of life.
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By adopting these practices and embracing body positivity, recognizing the achievements of motherhood, and focusing on overall well-being, your postpartum weight loss journey can be a fulfilling and empowering experience. Remember, it's not just about losing weight; it's about nurturing and honoring the incredible vessel that brought new life into the world.
Conclusion
Recap of Key Points
In wrapping up this comprehensive guide to postpartum weight loss, let's revisit the fundamental takeaways that will empower you on your wellness journey. Acknowledging the physiological changes postpartum is crucial, understanding the impact of hormones and the diversity of body responses. Recognizing the importance of a nutrient-rich diet, mindful eating habits, and staying well-hydrated lays a robust foundation for your weight loss endeavors post-pregnancy. Additionally, incorporating safe and gradual exercises, tailored to the postpartum phase, is integral for achieving sustainable results.
As you strive for your postpartum weight loss goals, remember the significance of sufficient sleep and stress management. Research consistently emphasizes the link between sleep deprivation, stress, and weight retention. Therefore, establishing a supportive sleep routine and adopting stress reduction techniques can significantly contribute to your overall well-being.
Encouragement for the Postpartum Journey
Embarking on postpartum weight loss is a commendable endeavor, and it's essential to recognize and celebrate every milestone, no matter how small. The journey is uniquely yours, and progress may vary. Be patient with yourself and stay motivated by the positive changes you witness. Remember, it's not just about shedding pounds but also about nurturing your body and mind, embracing the strength that comes with motherhood.
Drawing upon the experiences of other moms who have successfully navigated this journey can provide inspiration and motivation. Consider joining online communities or support groups where you can share your challenges and triumphs with like-minded individuals. The encouragement and insights gained from a supportive network can make a significant difference in your postpartum experience.
Final Thoughts on Long-Term Well-being
As we conclude, it's essential to shift the focus from immediate weight loss to long-term well-being. Sustainable lifestyle changes are key to maintaining a healthy weight and overall health. View postpartum weight loss as a holistic approach that encompasses not only physical health but also mental and emotional well-being.
In nurturing your long-term well-being, consider seeking professional guidance from healthcare providers, nutritionists, or fitness experts. They can provide personalized advice based on your unique postpartum journey, ensuring a balanced and sustainable approach to health.
In the spirit of continued support for your well-being, explore personalized nutrition plans tailored to your postpartum needs. A resource like this can guide you toward a customized approach, helping you achieve your health and weight goals effectively.
In conclusion, embrace your postpartum body, celebrate your achievements, and prioritize your long-term well-being. This journey is a testament to your strength and resilience as a new mom, and with the right mindset and strategies, you can achieve lasting health and vitality.

1972 - "Ben" is the #1 song in the US
1979- On their Destiny tour, The Jacksons perform at Spectrum Arena (closed-2009) in Philadelphia, Pennsylvania
1979- "Don't Stop 'Til You Get Enough" hit #1 on Billboard's Hot 100, giving Michael his first #1 hit since "Ben" in 1972
The song also gave Michael his first solo #1 for five weeks on the R&B singles chart.
1984 - On their Victory Tour, The Jacksons perform at Comiskey Park(closed-1990) in Chicago, Illinois
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1985- Diana Ross' single "Eaten Alive" hit the charts in the US. The song was co-written, co-produced and co-vocalized with Michael Jackson and Barry Gibb
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1987- Michael plays the last of three nights at Osaka Stadium (closed-1998) in Naniwa-ku, Osaka, Japan
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1987- Michael is on the cover of People magazine with the headline "MESSAGE FROM MICHAEL", featuring a handwritten letter from Michael
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He sat down at the desk in his room at the Capitol Tokyo Hotel in Tokyo and, on the back of a piece of hotel stationery, wrote what he said would be his only discussion of his private life.
"As an old Indian proverb says... 'Don't judge a man until you've walked two moons in his loafers.' Most people don't know me, that's why they write things that most of them aren't true. I cry a lot because it hurts and I care about the kids, all my kids all over the world, I live for them If a man can't say anything he can't prove, against a character, the story can't be written. Animals don't attack out of malice, but because they want to live, it's the same with those who criticize me, they want our blood, not our pain. But I still have to reach my goals, I have to seek the truth in all things. I have to bear for the power that I was sent, into the world for the children. But have mercy, because I'm bleeding already long time now." - MJ
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1993- On his Dangerous tour, Michael performs the 3rd & final night at the Estadio Monumental in Buenos Aires, Argentina
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1995- "You Are Not Alone" was certified Gold and Platinum.
1997- Michael plays the second of two nights at Johannesburg Stadium in Johannesburg, South Africa to an audience of 58,000. His parents, Lisa Marie & her children attend
1999- History: Past, Present & Future Book 1 was certified 7X Platinum
2001 –Tele Poche magazine (France) featured Michael on the cover with the headline: "Michael Jackson – Verites ou mensonges?" ["Michael Jackson – Truth or lies?"]
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2002- As a personal acknowledgement of the gallantry and sacrificial services made by the military in his community, Michael invites over 200 US Air Force members from "Team Vandenberg" (recently returned from overseas deployments) and their families to spend the day at Neverland.
2004- Michael calls the Steve Harvey Morning Radio Show to ask TV networks not to air Eminem's video for the song "Just Lose It", the new video which makes fun of him.

"I would like to thank you, Steve, Radio One, the African-American community, my fans from around the world, and some of the members of the media, for the support that you have given to me. I would also like to thank Mr. Robert Johnson, Chairman and Founder of BET for pulling the Eminem video from BET's airplay. I appreciate very much the love and support that you all have shown me. I am very angry at Eminem's depiction of me in his video. I feel that it is outrageous and disrespectful. It is one thing to spoof, but it is another to be demeaning and insensitive. I've admired Eminem as a artist, and was shocked by this. The video was inappropriate and disrespectful to me, my children, my family, and the community at large. It is my hope that the other networks will take BET's lead and pull it"

BET accepts but not MTV which creates a new controversy
2004 – CBS Early Show airs an interview of Genevieve, Randy Jr, Dante, Jaffar, & Jermajesty Jackson at Hayvenhurst defending their uncle Michael.
2005- Michael takes Prince, Paris & Blanket to Harrods where they are greeted by owner Mohamed Al Fayed.
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Michael raced around the posh London store and reserved two watches worth £55,000 and £30,000
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His children Prince Michael, eight, Paris, seven and Prince Michael II, three, then descended upon the toy department.
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An insider said:

"He was only in the store for about 30 minutes. His kids had a fantastic time in the toy department. They fell in love with this gigantic toy Hummer".
"After spending thousands of pounds on gifts for them, including life-size teddy bears, Michael signed autographs for fans."

Michael’s spokesman said:

"Last time he came to London he went to Hamleys - but he loves the cuddly toys at Harrods."

2009- A never-before released song from Michael, "This Is It", was unveiled on his website
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2011 - People v. Murray Trial Day 11
Dr. Alon Steinberg (Cardiologist) Testimony
Walgren Direct
Steinberg is a board certified cardiologist for 13 years. He is not an expert in anesthesia, sleep medicine, pharmacology or addiction medicine.
Steinberg has reviewed Conrad Murray's resume. Murray was not board certified on 6/25/09. Steinberg tells board certification is an extensive 2 day test and 90% of the cardiologists that take it pass it.
Steinberg is an expert reviewer for the California Medical Board, he reviews other doctors' actions to ensure the standard of care has been respected. 3 levels are possible:

• no deviation
• simple deviation
• extreme deviation

Extreme deviation is also defined as gross negligence.
Steinberg has conducted a review for this case. He had conducted 8 prior reviews. In 4 cases he found no deviation; in 4 cases he found simple deviation of care. This is the first time he's seen an extreme deviation from standard of care.
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Cardiologists use sedation for many procedures and sometimes they use Propofol. Cardiologists are experts in mild or moderate sedation. In conscious sedation the patient is able to talk and respond to touching. Deep sedation is when patients are only responsive to pain or repeated stimuli. General anesthesia is when patients feel no pain. Cardiologists are not trained in deep sedation. When deep sedation is needed, they call an anesthesiologist and that’s the only time they use Propofol.
When they are giving mild or moderate sedation they use benzodiazepines. For deep sedation they are required to give Propofol with an anesthesiologist.
Steinberg has reviewed this case. He has focused his review based on Murray's interview with police. Steinberg wanted to judge Murray on his own words.
Steinberg found 6 separate extreme deviations from standard of care.

• Propofol was not medically indicated. Steinberg mentions Propofol is an anesthetic. Steinberg tells there was no written informed consent. The patient must be informed of the risks and benefits of treatment. Steinberg never heard of Propofol being used for insomnia. Steinberg says that using propofol for insomnia is gross negligence and extreme deviation.
• Propofol was given in a home setting, without proper equipment and without proper staff.

Walgren asks what equipment is needed. Steinberg says that first a pulse oximeter with an alarm is needed but Murray's oximeter didn't have an alarm. Steinberg says he'd have to stare at Michael nonstop every second. Steinberg says he should have an automated blood pressure cuff, to check blood pressure at least every 5 minutes. Murray had a manual cuff and did not use it. Next thing is needed is an EKG monitor to track the heart rhythm. Another thing that is needed is oxygen with a nasal cannula or mask. You need suction in case the patient regurgitates and you need to get it before it goes into patient’s lungs. Another equipment needed is an Ambu bag. Murray had an Ambu bag but did not use it, he did mouth to mouth. You also need to have a way to call for help. Backboard is needed in case CPR is needed. You also need a back up battery for the equipment in case of a black out. Other equipment needed is equipment needed for airway such as endotracheal tube. Endotracheal tube requires trained staff to place it. Also you need a defibrillator.
A lot of special drugs are also needed. Those are fluamzenil, narcan, lidocaine, betablockers, atropine, dopamine, epinephrine, prednisone, dextrose.
Steinberg says when giving sedation you also need BLS (basic life support) and ACLS (advanced cardiac life support) trained assistant.

• Inadequate preparation for an emergency. You need to have the drugs ready, equipment ready, have a person ready to help you. You need to be prepared to use those medicines and equipment in the case of emergency.
• Improper care during the arrest. Michael’s breathing had stopped and Murray didn't follow proper protocol.

Steinberg explains cardiac arrest which is when the heart stops beating. There’s no blood pressure and the patient collapses. In that case you call 911, use a defibrillator, and do CPR on a hard surface.
In Michael's case, it was a respiratory arrest. Michael stopped breathing and the oxygen went down. Then the heart started to beat harder while trying to distribute little oxygen in the body. According to Murray's statement this is when Murray found Michael. If you do nothing, the heart weakens because of lack of oxygen, and stops contracting but there is still an electrical activity. That’s PEA (Pulseless Electrical Activity). After PEA, there's asystole.
Steinberg says Murray should have called 911 immediately then try to arouse Michael, should have used the Ambu bag and give him Flumanezil. Steinberg says it’s inexcusable that Murray did chest compressions. This was a respiratory arrest not a cardiac arrest and there was blood pressure and pulse. Murray should NOT have done CPR.
Conrad Murray’s CPR was poor quality because Michael was on a bed. It has to be done on a hard surface such as on the floor and should have done CPR with 2 hands. Steinberg says it would have been very easy to put Michael on the floor.

• Failing to call for help. Murray should have called 911 immediately. He should have known that he didn’t have any of the medications and the equipment and he had to call for help. But Murray instead called Michael Amir Williams which caused a significant delay. EMS was only 4 minutes away. If Murray had called them he could have gotten help sooner.

