6 Onions
1 clove of garlic
1 teaspoon of salt
1 teaspoon of blackpepper
1/2 cup of olive oil add more if you need too.
2 tablespoons of butter.


Peel the onions and rinse them in cold water. Then slice them. Peel then chop the garlic. Add the onions then the garlic. Add the olive oil. Then add the butter. Saute the onions and the garlic until they turn yellow and you smell the aroma. Add the chicken broth or water. Cover the pot. When it starts to boil add salt and pepper. Let it simmer for two hours or until done.

This is very good for the flu, coughs, or colds.




colds, coughs, flu,
Turbo Tagger

A desire to continue providing colonoscopy, combined with a lack of resources, led one physician to offer the procedure without sedation. Now, that solution may lead to no-sedation colonoscopy becoming a more widely considered option.

A few years ago, the Sepulveda Ambulatory Care Center in North Hills, Calif., experienced a nursing shortage, and Felix Leung, MD, a staff gastroenterologist, was faced with two options. He could stop performing the procedure, or he could start offering it without sedatives. The Sepulveda center is part of the Veterans Affairs Greater Los Angeles Healthcare System. In response to patients who didn't want to travel 15 miles to another facility, he offered the no-sedation approach. Quite a few -- 30% between 2002 and 2005 -- accepted.

"The veterans asked if there was an alternative, and we found out that unsedated colonoscopy is done in many parts of the world," said Dr. Leung, who also is a professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles. "The U.S. seems to be unusual in that we, by and large, only do sedated colonoscopy."

He has since documented his experiences in a series of papers, including one in the December 2008 Journal of Family Practice. This article reported that, from September 2002 to June 2005, 145 out of 483 eligible patients opted to undergo colonoscopy without sedation. Of this group, 112 were able to complete it. Twenty-six could not, because of the discomfort, and later underwent sedated colonoscopy or barium enema. Another seven had poor bowel preparation or obstructing lesions that blocked the procedure. Some physicians said these numbers indicated that unsedated colonoscopy is a viable alternative.

"It's not going to be for everyone, but it's an option that I think patients would want to consider," said Thomas Kintanar, MD, a family physician in Fort Wayne, Ind. "There are some patients who will do just great without any anesthetic." He is also a board member of the American Assn. for Primary Care Endoscopy, although he was speaking for himself.

Colonoscopies without sedation are common in Europe and Asia.

Colonoscopy without sedation is common in Europe and Asia, and efficacy is comparable.

"There have been several studies that show that if you have motivated patients, a significant fraction of them can have a colonoscopy without sedation," said Douglas Rex, MD, past president of the American College of Gastroenterology. "But what has to be kept in mind is that most American patients actually prefer to be sedated. If you use sedation, there is better patient satisfaction and better physician satisfaction. That's really important."

Dr. Rex, who is also professor of medicine at Indiana University School of Medicine and director of endoscopy at Indiana University Hospital, has performed a small number of colonoscopies on unsedated patients and has undergone one without sedation himself. "For the great majority, having sedation offers a lot of advantages and a lot of positives," he said.

But with the demand for colonoscopy growing, performing it without sedation could reduce both associated work force needs and costs to the health care system. In his efforts, for instance, Dr. Leung eliminated the need for two registered nurses.

Also, a report released Jan. 7 by the Lewin Group, a health care consulting firm, projected that demand for gastroenterologists would grow at a rate nearly double the supply. If this projection bears out, it could impact the availability of traditional colorectal cancer screening, thereby increasing interest in the no-sedation option.

Neither the American Gastrological Assn. nor the ACG has policy regarding no-sedation colonoscopy. In broader terms, ACG policy notes that a well-trained endoscopist is key to a good colonoscopy. The American Academy of Family Physicians takes the position that family physicians trained in colonoscopy should be allowed to perform them and that specialty should not affect privileging.

Going without sedation also could provide some benefits for patients. Dr. Leung discovered many preferred being able to communicate and remember the conversations with the physician during and after. In addition, the unsedated approach is less expensive and does not require patients to have an escort or restrict activities afterward.

"Some patients just didn't have anybody to shuttle them around, and these patients would not have been able to have screening by colonoscopy if this option was not available," Dr. Leung said.

Additionally, this approach cuts to zero the already very low risk of complications associated with the sedative medications and significantly reduces the chance of a perforation.

"You cannot perforate [the bowel of] an awake patient. They will get off the table and smack you," said Ricardo G. Hahn, MD, professor of family medicine at the University of Southern California in Los Angeles. Unsedated colonoscopy is "not a comfortable procedure, but it's only once every five to 10 years."

Dr. Hahn co-authored a paper in the September-October 2007 Journal of the American Board of Family Medicine comparing unsedated colonoscopy with flexible sigmoidoscopy in a family medicine clinic.

Several physicians, however, expressed caution, because unsedated colonoscopy may not be possible or appropriate for everyone. Data from a VA population, which tends to be older and predominantly male, may not apply to the wider world. For example, female physiology tends to make this procedure more difficult.

Experts also worry that an uncomfortable experience may keep a patient from completing this screening.

"The key for us is to ensure a good exam, a comfortable exam for