For every minute delay in calling EMS, there are less and less chances the patient will survive and there is a risk of permanent brain damage. Walgren: “Every minute counts”.
Steinberg also thought it was bizarre to call an assistant instead of calling 911. Murray as a medical doctor should have realized he needed help and called 911.

• Failure to maintain proper medical records. Medical records are important for several reasons. Insurance companies want them. Second reason is litigation. The most important reason is for better health care for the patient. Murray did not document a single thing. He didn’t ask when the last time Michael ate was, he had no vital sign records, he had no physical exam. There was no informed consent. He didn’t write what medication he gave and what was the reaction. Murray was confused and was not able to explain Michael's history or what he gave him to the ER doctor or EMTs. Walgren asks if he could be dishonest rather than confused.

Steinberg concluded that these extreme deviations directly contributed to Michael's death. Without these deviations, he would still be alive.
Walgren asks based on Murray’s statement if he gave benzodiazepines and only 25mg Propofol if the risk of respiratory depression is foreseeable. Steinberg answers yes.
Walgren assumes everything happened as Murray described and as Murray left Michael alone, Michael was able to take Lorazepam pills or Propofol. Steinberg says all the things he said still apply. Steinberg says you never leave the patient and always monitor patient. If Michael self administered, it means that Murray was away, and that should not have happened. Steinberg compares leaving a patient under the effect of Propofol to leaving a baby sleeping alone on the kitchen counter. Steinberg says the baby might have woken up and fallen down.
Steinberg also mentions that medication should not have been within Michael's reach. Steimberg explains how in hospitals every medication will be under lock and says that having medications out in the open is a foreseeable risk that the patient can self administer and take the wrong medication.
Mid morning break
Flanagan Cross
Steinberg is not currently trained in using Propofol. When Steinberg was NY he had privileges to use Propofol. In his current work he does not have the privileges and he hasn’t used it in 7 years. When he was in NY he felt confident in using Propofol because he was trained in protecting airways.
Flanagan asks if there is a difference in the equipment needed for moderate and deep sedation. Steinberg answers no, they will be the same.
Flanagan asks if Steinberg thought Murray's declaration to the cops was thorough and complete. Steinberg says he assumed it was complete.
Flanagan asks how Steinberg knows Murray didn’t have informed consent. Steinberg says because there was none. Flanagan asks if the informed consent can be oral. Steinberg says it has to be written. “If it's not written it's not done.” Steinberg says he has never heard an oral consent. Flanagan asks if any written document had anything to do with Michael's death. Steinberg says if Michael had been informed about risk and benefits, he might not have agreed to this.
Steinberg says he cannot know if Michael had been informed, but assumes he was not informed that a powerful dangerous drug would be used on him without proper monitoring. Steinberg assumes he would not have agreed to it.
Flanagan asks if Steinberg knows anything about Michael's propensity towards drugs and mentions Demerol and Klein. Flanagan asks what if Michael was an addict; would he have agreed to it? Steinberg says if he was an addict, he wouldn't give it to him in the first place.
Other doctors that use Propofol could be dentists, gastroenterologist, pulmonary doctors, ER doctors. But their societies have advice on how to use it and they are trained. Their societies outline the same monitoring equipment that Steinberg mentioned. Steinberg says there’s no difference in equipment needed for conscious sedation.
Flanagan asks what killed Michael? Steinberg says a respiratory arrest because he still had a pulse that means there was a heart rate and blood pressure. Murray said there was blood pressure and a pulse, it was later PEA.
Steinberg says that according to Murray he found Michael around noon and EMS arrived at 12:26. There was a delay in calling 911 for at least 12 minutes. Flanagan mentions Murray made a lot of time estimations and it might be all precise.
Flanagan asks what 2mg of Lorazepam would do to a patient. Steinberg says he’s not an expert, he gave it as a sedative orally before but he never used IV. Steinberg says he gives it an hour before the procedure orally. Flanagan asks further questions about Lorazepam, Midazolam. Objections. Sustained. It’s beyond his area of expertise.
Flanagan turns the subject to Propofol and say that Michael and Murray had been discussing Propofol for the past 3 nights and Murray told him it was not good for him and he was trying to wean him off.
Steinberg states that Murray said that he gave 25mg initially and started Michael on IV. Flanagan denies that there was an IV. Steinberg understood that after that initial 25mg dose, there was a drip based on his police interview. Steinberg cites a lot of examples in Murray interview referencing IV and says it makes sense because 25mg would not keep Michael asleep.
Flanagan insists there was no drip on the 25th, Steinberg insists there was a drip, they both give examples in Murray's LAPD interview. They agree it's not clear, but Steinberg says it makes no sense. It's logical Murray gave a drip. Michael logically would have woken up, and there was no reason that Murray changed his methods.
Flanagan says that 25mg is not a heavy dose and it would make Michael sleep 4 to 7 minutes. Steinberg agrees. So Flanagan asks if Michael was still asleep he was sleeping for other reasons such as being tired. Steinberg says that he would have worried that Michael was still asleep if he was not on a drip. Protocol says that after Propofol you should watch the patient. Steinberg says just looking at Michael doesn't tell if he's in mild sedation or in deep sedation. Steinberg says they need to be continuously checked for their reaction to stimuli. Steinberg says Murray should have woken him up. Steinberg says the fact that he was still asleep after 10 minutes, if there was no drip, is very alarming. Steinberg it might mean that something was going wrong.
Flanagan mentions a study that Propofol was successfully used on refractory chronic primary insomnia in Taiwan. Steinberg says that the article dates back to 2010, in 2009 when Murray gave propofol there was no medical knowledge that Propofol could be given for sleep. Murray was unethical in giving Propofol with no medical knowledge. Article mentions Propofol given for 2 hrs per night 5 nights, not 8 hours per night for 2 straight months. The article says that this test was successful, but it's still not used as a sleep medication because it's still experimental, there is not enough data about this. It needs to be extensively researched and tested. Murray is the first doctor he's heard who used propofol for insomnia.
Flanagan asks how Steinberg knows Murray didn't use Ambu bag, Steinberg says because Murray said he did mouth to mouth. Flanagan asks how Steinberg knows Murray didn’t use the blood pressure cuff, Steinberg says because it was not on Michael. Steinberg says pulse oximeter was not on Michael
Steinberg says he doesn’t know what happened between 11 and 12 or how long Murray watched Michael or when Murray went to bathroom. Flanagan asks if he has an idea about the actual time of death. Steinberg says Michael was pronounced dead at 2:26PM but he was probably clinically dead for some time.
Steinberg says Michael was savable when Murray found him based on his interview. Steinberg says Murray said he left Michael for 2 minutes. By using Ambu bag, by arousal and changing the effects of the medicines and if 911 was called Michael was savable.
Flanagan tries to get Steinberg to assume that Murray was gone longer than 2 minutes. Steinberg is not comfortable making those assumptions as he based his report on Murray’s statements. Flanagan mentions the phone calls; Steinberg does not want to comment on them. Steinberg says saying Murray was on the phone tells him that he shouldn’t have been on the phone and if Michael was only given 25mg it would wake him up. Steinberg says that it tells Michael was on a drip.
Flanagan wants him to assume that if Murray was gone longer than 2 minutes if Michael was savable. Steinberg says he was savable because according to Murray’s statement Michael had a pulse, blood pressure and heart was still beating and with proper equipment he could have been saved. He could have given Michael oxygen. Steinberg says Michael wasn’t PEA when Murray came back because he had a pulse. Flanagan asks how he knows know Michael had a pulse, Steinberg says because Murray said so. Flanagan asks if it could PEA. Steinberg says in PEA there’s no pulse.
Flanagan asks what Murray should have done. Steinberg says he should have called 911 and it would have taken 2 seconds. Steinberg says protocol says doctors are allowed 2 minutes to determine the situation. Flanagan asks if Murray went down to ask for help in 12:05 – 5 minutes after – if it would be a violation of standard of care. Steinberg says he didn’t have the right equipment so he should have called 911 immediately.
Flanagan tries to talk about Kai Chase. Steinberg says Murray didn’t ask Kai to call 911. Flanagan asks what if Murray called for help in 5 minutes but not in 2 minutes. Steinberg says it’s still a deviation from standard of care.
Flanagan asks if he talked to Murray to review the case. Steinberg says no and he didn’t ask. Steinberg used Murray’s 2 hour interview.
Flanagan asks what Murray should have done in 2 minutes. Steinberg says call 911, tilt the head to open airway, make him breathe with Ambu bag and give Flumazenil. Steinberg says he would have called 911 first. Steinberg says Murray had to increase Michael’s breathing.
Flanagan asks if Murray made a mistake in asking someone to call 911 Steinberg says he had no one around and he had to call 911. Steinberg says for the time it takes to call for security Murray could have called 911. He had a cell phone. Steinberg says it would have taken him 2 seconds to say “I’m a doctor, there’s an arrest, come to 100 Carolwood now” and then Murray could have put 911 on loudspeaker and continue to do what he was doing.
Flanagan asks if he’s aware that EMS said Michael was cool to the touch. Yes but Murray said he was warm. Steinberg says you get cold in 26 minutes when you have no blood pressure.
Flanagan asks if Steinberg has no doubts that if 911 had been called immediately Michael would still be alive. Steinberg says he has no doubt about that, they could have saved him. Murray said that he lost the pulse after calling Williams at 12:12. So if the paramedics had been there at 12:05 or 12:10, they could have saved him.
Flanagan says that Murray was in an emergency situation and he could be mistaken in his estimations. Steinberg says there is clear evidence that there was a delay in calling 911 as Murray went downstairs and called Williams rather than calling 911.
Flanagan asks based upon these facts if Steinberg thinks Murray is responsible for Michael's death. Steinberg says yes.
Flanagan asks if Murray should have dropped Michael on the floor, in spite of the IV line. Steinberg says he should stop the Propofol drip first and then he should be careful with the line when he’s putting Michael down the floor.
Flanagan asks rather than suction would it be okay to turn the patient on his side and clean the mouth with a finger will be okay. Steinberg says suction is needed.
Flanagan asks if a doctor has only 1 patient, he would still need to document everything he does. Steinberg says he does because obviously Murray didn't recall what he had given when he talked to UCLA or with the paramedics.
Flanagan says that not having records did not kill Michael. Steinberg says it wouldn’t cause his death but it’s still a deviation.
Lunch break
Afternoon Session
Dr.Steinberg Testimony/Walgren Redirect
Steinberg states that Murray did not act like he was ACLS certified.
Steinberg states that he used propfol in New York, but it was in hospital settings.
Steinberg states that gastroenterologists, dentists and ER doctors who use propofol receive appropriate training, with a trained staff and appropriate monitoring equipment are necessary.
Steinberg states that an article about the propofol study in Taiwan, published in 2010, was an experimental study. The patients were given propofol in a hospital , with the appropriate equipment, the experiment was approved by their ethics committee. Steinberg states that written, informed consents were obtained from the patients. Steinberg states that 8 hours of fasting occurred prior to being given propofol, and that the propofol was given by an anesthesiologist. Steinberg states that the patients were constantly monitored and pulse oximeters were attached to the patients. Steinberg states that the propofol was administered by an infusion pump, a drip was not used. Steinberg states that no other benzos were used. Steinberg states that the authors of the article specifically state that the study was an experiment, and that is does not dictate a standard of care. Steinberg states that what Murray was doing was essentially an experiment.
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Steinberg states that if he had to assume that Murray gave only 25mg, that there was no drip, would he draw the same conclusions? Steinberg states yes, that standard of care was deviated from in an unmonitored setting, without appropriate equipment, response was inappropriate, medical records were inappropriate and that it was be a foreseeable prediction that there would be respiratory depression (stop breathing).
Steinberg states that Murray played a direct, causal role in Michael's death.
Recross Flanagan
Steinberg states that the sleep study showed that propofol helped insomnia.
Steinberg states that in his analysis for the CA medical Board, that Murray deviated from the standard of care for Michael
Steinberg states that the lack of a backup battery did not lead to the cause of Michael's death, however, 5 out of 6 deviations did lead to his death.
Steinberg states that he did read Murray's interview with LAPD that he gave Michael propofol for 40-50 days without incident. Flanagan asks if Steinberg has made certain assumption, Steinberg states no. Steinberg states that he didn't assume that Murray gave propofol, that Murray didn't have the proper equipment, the delay in calling 911, improper care during the arrest, that all of these things are facts.
Walgren Re-redirect
Steinberg states that even if the defense theory that Michael self-injected propofol and therefore accidentally killed himself, according to Conrad Murray's own words, Murray would still be the causal factor in his death.
Dr. Nader Kamangar (Sleep Medicine Expert) Testimony
Walgren Direct
Kamangar states he is a pulmonary care/sleep medicine/critical care physician at UCLA. He states he is board certified in four areas: internal medicine, pulmonary medicine, critical care, and sleep medicine.
Kamangar states he is a medical reviewer for the CA Medical Board , and that he assessed Murray's care to Michael for the medical board. Kamangar states that propofol is used in critical care unit on a daily basis. He states he is trained in using propofol. Kamangar states propofol is used for placement of endotracheal tubes, and for people on breathing machines. Kamangar states that propofol is the most commonly used drug for this.
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Kamangar states that he found multiple deviations of standard of care with regard to Conrad Murray's care of Michael :

• Propofol was given in an unacceptable setting : using this deep sedation agent in a home setting is inconceivable and an egregious violation of standard of care.
• ACLS certified : the person who gives propofol must be trained in ACLS and airways management. There was a risk of hypoventilation (diminishment in rate of breathing), apnea and obstruction of the airway.
• Need of assistance : Murray needed a second person (a nurse) to monitor, to pay complete and utter attention to Michael, especially if Murray was going to leave the room; this goes without saying. This violations Hippocratic oath, to abandon his patient.
• Pre-procedure setup : imperative to be prepared for unforeseen circumstances. Things can change very quickly. A patient may look good, and the next minute there's a problem. Murray needed a suction catheter, because patients can regurgitate into their airway, and block the airway, this can cause death. A crash cart (medication on hand : adrenaline, ephedrine, medication to correct the heart beat, etc...) , pulse oximeter, defibrillator, automated infusion pump (precise dosing for propofol) even with people who are intubated;

Kamangar states that all of these factors are extreme deviations of standard of care and are the equivalent of gross negligence.
Kamangar states that he has never seen someone giving propofol at home in such settings, and would not have expected to see that.

• Charts / medical documentation : or medical history, reactions to a medication. For example a blood pressure can look normal, but not be normal for a particular patient, and that change in blood pressure could be the indication of a problem.
• Michael was left alone, which is not acceptable, especially since Murray didn't have the right equipment.
• Use of benzodiazapines: using lorazepam and midazolam on top of propofol can have higher effects : more significant respiratory depression, decrease cardiac output (often a consequence of respiratory depression), decreased blood pressure and cardiac arrest can occur directly, or because of low levels of oxygen.
• Dehydration : blood circulation is not good when you are dehydrated , causes low blood pressure. Benzos and propofol would also lower blood pressure . Murray should not have used benzos or propofol if the patient is dehydrated.
• Failure to call 911 : 911 should have been called immediately.
• Improper CPR : Murray stated there was a pulse, therefore the heart was beating, so the problem was respiratory not cardiac. Murray should have dealt with airway management by placing an ambu-bag over Michael's mouth. Murray's administration of CPR was ineffective; it was not on a hard surface, and it was done with one hand . Correct CPR correctly allows about 20% of the normal blood circulation, so if you do it incorrectly

Kamangar states that assuming Murray found Michael at noon, and calls Williams at 12:12 pm, the significance of the 12 minutes is the lack of blood flow to vital organs, especially to the brain. He states that some individuals are more susceptible than others to a lack of oxygen. Kamangar states that generally it takes 3 to 4 minutes before brain cells start to die. He states that time is really important. Kamangar states that because 911 was called at 12:20 pm, with the passage of 20 minutes, it reaches a point where it becomes irreversible.
Kamangar states that Murray Deceived paramedics and ER staff because he did not provide the accurate information, which is a deviation of standard of care.
Kamangar states that Murray did not properly evaluate insomnia. He states that insomnia can have many causes, so it's important to have a detailed history. Kamangar states that Murray needed to exclude secondary problems (psychological problems, substance abuse, underlying conditions, chronic anxiety, depression , etc...) He states that insomnia is defined by no restful sleep for 4 weeks or more. Kamangar states that once all the secondary problems are ruled out, primary insomnia is considered.
Kamangar states that in order to diagnose/treat insomnia. a detailed sleep history is needed : when do they go to bed, when do they fall asleep, when do you wake up, etc.. check sleep apnea. In some cases you need a sleep study.
Kamangar states that a detailed pharmaceutical history was needed; both prescribed or over the counter (example migraine pills contain caffeine, that can cause insomnia), illicit drugs.
Kamangar states that a detailed physical examination was needed; some underlying conditions can cause insomnia, for example asthma, congestive heart failure, diabetes, bladder problems, enlargement of prostate, thyroid conditions, etc..
Kamangar stated blood testing was needed to rule out certain conditions; examples: diabetes, kidney problems, restless legs , etc..
Kamangar states that a good blood workup would reveal the use of narcotics, if the doctor asks the patient for one. He states that if the patient is not giving the information, a doctor can simply refuse to treat the patient.
Kamangar states that when all the above mentioned are done, then the doctor can treat the underlying condition that causes the insomnia.
Kamangar states that in this case , Murray didn't have a detailed history. In addition, Murray didn't check what the root problem for Michael's insomnia was before treating him.
Kamangar states that Murray did say that he saw that other doctors were treating Michael, he said he saw IV sites. Kamangar states that if Murray could not get that info from Michael, Murray should have refused care and refused to give further medication. Murray didn't do that, and that was unethical.
Kamangar states that Murray bypassed the evaluation of insomnia, bypassed the detailed history which was a deviation of care.
Kamangar states it was obvious there was probably secondary causes in Michael's insomnia (substance abuse or anxiety or depression ) and that these underlying causes should have been treated.
Kamangar explains about sleep hygiene techniques that can help in case of insomnia (using a bedroom to sleep only, among other things)
Kamangar explains about sleep restriction, that the doctor should tell the patient to go to bed later , and limit their time in bed.
He states that relaxation techniques can be used to treat insomnia.
Kamangar states that all these can usually work better to treat insomnia than pharmacological approach, but that the pharmacological approach can also be used.
He states that Murray did not use any of the above approaches on Michael, that Murray went direct to the pharmacological approach.
Kamangar states that the pharmaceutical approach : 3 medications that are not benzos should be used first, because they are not addictive . He states that a newer drug is melatonin something less addictive.
Kamangar cites 4 different benzodiazepines that deal with insomnia. He states that others are used also, but their main goal is to treat underlying conditions (anxiety). They are used in tablet form.

1. Midazolam : not appropriate for long term use for primary insomnia
2. Valium : not appropriate for long term use for primary insomnia
3. Lorazepam : can be used on short term basis, tablet form. Really addictive after 3 to 4 weeks. Used to treat underlying conditions, not primary innsomnia.

Kamangar states that the use of midazolam and lorazepam to treat insomnia was an extreme deviation of care, especially in IV form.
He states that it is inconceivable to use propofol for the management of insomnia, regardless of the setting. Kamangar states that it is "beyond comprehension, inconceivable and disturbing." He states that it is beyond a departure of standard of care, especially when underlying causes for insomnia were not treated.
Kamangar states that even if Michael took lorazepam and propofol himself, Murray was the causal factor in his death, especially if Michael had substance abuse problems. He states that the lorazepam and the propofol should not have been readily available
Kamangar states that there is a risk of respiratory complications, especially if Michael was dehydrated, and that any competent doctor would have been aware of the risk.
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doctor on call - home nursing dubai

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Neotonics is a natural formula that has been garnering a lot of attention among supplement users over the past few weeks. The formula is said to be helping in improving skin health by working on the root cause of skin aging.
At first glance, Neotonics seems to be an effective skin health solution. Although, there are many questions that need to be answered before coming to a conclusion on the effectiveness and safety of the formula. In this Neotonics review, we will be clearing all these questions and also give you an honest analysis of the supplement.
Neotonics skin and gut health supplement is formulated with clinically proven ingredients and the manufacturer assures that it does not cause any sort of side effects. Many tropical products are now available on the market that claims to make your skin and gut healthier. Now you might be confused about what to purchase and how to believe them.
In this Neotonics review, I will be revealing everything that you have to know about the formula and how it affects your body. The Neotonics manufacturer is providing many discount offers and free bonus gifts that help to boost your result. So keep reading this Neotonics review and decide whether purchasing this probiotic formula is worth it or not.

What Is Neotonics?

Neotonics is a probiotic formula that supports healthy and glowing skin and also improves your gut health. It is formulated with 500 million units of extra-strong bacteria and 9 potent natural ingredients that target the root cause of skin aging.
Neotonics skincare supplement is backed by natural formula only and does not contain any sort of stimulants or additives that cause harm to your health.
The Neotonics supplement comes in the form of gummies so it will be easy to use too. It is manufactured in an FDA-approved facility and the manufacturing process follows all GMP guidelines and instructions.
Also, the manufacturer assures that the Neotonics gummies are non-habit forming, non-GMO, gluten-free, and vegan-friendly. So there shouldn’t be any concerns regarding Neotonics side effects.
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Neotonics Reviews - How Does This Probiotic Gummy Support Skin And Gut Health?

How Does Neotonics Skin Care Formula Work?

Neotonics skin and gut essential probiotic formula works by controlling the cell turnover process in your body. The formula contains specific nutrients and compounds that support your skin and gut health.
Neotonics anti-aging formula contains ingredients that are essential for overall cell health and function and supports the renewal and turnover of skin cells and the inner linings of your stomach.
The Neotonics gummies contain ingredients that promote collagen and elastin production which helps to maintain skin elasticity and health. The formula behind Neotonics probiotic supplement exhibits anti-inflammatory properties and thus supports skin and gut health by reducing inflammation.
Also, it is formulated with essential prebiotics and probiotics that help to maintain a balanced gut microbiome.

What Are The Ingredients In Neotonics?

Let’s discuss the role of each ingredient in this section of the Neotonics review:
👉 Fennel
It is an aromatic herb that contains compounds such as flavonoids and Vitamin C which help protect skin cells from damage caused by free radicals and oxidative stress. This Neotonics ingredient can also help relax the muscles in the gastrointestinal tract and reduce bloating and discomfort.
👉 Organic Lion's Mane
It is a good source of dietary fiber and supports regular bowel movements and provides nourishment for beneficial gut bacteria. Organic Lion’s Mane keeps your skin hydrated for maintaining skin moisture.
👉 Lemon Balm
Lemon Balm has been used to relieve gastrointestinal issues and it can potentially reduce stomach discomfort. Some of the compounds in Lemon Balm have anti-inflammatory properties and help to reduce chronic inflammation.
👉 Fenugreek
Fenugreek is an herb that is rich in antioxidants that help protect your skin and provide more youthful-looking skin. This Neotonics ingredient has been most commonly used to help soothe digestive discomfort and reduce bloating.
👉 Bacillus Coagulan
It is a probiotic bacteria that helps to maintain a healthy gut microbiome. It may enhance nutrient absorption and ensure that your body is getting enough vitamins and minerals.
👉 Inulin
It is a soluble fiber found in certain plants and herbs. Inulin is considered a prebiotic fiber and it can alleviate constipation and promote bowel movement. This Neotonics ingredient can also support the detoxification processes in your body and eliminate toxins.

How To Use Neotonics Gummies?

Always follow the suggested Neotonics dosage and instructions provided by the manufacturer to get optimal results. As per the manufacturer, you have to take one Neotonics gummy daily to get the best results.
Do not exceed this dosage as it might cause severe side effects. A Neotonics bottle comes with 30 easy-to-swallow gummies and it is enough for a month’s usage.

Key Advantages Of Using Neotonics Probiotic Gummies

The proprietary blend of unique ingredients added to the Neotonics skincare gummies is backed by several health benefits beyond supporting your skin and gut health. Some of the key benefits associated with the Neotonics probiotic formula are listed below:
✅ The Neotonics gummy can boost skin rejuvenation and support collagen production.
✅ It contains strong probiotics that help to improve gut health and helps in the growth of beneficial bacteria in your gut.
✅ Neotonics supplement has skin-protecting qualities and it is rich in antioxidants which also act as a strong moisturizer.
✅ It can tighten your skin, unclog the pores, and provide protection against skin rashes and irritations.
✅ The Neotonics supplement ingredients have long-term anti-aging effects and they can protect your stomach lining.

Pros And Cons Of Neotonics Skin And Gut Health Supplement

It is very important to understand how a dietary supplement that you consume will affect your body. So before deciding whether to purchase Neotonics gummy-shaped formula or not, here I have listed some of the pros and cons of taking it. Go through them.
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Neotonics Reviews - How Does This Probiotic Gummy Support Skin And Gut Health?
Neotonics Pros

• Neotonics dietary supplement comes in the form of gummies. So you easily use it and it is easy to incorporate into your daily life.
• Based on herbal ingredients that are 100% natural and do not cause any harmful side effects.
• Ingredients have undergone rigorous testing and proven their safety and effectiveness.
• The Neotonics ingredients are scientifically and clinically proven to support your skin and gut.

Neotonics Cons

• Some users reported that they felt mild side effects such as dizziness and headaches for the first two days after starting using the Neotonics supplement.
• The original probiotic formula is only available to purchase through Neotonics official website.

Click Here To Purchase Neotonics From Official Website

What Neotonics Customers Are Saying?

There are several Neotonics reviews and customer comments that claim the effectiveness of the probiotic formula. I couldn’t find any Neotonics complaints as most of the users who already used it experienced great results.
Neotonics customer reviews reported that the formula helped them to alleviate all stomach discomfort including bloating, constipation, etc.
It also helps them to get smooth, brighter, and supple skin when used as suggested by the manufacturer. Since the supplement comes in the form of gummies, it made the Neotonics regimen easy for the users.

Is Neotonics Safe To Use? Were Any Side Effects Reported?

Neotonics dietary formula consists of natural ingredients that help you to get healthy skin and promote a healthy gut microbiome. So the supplement causes no potential side effects for the users.
However, you have to follow the correct Neotonics dosage and instructions provided by the manufacturer to reduce the risk of getting adverse effects. Also, keep in mind that an individual's response to a dietary supplement might be different.
Some people may experience allergic reactions even to natural and plant-based ingredients. So carefully go through the Neotonics ingredients list provided by the manufacturer and make sure that none of the ingredients are allergic to you.
If you are experiencing any difficulties or health issues after starting using the formula, then immediately discontinue using it and seek medical advice as soon as possible. Neotonics anti-aging supplement can be used by both men and women, but it is not recommended for children below 18 years old, pregnant ladies, and nursing mothers. If you are having any underlying medical issues or are under any treatment, seek medical advice before starting to use the supplement.

Neotonics Price Plans And How To Get It?

The Neotonics skin and gut health formula is only available to purchase from its official website and it is not sold through any eCommerce websites or retail stores. This is done by the manufacturer to ensure that their customers are getting the original formula.
It has been noticed that many counterfeit supplements with the same likeness as Neotonics have been released into the market and are selling at much lower than the original price.
Beware of those duplicate supplements as they might not contain the original formula of Neotonics and might cause harm to your health beyond deceiving your money. To overcome those imitated versions, place your order through the Neotonics official website.
To order from its website, log in to its official Neotonics website, and select your favorite package. Then you will be redirected to a checkout page where you have to process the payment. Once the payment is done, your Neotonics package will reach your home within 5 to 7 days.
The Neotonics supplement manufacturer provides many discount packages and offers through their website and you can also get access to the 60-day, 100% money-back guarantee offered by the manufacturer on purchasing Neotonics from its official website.
Among the discount packages offered by the manufacturer, some of the available ones are listed below:

• 1 bottle package - 30-day supply - $69 per bottle + free shipping
• 3 bottles package - 90-day supply - $59 per bottle + free shipping + 2 free ebooks
• 6 bottles package - 180-day supply - $49 per bottle + free shipping + 2 free ebooks

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The Operating Room (OR):
The operating room, often referred to as the OR, is a critical area within a hospital or medical facility where surgical procedures are performed. It is a highly specialized and controlled environment designed to provide a safe and sterile setting for surgical teams to carry out various medical interventions. The OR plays a pivotal role in the continuum of patient care, as it is where many life-saving and complex surgeries take place.
Components of the Operating Room:
The operating room is a complex space with various components that contribute to its functionality and safety. Some of the key components include:

1. Surgical Team: The surgical team is a group of highly skilled medical professionals, including surgeons, anesthesiologists, nurses, surgical technicians, and other support staff, all working together to ensure the success of the surgical procedure.
2. Sterile Environment: Maintaining a sterile environment is paramount in the OR to prevent infections and complications. All personnel entering the OR must adhere to strict protocols, including wearing sterile attire and following proper handwashing procedures.
3. Surgical Table: The surgical table is a specialized platform where the patient lies during the procedure. It is designed to be adjustable and positionable to provide optimal access for the surgical team.
4. Anesthesia System: Anesthesia is administered to the patient to induce unconsciousness and manage pain during surgery. An anesthesia machine and various monitoring devices are used to deliver and monitor anesthesia throughout the procedure.
5. Surgical Equipment: The OR is equipped with a wide range of specialized surgical instruments and equipment specific to different procedures, such as scalpels, forceps, retractors, and electrosurgical devices.
6. Imaging and Visualization Technology: Modern ORs often have advanced imaging and visualization technology, such as X-ray machines, fluoroscopy, endoscopy, and laparoscopic equipment, which aid surgeons in performing minimally invasive procedures.
7. Environmental Controls: The OR maintains strict environmental controls, including temperature, humidity, and air filtration, to ensure optimal conditions for surgery and prevent infections.
8. Surgical Lights: Bright, adjustable surgical lights are essential for providing adequate illumination of the surgical field, enabling surgeons to perform precise maneuvers.
9. Communication Systems: Effective communication is vital in the OR. Intercoms and audiovisual equipment allow the surgical team to communicate with each other and seek consultations with experts outside the OR when needed.

The Role of the Operating Room in Healthcare:
The operating room serves as a crucial component of the healthcare system, providing a controlled and safe environment for various surgical interventions. It plays a pivotal role in improving patient outcomes by facilitating the following:

1. Life-Saving Procedures: The OR is where emergency surgeries, such as trauma interventions and organ transplants, are performed, often saving patients' lives.
2. Elective Surgeries: Many elective procedures, such as joint replacements, cardiac surgeries, and tumor removals, are carried out in the OR to improve patients' quality of life and alleviate pain.
3. Diagnostics and Therapeutics: In some cases, exploratory surgeries are performed to diagnose and determine the extent of certain medical conditions. Additionally, surgeries may be therapeutic, removing tumors or correcting abnormalities.
4. Minimally Invasive Techniques: The OR is a hub for innovative minimally invasive techniques, such as laparoscopy and robotic-assisted surgery, which reduce patient trauma, minimize scarring, and accelerate recovery times.
5. Research and Education: The OR often serves as a platform for medical research and education. Surgeons may utilize it to train medical students and residents, as well as to explore and refine new surgical techniques.
6. Multi-Disciplinary Collaboration: Complex cases often require input from various medical specialties. The OR allows surgeons, specialists, and other healthcare professionals to collaborate in real-time to optimize patient care.

Sterile Procedures and Infection Control:
One of the primary goals of the OR is to maintain a sterile environment to minimize the risk of surgical site infections (SSIs). SSIs can lead to significant complications, prolonged hospital stays, and increased healthcare costs. To ensure infection control, the following practices are meticulously followed:

1. Surgical Attire and Hand Hygiene: All OR personnel, including surgeons, nurses, and technicians, must wear sterile gowns, gloves, masks, and caps. They also perform thorough handwashing and use surgical hand scrubs before entering the OR.
2. Surgical Site Preparation: The patient's surgical site is prepared and sterilized using antiseptic solutions to minimize the presence of bacteria on the skin.
3. Aseptic Technique: The surgical team uses aseptic techniques during the entire procedure, ensuring that sterile instruments and equipment are handled appropriately and that the surgical field is maintained free of contamination.
4. Sterile Instrumentation and Supplies: All surgical instruments, drapes, and supplies used in the OR are carefully sterilized using methods such as autoclaving or chemical disinfection before use.
5. Air Quality and Filtration: The OR's ventilation system includes high-efficiency particulate air (HEPA) filters to reduce airborne particles, bacteria, and viruses, helping maintain a clean environment.
6. Traffic Control and Restricted Access: The OR restricts access to authorized personnel only and enforces strict traffic control to minimize the potential for contamination.

ICU - Intensive Care Unit:
The Intensive Care Unit (ICU) is a specialized department in a hospital that provides critical care and continuous monitoring to patients with severe, life-threatening conditions. It is also known as the critical care unit or intensive therapy unit. The ICU is staffed with a highly trained team of healthcare professionals who are experienced in managing critically ill patients and using advanced medical equipment to provide essential support and interventions.
Types of Intensive Care Units:
There are various types of ICUs within a hospital, each catering to specific medical needs:

1. Medical ICU (MICU): MICUs focus on providing intensive care for patients with severe medical conditions, such as respiratory failure, sepsis, heart failure, and organ dysfunction.
2. Surgical ICU (SICU): SICUs are dedicated to caring for postoperative patients who require critical care after undergoing complex surgical procedures.
3. Cardiac ICU (CICU): CICUs specialize in managing patients with severe cardiac conditions, such as heart attacks, heart failure, and arrhythmias.
4. Neonatal ICU (NICU): NICUs are designed to provide specialized care for premature infants and newborns with critical medical conditions.
5. Pediatric ICU (PICU): PICUs focus on caring for critically ill children and adolescents, including those with severe infections, traumatic injuries, or chronic medical conditions.

Characteristics of the ICU:
ICUs possess unique characteristics that distinguish them from other hospital departments:

1. High-Level Monitoring: ICU patients are continuously monitored using advanced medical equipment, such as cardiac monitors, ventilators, pulse oximeters, and intravenous infusion pumps. This constant monitoring allows healthcare providers to promptly address any changes in the patient's condition.
2. Close Patient Observation: ICU staff conduct frequent patient assessments, closely monitoring vital signs, neurological status, and response to treatment. Minute changes can have significant implications in the critically ill, necessitating immediate intervention.
3. Specialized Medical Equipment: ICUs are equipped with a wide range of specialized medical devices and equipment to support critical patients, including mechanical ventilators, hemodynamic monitoring systems, renal replacement therapy machines, and more.
4. Trained ICU Staff: The ICU team consists of experienced and highly trained professionals, including critical care physicians, nurses, respiratory therapists, pharmacists, and other specialists, all working collaboratively to provide comprehensive care.
5. Family Support: Recognizing the emotional toll on patients and their families, ICUs often have designated areas for family members to receive updates and support from the medical team.
6. Round-the-Clock Care: The ICU operates 24/7 to ensure continuous care and prompt response to any emergencies that may arise.

The Role of the ICU in Healthcare:
ICUs play a critical role in the healthcare system by providing specialized care for patients with severe and life-threatening conditions. Some key roles of the ICU include:

1. Life Support and Stabilization: The ICU serves as a bridge for patients in critical condition, providing life-saving interventions and stabilizing them until their condition improves or a definitive treatment plan is established.
2. Postoperative Care: After complex surgical procedures, patients may be transferred to the ICU for close monitoring and immediate management of any postoperative complications.
3. Management of Complex Conditions: ICUs care for patients with a wide range of medical conditions, such as sepsis, acute respiratory distress syndrome (ARDS), multiple organ failure, and severe trauma.
4. Ventilator Support: Patients with respiratory failure often require mechanical ventilation. The ICU staff are proficient in managing ventilators and optimizing respiratory support.
5. Hemodynamic Monitoring: In cases of shock or cardiovascular instability, hemodynamic monitoring techniques are used to assess blood pressure, heart function, and fluid status.
6. Nutritional Support: Many critically ill patients are unable to eat normally, requiring specialized nutritional support, such as enteral or parenteral feeding.
7. Pain Management and Sedation: Patients in the ICU may require pain management and sedation to keep them comfortable and reduce anxiety.

Challenges and Ethical Considerations:
The ICU environment presents various challenges and ethical considerations due to the complexity and severity of patients' conditions:

1. Resource Allocation: ICU beds and resources are often limited. Healthcare providers must make challenging decisions regarding patient prioritization and resource allocation.
2. End-of-Life Care: In the ICU, difficult decisions regarding end-of-life care and withdrawal of life support may arise. Healthcare providers work closely with patients and families to ensure appropriate and compassionate care.
3. Compassion Fatigue: Providing care in the ICU can be emotionally taxing for healthcare professionals, leading to compassion fatigue and burnout. Institutions must implement strategies to support the well-being of ICU staff.
4. Family Communication: Communicating with families about a critically ill patient's condition and prognosis requires sensitivity and empathy.
5. Advance Care Planning: Encouraging advance care planning and discussions about patients' treatment preferences can assist in making decisions aligned with their wishes.

In conclusion, the Operating Room and Intensive Care Unit are two vital components of modern healthcare, each playing a unique and indispensable role in the treatment and care of patients. The Operating Room provides a controlled and sterile environment for surgical procedures, while the ICU offers critical care and continuous monitoring for patients with severe medical conditions. Both settings are staffed with highly trained professionals who work tirelessly to ensure patient safety and optimal outcomes. The fields of surgery and critical care continue to evolve with advancements in medical technology and research, further enhancing their ability to save lives and improve patient well-being.
https://www.arshinemedical.com/Industry-information/the-definition-of-operation-room--icu

AMA RESOLUTION 235 November 2018 INAPPROPRIATE USE OF CDC Guidelines FOR PRESCRIBING OPIOIDS (Entire Document)
“Resolution 235 asks that our AMA applaud the CDC for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths; and be it further, that no entity should use MME thresholds as anything more than guidance and that MME thresholds should not be used to completely prohibit the prescribing of, or the filling of prescriptions for, medications used in oncology care, palliative medicine care, and addiction medicine care: and be it further, that our AMA communicate with the nation’s largest pharmacy chains and pharmacy benefit managers to recommend that they cease and desist with writing threatening letters to physicians and cease and desist with presenting policies, procedures and directives to retail pharmacists that include a blanket proscription against filling prescriptions for opioids that exceed certain numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care; and be it further, that AMA Policy opposing the legislating of numerical limits on medication dosage, duration of therapy, numbers of pills/tablets, etc., be reaffirmed; and be it further, that physicians should not be subject to professional discipline or loss of board certification or loss of clinical privileges simply for prescribing opioids at a quantitative level that exceeds the MME thresholds found in the CDC Guidelines; and be it further, that our AMA encourage the Federation of State Medical Boards and its member boards, medical specialty societies, and other entities to develop improved guidance on management of pain and management of potential withdrawal syndromes and other aspects of patient care for “legacy patients” who may have been treated for extended periods of time with high-dose opioid therapy for chronic non-malignant pain.
RESOLVED, that our American Medical Association (AMA) applaud the Centers for Disease Control and Prevention (CDC) for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths
RESOLVED, that our AMA actively continue to communicate and engage with the nation’s largest pharmacy chains, pharmacy benefit managers, National Association of Insurance Commissioners, Federation of State Medical Boards, and National Association of Boards of Pharmacy in opposition to communications being sent to physicians that include a blanket proscription against filing prescriptions for opioids that exceed numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care.
RESOLVED, that our AMA affirms that some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and that such care may be medically necessary and appropriate, and be it further
RESOLVED, that our AMA advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia, and be it further
RESOLVED, that our AMA advocate that no entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids.””
Pain Management Best Practices Inter-Agency Task Force - Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations Official Health and Human Services Department Released December 2018
“The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health.”
In addition to identifying approximately 60 gaps in clinical best practices and the current treatment of pain in the United States, HHS PMTF provided recommendations for each of these major areas of concern. In alignment with their original charter, the PMTF will submit these recommendations to Congress to become our ‘National Pain Policy’. The 60+ gaps and inconsistencies with their recommendations will serve to fill gaps in pain treatment at both the state and federal level; and the overwhelming consensus was that the treatment of pain should be multimodal and completely individualized based on the individual patient. The heart of each recommendation in each section was a resounding call for individualization for each patient, in regards to both non-pharmacological and pharmacological modalities; including individualizations in both opioid and non-opioid pharmacological treatments.
While each of the gap+recommendation sections of what is poised to become our national pain policy is extremely important, one that stands out the most (in regards to opioid prescribing) is the Stigma section. Contained in this section is one of the core statements that shows our Health and Human Services agency - the one that should have always been looked to and followed - knew the true depth of the relationship (or lack of) between the overdose crisis and compassionate prescribing to patients with painful conditions:
“The national crisis of illicit drug use, with overdose deaths, is confused with appropriate therapy for patients who are being treated for pain. This confusion has created a stigma that contributes to raise barriers to proper access to care.”
The recommendation that follows - “Identify strategies to reduce stigma in opioid use so that it is never a barrier to patients receiving appropriate treatment, with all cautions and considerations for the management of their chronic pain conditions” - illustrates an acknowledgment by the top health agency of the federal government that the current national narrative conflating and confusing compassionate treatment of pain with illicit drug use, addiction, and overdose death is incorrect and only serving to harm patients.
Since March of 2016 when the CDC Guidelines were released, advocates, patients, clinicians, stakeholders, and others, have began pointing out limitations and unintended consequences as they emerged. In order to address the unintended consequences emerging from the CDC Guidelines, this task force was also charged with review of these guidelines; from expert selection, evidence selection, creation, and continuing to current misapplication in order to provide recommendations to begin to remedy these issues.
“A commentary by Busse et al. identified several limitations to the CDC guideline related to expert selection, evidence inclusion criteria, method of evidence quality grading, support of recommendations with low-quality evidence, and instances of vague recommendations. In addition, the CDC used the criterion of a lack of clinical trials with a duration of one year or longer as lack of evidence for the clinical effectiveness of opioids, whereas Tayeb et al. found that that was true for all common medication and behavioral therapy studies.
Interpretation of the guideline, in addition to some gaps in the guideline, have led to unintended consequences, some of which are the result of misapplication or misinterpretation of the CDC guideline.
However, at least 28 states have enacted legislation related to opioid prescription limits, and many states and organizations have implemented the guideline without recognizing that the intended audience was PCPs; have used legislation for what should be medical decision making by healthcare professionals; and have applied them to all physicians, dentists, NPs, and PAs, including pain specialists.441–444 Some stakeholders have interpreted the guideline as intended to broadly reduce the amount of opioids prescribed for treating pain; some experts have noted that the guideline emphasizes the risk of opioids while minimizing the benefit of this medication class when properly managed.”
“The CDC guideline was not intended to be model legislation for state legislators to enact”
“In essence, clinicians should be able to use their clinical judgment to determine opioid duration for their patients”
https://www.hhs.gov/ash/advisory-committees/pain/reports/2018-12-draft-report-on-updates-gaps-inconsistencies-recommendations/index.html
HHS Review of 2016 CDC Guidelines for responsible opioid prescribing
The Pain Management Task Force addressed 8 areas that are in need of update or expansion with recommendations to begin remediation for each problem area:
Lack of high-quality data exists for duration of effectiveness of opioids for chronic pain; this has been interpreted as a lack of benefit Conduct studies Focus on patient variability and response for effectiveness of opioids; use real-world applicable trials
Absence of criteria for identifying patients for whom opioids make up significant part of their pain treatment Conduct clinical trials and/or reviews to identify sub-populations of patients where long-term opioid treatment is appropriate
Wide variation in factors that affect optimal dose of opioids Consider patient variables for opioid therapy: Respiratory compromise Patient metabolic variables Differences in opioid medications/plasma concentrations Preform comprehensive initial assessment it’s understanding of need for comprehensive reevaluations to adjust dose Give careful considerations to patients on opioid pain regimen with additional risk factors for OUD
Specific guidelines for opioid tapering and escalation need to be further clarified A thorough assessment of risk-benefit ratio should occur whenever tapering or escalation of dose This should include collaboration with patient whenever possible Develop taper or dose escalation guidelines for sub-populations that include consideration of their comorbidities When benefit outweighs the risk, consider maintaining therapy for stable patients on long term opioid therapy
Causes of worsening pain are not often recognized or considered. Non-tolerance related factors: surgery, flares, increased physical demands, or emotional distress Avoid increase in dose for stable patient (2+ month stable dose) until patient is re-evaluated for underlying cause of elevated pain or possible OUD risk Considerations to avoid dose escalation include: Opioid rotation Non-opioid medication Interventional strategies Cognitive behavior strategies Complementary and integrative health approaches Physical therapy
In patients with chronic pain AND anxiety or spasticity, benzodiazepine co-prescribed with opioids still have clinical value; although the risk of overdose is well established When clinically indicated, co-prescription should be managed by specialist who have knowledge, training, and experience with co-prescribing. When co-prescribed for anxiety or SUD collaboration with mental health should be considered Develop clinical practice guidelines focused on tapering for co-prescription of benzodiazepines and opioids
The risk-benefit balance varies for individual patients. Doses >90MME may be favorable for some where doses <90MME may be for other patients due to individual patient factors. Variability in effectiveness and safety between high and low doses of opioids are not clearly defined. Clinicians should use caution with higher doses in general Using carefully monitored trial with frequent monitoring with each dose adjustment and regular risk reassessment, physicians should individualize doses, using lowest effective opioid dose that balances benefit, risk, and adverse reactions Many factors influence benefits and risk, therefore, guidance of dose should not be applied as strict limits. Use established and measurable goals: Functionality ADL Quality of Life
Duration of pain following acute and severely painful event is widely variable Appropriate duration is best considered within guidelines, but is ultimately determined by treating clinician. CDC recommendation for duration should be emphasized as guidance only with individualized patient care as the goal Develop acute pain management guidelines for common surgical procedures and traumas To address variability and provide easy solution, consideration should be given to partial refill system
Human Rights Watch December 2018 (Excerpt from 109 page report)
“If harms to chronic pain patients are an unintended consequence of policies to reduce inappropriate prescribing, the government should seek to immediately minimize and measure the negative impacts of these policies. Any response should avoid further stigmatizing chronic pain patients, who are increasingly associated with — and sometimes blamed for — the overdose crisis and characterized as “drug seekers,” rather than people with serious health problems that require treatment.
Top government officials, including the President, have said the country should aim for drastic cutbacks in prescribing. State legislatures encourage restrictions on prescribing through new legislation or regulations. The Drug Enforcement Administration (DEA) has investigated medical practitioners accused of overprescribing or fraudulent practice. State health agencies and insurance companies routinely warn physicians who prescribe more opioids than their peers and encourage them to reduce prescribing. Private insurance companies have imposed additional requirements for covering opioids, some state Medicaid programs have mandated tapering to lower doses for patients, and pharmacy chains are actively trying to reduce the volumes of opioids they dispense.
The medical community at large recognized that certain key steps were necessary to tackle the overdose crisis: identifying and cracking down on “pill mills” and reducing the use of opioids for less severe pain, particularly for children and adolescents. However, the urgency to tackle the overdose crisis has put pressure on physicians in other potentially negative ways: our interviews with dozens of physicians found that the atmosphere around prescribing for chronic pain had become so fraught that physicians felt they must avoid opioid analgesics even in cases when it contradicted their view of what would provide the best care for their patients. In some cases, this desire to cut back on opioid prescribing translated to doctors tapering patients off their medications without patient consent, while in others it meant that physicians would no longer accept patients who had a history of needing high-dose opioids.
The consequences to patients, according to Human Rights Watch research, have been catastrophic.”
[https://www.hrw.org/report/2018/12/18/not-allowed-be-compassionate/chronic-pain-overdose-crisis-and-unintended-harms-us](
Opioid Prescribing Workgroup December 2018
This is material from the Board of Scientific Counselors in regards to their December 12, 2018 meeting that culminated the works of a project titled the “Opioid Prescribing Estimates Project.” This project is a descriptive study that is examining opioid prescribing patterns at a population level. Pain management is a very individualized process that belongs with the patient and provider. The Workgroup reviewed work done by CDC and provided additional recommendations.
SUMMARY There were several recurrent themes throughout the sessions.
Repeated concern was voiced from many Workgroup members that the CDC may not be able to prevent conclusions from this research (i.e. the benchmarks, developed from limited data) from being used by states or payors or clinical care systems to constrain clinical care or as pay-for- performance standards – i.e. interpreted as “guidelines”. This issue was raised by several members on each of the four calls, raising the possibility that providers or clinical systems could thus be incentivized against caring for patients requiring above average amounts of opioid medication.
Risk for misuse of the analysis. Several members expressed concerns that this analysis could be interpreted as guidance by regulators, health plans, or clinical care systems. Even though the CDC does not plan to issue this as a guideline, but instead as research, payors and clinical care systems searching for ways to reign in opioid prescribing may utilize CDC “benchmarks” to establish pay-for-performance or other means to limit opioid prescribing. Such uses of this work could have the unintended effect of incentivizing providers against caring for patients reliant upon opioids.
…It was also noted that, in order to obtain sufficient granularity to establish the need for, dosage, and duration of opioid therapy, it would be necessary to have much more extensive electronic medical record data. In addition, pain and functional outcomes are absent from the dataset, but were felt to be important when considering risk and benefit of opioids.
...Tapering: Concerns about benchmarks and the implications for tapering were voiced. If tapering occurs, guidance was felt to be needed regarding how, when, in whom tapering should occur. This issue was felt to be particularly challenging for patients on chronic opioids (i.e. “legacy” patients). In addition, the importance of measuring risk and benefit of tapering was noted. Not all high-dose patient populations benefit from tapering.
Post-Surgical Pain
General comments. Workgroup members noted that most patients prescribed opioids do not experience adverse events, including use disorder. Many suggested that further discussion of opioids with patients prior to surgery was important, with an emphasis on expectations and duration of treatment. A member suggested that take-back programs would be more effective than prescribing restrictions.
Procedure-related care. Members noted that patient factors may drive opioid need more than characteristics of a procedure.
Patient-level factors. Members noted that opioid-experienced patients should be considered differently from opioid-inexperienced patients, due to tolerance.
Chronic Pain
It was noted that anything coming out of the CDC might be considered as guidelines and that this misinterpretation can be difficult to counter. There was extensive discussion of the 50 and 90 MME levels included in the CDC Guidelines. It was recommended that the CDC look into the adverse effects of opioid tapering and discontinuation, such as illicit opioid use, acute care utilization, dropping out of care, and suicide. It was also noted that there are major gaps in guidelines for legacy patients, patients with multiple diagnoses, pediatric and geriatric patients, and patients transitioning to lower doses.
There were concerns that insufficient clinical data will be available from the dataset to appropriately consider the individual-level factors that weigh into determination of opioid therapy. The data would also fail to account for the shared decision-making process involved in opioid prescribing for chronic pain conditions, which may be dependent on primary care providers as well as ancillary care providers (e.g. physical therapists, psychologists, etc).
Patient-level factors. Members repeatedly noted that opioid-experienced patients should be considered differently from opioid-experienced patients, due to tolerance.
Members noted that the current CDC guidelines have been used by states, insurance companies, and some clinical care systems in ways that were not intended by the CDC, resulting in cases of and the perception of patient abandonment. One option raised in this context was to exclude patients on high doses of opioids, as those individuals would be qualitatively different from others. A variant of this concern was about management of “legacy” patients who are inherited on high doses of opioids. Members voiced concerns that results of this work has caused harm to patients currently reliant upon opioids prescribed by their providers.
Acute Non-Surgical Pain
Patient-level factors. Members felt that opioid naïve versus experienced patients might again be considered separately, as opioid requirements among those experienced could vary widely.
...Guidelines were also noted to be often based on consensus, which may be incorrect.
Cancer-Related and Palliative Care Pain
It was noted that the CDC guidelines have been misinterpreted to create a limit to the dose of opioids that can be provided to people at all stages of cancer and its treatment. It was also noted that the cancer field is rapidly evolving, with immunotherapy, CAR-T, and other novel treatments that affect response rates and limit our ability to rely upon historical data in establishing opioid prescribing benchmarks.
Concern that data would not be able to identify all of the conditions responsible for pain in a patient with a history of cancer (e.g. people who survive cancer but with severe residual pain). Further, it was noted that certain complications of cancer and cancer treatment may require the least restrictive long-term therapy with opioids.
The definition of palliative care was also complicated and it was suggested that this include patients with life-limiting conditions.
Overall, it was felt that in patients who may not have long to live, and/or for whom returning to work is not a possibility, higher doses of opioids may be warranted.
https://www.cdc.gov/injury/pdfs/bsc/NCIPC_BSC_OpioidPrescribingEstimatesWorkgroupReport_December-12_2018-508.pdf
CDC Scientists Anonymous ‘Spider Letter’ to CDC
Carmen S. Villar, MSW Chief of Staff Office of the Director MS D­14 Centers for Disease Control and Prevention (CDC) 1600 Clifton Road Atlanta, Georgia 30329­-4027
August 29, 2016
Dear Ms. Villar:
We are a group of scientists at CDC that are very concerned about the current state of ethics at our agency. It appears that our mission is being influenced and shaped by outside parties and rogue interests. It seems that our mission and Congressional intent for our agency is being circumvented by some of our leaders. What concerns us most, is that it is becoming the norm and not the rare exception. Some senior management officials at CDC are clearly aware and even condone these behaviors. Others see it and turn the other way. Some staff are intimidated and pressed to do things they know are not right. We have representatives from across the agency that witness this unacceptable behavior. It occurs at all levels and in all of our respective units. These questionable and unethical practices threaten to undermine our credibility and reputation as a trusted leader in public health. We would like to see high ethical standards and thoughtful, responsible management restored at CDC. We are asking that you do your part to help clean up this house!
It is puzzling to read about transgressions in national media outlets like USA Today, The Huffington Post and The Hill. It is equally puzzling that nothing has changed here at CDC as a result. It’s business as usual. The litany of issues detailed over the summer are of particular concern:
Recently, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) has been implicated in a “cover up” of inaccurate screening data for the Wise Woman (WW) Program. There was a coordinated effort by that Center to “bury” the fact that screening numbers for the WW program were misrepresented in documents sent to Congress; screening numbers for 2014 and 2015 did not meet expectations despite a multi­million dollar investment; and definitions were changed and data “cooked” to make the results look better than they were. Data were clearly manipulated in irregular ways. An “internal review” that involved staff across CDC occurred and its findings were essentially suppressed so media and/or Congressional staff would not become aware of the problems. Now that both the media and Congresswoman DeLauro are aware of these issues, CDC staff have gone out of their way to delay FOIAs and obstruct any inquiry. Shouldn’t NCCDPHP come clean and stop playing games? Would the ethical thing be to answer the questions fully and honestly. The public should know the true results of what they paid for, shouldn’t they?
Another troubling issue at the NCCDPHP are the adventures of Drs. Barbara Bowman and Michael Pratt (also detailed in national media outlets). Both seemed to have irregular (if not questionable) relationships with Coca­Cola and ILSI representatives. Neither of these relationships were necessary (or appropriate) to uphold our mission. Neither organization added any value to the good work and science already underway at CDC. In fact, these ties have now called into question and undermined CDC’s work. A cloud has been cast over the ethical and excellent work of scientists due to this wanton behavior. Was cultivating these relationships worth dragging CDC through the mud? Did Drs. Bowman and Pratt have permission to pursue these relationships from their supervisor Dr. Ursula Bauer? Did they seek and receive approval of these outside activities? CDC has a process by which such things should be vetted and reported in an ethics review, tracking and approval system (EPATS). Furthermore, did they disclose these conflicts of interest on their yearly OGE 450 filing. Is there an approved HHS 520, HHS 521 or “Request for Official Duty Activities Involving an Outside Organization” approved by Dr. Bauer or her Deputy Director Ms. Dana Shelton? An August 28, 2016 item in The Hill details these issues and others related to Dr. Pratt.
It appears to us that something very strange is going on with Dr. Pratt. He is an active duty Commissioned Corps Officer in the USPHS, yet he was “assigned to” Emory University for a quite some time. How and under what authority was this done? Did Emory University pay his salary under the terms of an IPA? Did he seek and receive an outside activity approval through EPATS and work at Emory on Annual Leave? Formal supervisor endorsement and approval (from Dr. Bauer or Ms. Shelton) is required whether done as an official duty or outside activity.
If deemed official, did he file a “Request for Official Duty Activities Involving an Outside Organization” in EPATS? Apparently Dr. Pratt’s position at Emory University has ended and he has accepted another position at the University of California ­ San Diego? Again, how is this possible while he is still an active duty USPHS Officer. Did he retire and leave government service? Is UCSD paying for his time via an IPA? Does he have an outside activity approval to do this? Will this be done during duty hours? It is rumored that Dr. Pratt will occupy this position while on Annual Leave? Really? Will Dr. Pratt be spending time in Atlanta when not on Annual Leave? Will he make an appearance at NCCDPHP (where he hasn’t been seen for months). Most staff do not enjoy such unique positions supported and approved by a Center Director (Dr. Bauer). Dr. Pratt has scored a sweet deal (not available to most other scientists at CDC). Concerns about these two positions and others were recently described in The Huffington Post and The Hill. His behavior and that of management surrounding this is very troubling.
Finally, most of the scientists at CDC operate with the utmost integrity and ethics. However, this “climate of disregard” puts many of us in difficult positions. We are often directed to do things we know are not right. For example, Congress has made it very clear that domestic funding for NCCDPHP (and other CIOs) should be used for domestic work and that the bulk of NCCDPHP funding should be allocated to program (not research). If this is the case, why then is NCCDPHP taking domestic staff resources away from domestic priorities to work on global health issues? Why in FY17 is NCCDPHP diverting money away from program priorities that directly benefit the public to support an expensive research FOA that may not yield anything that benefits the public? These actions do not serve the public well. Why is nothing being done to address these problems? Why has the CDC OD turned a blind eye to these things. The lack of respect for science and scientists that support CDC’s legacy is astonishing.
Please do the right thing. Please be an agent of change.
Respectfully,
CDC Spider (CDC Scientists Preserving Integrity, Diligence and Ethics in Research)
https://usrtk.org/wp-content/uploads/2016/10/CDC_SPIDER_Letter-1.pdf
January 13, 2016
Thomas Frieden, MD, MPH Director Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329-4027
Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain
Dear Dr. Frieden:
There is no question that there is an opioid misuse epidemic and that efforts need to be made to control it. The Centers for Disease Control and Prevention (CDC) is applauded for its steps to undertake this lofty effort. However, based on the American Academy of Family Physicians’ (AAFP’s) review of the guideline, it is apparent that the presented recommendations are not graded at a level consistent with currently available evidence. The AAFP certainly wants to promote safe and appropriate prescribing of opioids; however, we recommend that the CDC still adhere to the rigorous standards for reliable and trustworthy guidelines set forth by the Institute of Medicine (IOM). The AAFP believes that giving a strong recommendation derived from generalizations based on consensus expert opinion does not adhere to evidence-based standards for developing clinical guideline recommendations.
The AAFP’s specific concerns with the CDC’s methodology, evidence base, and recommendations are outlined below.
Methodology and Evidence Base
All of the recommendations are based on low or very low quality evidence, yet all but one are Category A (or strong) recommendations. The guideline states that in the GRADE methodology "a particular quality of evidence does not necessarily imply a particular strength of recommendation." While this is true, it applies when benefits significantly outweigh harms (or vice versa). When there is insufficient evidence to determine the benefits and harms of a recommendation, that determination should not be made.
When evaluating the benefits of opioids, the evidence review only included studies with outcomes of at least one year. However, studies with shorter intervals were allowed for analysis of the benefits of nonopioid treatments. The guideline states that no evidence shows long-term benefit of opioid use (because there are few studies), yet the guideline reports "extensive evidence" of potential harms, even though these studies were of low quality. The accompanying text also states "extensive evidence" of the benefits of non-opioid treatments, yet this evidence was from shorter term studies, was part of the contextual review rather than the clinical systematic review, and did not compare non- opioid treatments to opioids.
The patient voice and preferences were not explicitly included in the guideline. This raises concerns about the patient-centeredness of the guideline.
https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/risk/LT-CDC-OpioidGuideline011516.pdf The Myth of Morphine Equivalent Daily Dosage Medscape Neuro Perspective
For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the "relative corresponding quantity" of the numerous opioid molecules that are important tools in the treatment of chronic pain.
...And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as "voluntary," their chilling effect on prescribers and adaptation into state laws[2] makes calling them "voluntary" disingenuous.
Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study[3] has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development.
The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.
Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized[7] to allow this type of practice to continue to be the norm.
Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee[8] and the Centers for Disease Control and Prevention Guideline Committee[9]) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.
Above 100% extracted from: Medscape Journal Brief https://www.medscape.com/viewarticle/863477_2
Actual Study https://www.dovepress.com/the-medd-myth-the-impact-of-pseudoscience-on-pain-research-and-prescri-peer-reviewed-article-JPR
Are Non-Opioid Medications Superior in Treatment of Pain than Opioid Pain Medicine? Ice Cream Flavor Analogy...
In the Oxford University Press, a November 2018 scientific white paper[5] was released that examined the quality of one of the primary studies that have been used to justify the urgent call to drastically reduce opioid pain medication prescribing while claiming that patients are not being harmed in the process.
The study is commonly referred to as ‘the Krebs study’. “The authors concluded that treatment with opioids was not superior to treatment with non opioid medications for improving pain-related function over 12 months.”
Here is an excerpt from the first paragraph of the design section (usually behind a paywall) from the Krebs study that gives the first hint of the bias that led to them to ‘prove’ that opioids were not effective for chronic pain:

“The study was intended to assess long-term outcomes of opioids compared with non opioid medications for chronic pain. The patient selection, though, specifically excluded patients on long-term opioid therapy.” 

Here is an analogy given in the Oxford Journal white paper to illustrate how the study design was compromised:
If I want to do a randomized control study about ice cream flavor preferences (choices being: vanilla, chocolate, or no preference), the results could be manipulated as follows based on these scenarios:
Scenario A: If a study was done that included only current ice-cream consumers, the outcome would certainly be vanilla or chocolate, because of course they have tried it and know which they like.
Scenario B: If a study was done that included all consumers of all food, then it can change the outcome. If the majority of study participants do not even eat ice-cream, than the result would certainly be ‘no preference’. If the majority do eat ice-cream it would likely be ‘chocolate’. Although this study is wider based, it still does not reflect real world findings.
Scenario C: In an even more extreme example, if this same study is conducted excluding anyone who has ever ate ice-cream at all, then the conclusion will again be ‘no preference’ and the entire study/original question becomes so ludicrous that there is no useful information to be extracted from this study and one would logically question why this type of study would even be conducted (although we know the answer to that)
Scenario C above is how the study that has been used to shift the attitudes towards the treatment of pain in our nation's medical community was designed. “One has to look deep into the study to find that they began with 9403 possible patients and excluded 3836 of them just because they had opioids in their EMR. In the JAMA article, they do not state these obvious biases and instead begin the explanation of participants stating they started with 4485 patients and excluded 224 who were opioid or benzo users.” That is the tip of the iceberg to how it is extremely misleading. The Oxford white paper goes into further detail of the studies “many flaws and biases (including the narrow focus on conditions that are historically known to respond poorly to opioid medication management of pain)”, but the study design and participant selection criteria is enough to discredit this entire body of work. Based on study design alone, regardless of what happened next, the result would be that opioids are no more effective than NSAIDs and other non-opioid alternatives.
The DEA Is Fostering a Bounty Hunter Culture in its Drug Diversion Investigators[8]
A Good Man Speaks Truth to Power January 2019
Because I write and speak widely on public health issues and the so-called “opioid crisis”, people frequently send me references to others’ work. One of the more startling articles I’ve seen lately was published November 20, 2018 in Pharmacy Times. It is titled “Should We Believe Patients With Pain?”[9]. The unlikely author is Commander John Burke, “a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.”
The last paragraph of Commander Burke’s article is worth repeating here.
“Let’s get back to dealing with each person claiming to be in legitimate pain and believe them until we have solid evidence that they are scamming the system. If they are, then let’s pursue them through vigorous prosecution, but let’s not punish the majority of people receiving opioids who are legitimate patients with pain.”
This seems a remarkable insight from anyone in law enforcement — especially from one who has expressed this view in both Pain News Network, and Dr Lynn Webster’s video “The Painful Truth”. Recognizing Commander Burke’s unique perspective, I followed up by phone to ask several related questions. He has granted permission to publish my paraphrases of his answers here.
“Are there any available source documents which establish widely accepted standards for what comprises “over-prescription?” as viewed by diversion investigators?” Burke’s answer was a resounding “NO”. Each State and Federal Agency that investigates doctors for potentially illegal or inappropriate opioid prescribing is pretty much making up their own standards as they go. Some make reference to the 2016 CDC Guidelines, but others do not.

1. “Thousands of individual doctors have left pain management practice in recent years due to fears they may be investigated, sanctioned, and lose their licenses if they continue to treat patients with opioid pain relievers.. Are DEA and State authorities really pursuing the worst “bad actors”, or is something else going on?

Burke’s answer: “Regulatory policy varies greatly between jurisdictions. But a hidden factor may be contributing significantly to the aggressiveness of Federal investigators. Federal Agencies may grant financial bonuses to their in-house diversion investigators, based on the volume of fines collected from doctors, nurse practitioners, PAs and others whom they investigate.

"No law enforcement agency at any level should be rewarded with monetary gain and/or promotion due to their work efforts or successes. This practice has always worried me with Federal investigators and is unheard of at the local or state levels of enforcement.”

Commander Burke’s revelation hit me like a thunder-clap. It would explain many of the complaints I have heard from doctors who have been “investigated” or prosecuted. It’s a well known principle that when we subsidize a behavior, we get more of it. Financial rewards to investigators must inevitably foster a “bounty hunter” mentality in some. It seems at least plausible that such bonuses might lead DEA regulators to focus on “low hanging fruit” among doctors who may not be able to defend themselves without being ruined financially. The practice is at the very least unethical. Arguably it can be corrupting.
I also inquired concerning a third issue:

1. I read complaints from doctors that they have been pursued on trumped-up grounds, coerced and denied appropriate legal defense by confiscation of their assets – which are then added to Agency funds for further actions against other doctors. Investigations are also commonly announced prominently, even before indictments are obtained – a step that seems calculated to destroy the doctor’s practice, regardless of legal outcomes. Some reports indicate that DEA or State authorities have threatened employees with prosecution if they do not confirm improper practices by the doctor. Do you believe such practices are common?”

Burke’s answer: “I hear the same reports you do – and the irony is that such tactics are unnecessary. Lacking an accepted standard for over-prescribing, the gross volume of a doctor’s prescriptions or the dose levels prescribed to their patients can be poor indicators of professional misbehavior. Investigators should instead be looking into the totality of the case, which can include patient reports of poor doctor oversight, overdose-related hospital admissions, and patterns of overdose related deaths that may be linked to a “cocktail” of illicit prescribing. Especially important can be information gleaned from confidential informants – with independent verification – prior patients, and pharmacy information.”

No formal legal prosecution should ever proceed from the testimony of only one witness — even one as well informed as Commander John Burke. But it seems to me that it is high time for the US Senate Judiciary Committee to invite the testimony of others in open public hearings, concerning the practice of possible bounty hunting among Federal investigators.
C50 Patient, Civil Rights Attorney, Maine Department of Health, and Maine Legislature Collaborative Enacted Definition of Palliative Care
One suggestion that our organization would like to make is altering the definition of “palliative care” in such a manner that it can include high-impact or intractable patients; those who are not dying this year, but our lives have been shattered and/or shortened by our diseases and for whom Quality of Life should be the focus. Many of our conditions may not SIGNIFICANTLY shorten my life, therefore I could legitimately be facing 30-40 years of severe pain with little relief; that is no way to live and therefore the concern is a rapidly increasing suicide rate.
This is a definition that one of our coalition members with a civil rights attorney and the Maine Department of Health agreed upon and legislators enacted into statues in Maine. This was in response to a 100mme restriction. This attorney had prepared a lawsuit based on the Americans with Disability Act that the Department of Health in Maine agreed was valid; litigation was never the goal, it was always patient-centered care.
A. "Palliative care" means patient-centered and family-focused medical care that optimizes quality of life by anticipating, preventing and treating suffering caused by a medical illness or a physical injury or condition that substantially affects a patient's quality of life, including, but not limited to, addressing physical, emotional, social and spiritual needs; facilitating patient autonomy and choice of care; providing access to information; discussing the patient's goals for treatment and treatment options, including, when appropriate, hospice care; and managing pain and symptoms comprehensively. Palliative care does not always include a requirement for hospice care or attention to spiritual needs. B. "Serious illness" means a medical illness or physical injury or condition that substantially affects quality of life for more than a short period of time. "Serious illness" includes, but is not limited to, Alzheimer's disease and related dementias, lung disease, cancer, heart, renal or liver failure and chronic, unremitting or intractable pain such as neuropathic pain.
Here is the link to the most recent update, including these definitions within the entire statute: https://legislature.maine.gov/statutes/22/title22sec1726.html?fbclid=IwAR0dhlwEh56VgZI9HYczdjdyYoJGpMdA9TuuJLlQrO3AsSljIZZG0RICFZc
January 23, 2019
Dear Pharmacists,
The Board of Pharmacy has had an influx of communication concerning patients not able to get controlled substance prescriptions filled for various reasons, even when signs of forgery or fraudulence were not presented. As a result of the increased “refusals to fill,” the board is issuing the following guidance and reminders regarding the practice of pharmacy and dispensing of controlled substances:

1. Pharmacists must use reasonable knowledge, skill, and professional judgment when evaluating whether to fill a prescription. Extreme caution should be used when deciding not to fill a prescription. A patient who suddenly discontinues a chronic medication may experience negative health consequences;
   
2. Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription. Being a healthcare professional also means that you use your medication expertise during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to fill a prescription without trying to resolve the concern may call into question the knowledge, skill or judgment of the pharmacist and may be deemed unprofessional conduct;
   
3. Controlled substance prescriptions are not a “bartering” mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist;
   
4. Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases.
   
5. If a prescription is refused, there should be sound professional reasons for doing so. Each patient is a unique medical case and should be treated independently as such. Making blanket decisions regarding dispensing of controlled substances may call into question the motivation of the pharmacist and how they are using their knowledge, skill or judgment to best serve the public.
   

As a professional reminder, failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. These laws are:
AS 08.80.261 DISCIPLINARY ACTIONS
(a)The board may deny a license to an applicant or, after a hearing, impose a disciplinary sanction authorized under AS 08.01.075 on a person licensed under this chapter when the board finds that the applicant or licensee, as applicable, …
(7) is incapable of engaging in the practice of pharmacy with reasonable skill, competence, and safety for the public because of
(A) professional incompetence; (B) failure to keep informed of or use current professional theories or practices; or (E) other factors determined by the board;
(14) engaged in unprofessional conduct, as defined in regulations of the board.
12 AAC 52.920 DISCIPLINARY GUIDELINES
(a) In addition to acts specified in AS 08.80 or elsewhere in this chapter, each of the following constitutes engaging in unprofessional conduct and is a basis for the imposition of disciplinary sanctions under AS 08.01.075; …
(15) failing to use reasonable knowledge, skills, or judgment in the practice of pharmacy;
(b) The board will, in its discretion, revoke a license if the licensee …
(4) intentionally or negligently engages in conduct that results in a significant risk to the health or safety of a patient or injury to a patient; (5) is professionally incompetent if the incompetence results in a significant risk of injury to a patient.
(c) The board will, in its discretion, suspend a license for up to two years followed by probation of not less than two years if the licensee ...
(2) is professionally incompetent if the incompetence results in the public health, safety, or welfare being placed at risk.
We all acknowledge that Alaska is in the midst of an opioid crisis. While there are published guidelines and literature to assist all healthcare professionals in up to date approaches and recommendations for medical treatments per diagnosis, do not confuse guidelines with law; they are not the same thing.
Pharmacists have an obligation and responsibility under Title 21 Code of Federal Regulations 1306.04(a), and a pharmacist may use professional judgment to refuse filling a prescription. However, how an individual pharmacist approaches that particular situation is unique and can be complex. The Board of Pharmacy does not recommend refusing prescriptions without first trying to resolve your concerns with the prescribing practitioner as the primary member of the healthcare team. Patients may also serve as a basic source of information to understand some aspects of their treatment; do not rule them out in your dialogue.
If in doubt, we always recommend partnering with the prescribing practitioner. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.
Professionally,
Richard Holt, BS Pharm, PharmD, MBA Chair, Alaska Board of Pharmacy
https://www.commerce.alaska.gov/web/portals/5/pub/pha_ControlledSubstanceDispensing_2019.01.pdf
FDA in Brief: FDA finalizes new policy to encourage widespread innovation and development of new buprenorphine treatments for opioid use disorder
February 6, 2018
Media Inquiries Michael Felberbaum 240-402-9548
“The opioid crisis has had a tragic impact on individuals, families, and communities throughout the country. We’re in urgent need of new and better treatment options for opioid use disorder. The guidance we’re finalizing today is one of the many steps we’re taking to help advance the development of new treatments for opioid use disorder, and promote novel formulations or delivery mechanisms of existing drugs to better tailor available medicines to individuals’ needs,” said FDA Commissioner Scott Gottlieb, M.D. “Our goal is to advance the development of new and better ways of treating opioid use disorder to help more Americans access successful treatments. Unfortunately, far too few people who are addicted to opioids are offered an adequate chance for treatment that uses medications. In part, this is because private insurance coverage for treatment with medications is often inadequate. Even among those who can access some sort of treatment, it’s often prohibitively difficult to access FDA-approved addiction medications. While states are adopting better coverage owing to new legislation and resources, among public insurance plans there are still a number of states that are not covering all three FDA-approved addiction medications. To support more widespread adoption of medication-assisted treatment, the FDA will also continue to take steps to address the unfortunate stigma that’s sometimes associated with use of these products. It’s part of the FDA’s public health mandate to promote appropriate use of therapies.
Misunderstanding around these products, even among some in the medical and addiction fields, enables stigma to attach to their use. These views can serve to keep patients who are seeking treatment from reaching their goal. That stigma reflects a perspective some have that a patient is still suffering from addiction even when they’re in full recovery, just because they require medication to treat their illness. This owes to a key misunderstanding of the difference between a physical dependence and an addiction. Because of the biology of the human body, everyone who uses a meaningful dose of opioids for a modest length of time develops a physical dependence. This means that there are withdrawal symptoms after the use stops.
A physical dependence to an opioid drug is very different than being addicted to such a medication. Addiction requires the continued use of opioids despite harmful consequences on someone’s life. Addiction involves a psychological preoccupation to obtain and use opioids above and beyond a physical dependence.
But someone who is physically dependent on opioids as a result of the treatment of pain but who is not craving the drugs is not addicted.
The same principle applies to replacement therapy used to treat opioid addiction. Someone who requires long-term treatment for opioid addiction with medications, including those that are partial or complete opioid agonists and can create a physical dependence, isn’t addicted to those medications. With the right treatments coupled to psychosocial support, recovery from opioid addiction is possible. The FDA remains committed to using all of our tools and authorities to help those currently addicted to opioids, while taking steps to prevent new cases of addiction.”
Above is the full statement, find full statement with options for study requests: https://www.fda.gov/NewsEvents/Newsroom/FDAInBrief/ucm630847.htm
Maryland’s co-prescribing new laws/ amendments regarding benzos and opioids
Chapter 215 AN ACT concerning Health Care Providers – Opioid and Benzodiazepine Prescriptions – Discussion of Information Benefits and Risks
FOR the purpose of requiring that certain patients be advised of the benefits and risks associated with the prescription of certain opioids, and benzodiazepines under certain circumstances, providing that a violation of this Act is grounds for disciplinary action by a certain health occupations board; and generally relating to advice regarding benefits and risks associated with opioids and benzodiazepines that are controlled dangerous substances.
Section 1–223 Article – Health Occupations Section 4–315(a)(35), 8–316(a)(36), 14–404(a)(43), and 16–311(a)(8) SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, That the Laws of Maryland read as follows: Article – Health Occupations (a) In this section, “controlled dangerous substance” has the meaning stated in § 5–101 of the Criminal Law Article.
Ch. 215 2018 LAWS OF MARYLAND (B) On treatment for pain, a health care provider, based on the clinical judgment of the health care provider, shall prescribe: (1) The lowest effective dose of an opioid; and (2)A quantity that is no greater than the quantity needed for the expected duration of pain severe enough to require an opioid that is a controlled dangerous substance unless the opioid is prescribed to treat: (a.) A substance–related disorder; (b.) Pain associated with a cancer diagnosis; (c.) Pain experienced while the patient is receiving end–of–life, hospice, or palliative care services; or (d.) Chronic pain
(C.) The dosage, quantity, and duration of an opioid prescribed under [subsection (b)] of this [section] shall be based on an evidence–based clinical guideline for prescribing controlled dangerous substances that is appropriate for: (1.) The health care service delivery setting for the patient; (2.) The type of health care services required by the patient; (3.) and The age and health status of the patient.
(D) (1) WHEN A PATIENT IS PRESCRIBED AN OPIOID UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE OPIOID.

 (2) WHEN A PATIENT IS CO–PRESCRIBED A BENZODIAZEPINE WITH AN OPIOID THAT IS PRESCRIBED UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE BENZODIAZEPINE AND THE CO–PRESCRIPTION OF THE BENZODIAZEPINE. 

(E) A violation of [subsection (b) OR (D) of] this section is grounds for disciplinary action by the health occupations board that regulates the health care provider who commits the violation.
4-315 (a) Subject to the hearing provisions of § 4–318 of this subtitle, the Board may deny a general license to practice dentistry, a limited license to practice dentistry, or a teacher’s license to practice dentistry to any applicant, reprimand any licensed dentist, place any licensed dentist on probation, or suspend or revoke the license of any licensed dentist, if the applicant or licensee: (35) Fails to comply with § 1–223 of this article.
8–316. (a) Subject to the hearing provisions of § 8–317 of this subtitle, the Board may deny a license or grant a license, including a license subject to a reprimand, probation, or suspension, to any applicant, reprimand any licensee, place any licensee on probation, or suspend or revoke the license of a licensee if the applicant or licensee: (36) Fails to comply with § 1–223 of this article.
14–404. (a) Subject to the hearing provisions of § 14–405 of this subtitle, a disciplinary panel, on the affirmative vote of a majority of the quorum of the disciplinary panel, may reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the licensee: (43) Fails to comply with § 1–223 of this article.
16–311. (a) Subject to the hearing provisions of § 16–313 of this subtitle, the Board, on the affirmative vote of a majority of its members then serving, may deny a license or a limited license to any applicant, reprimand any licensee or holder of a limited license, impose an administrative monetary penalty not exceeding $50,000 on any licensee or holder of a limited license, place any licensee or holder of a limited license on probation, or suspend or revoke a license or a limited license if the applicant, licensee, or holder:
(8) Prescribes or distributes a controlled dangerous substance to any other person in violation of the law, including in violation of § 1–223 of this article;
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect October 1, 2018.
Approved by the Governor, April 24, 2018.
https://legiscan.com/MD/text/HB653/id/1788719/Maryland-2018-HB653-Chaptered.pdf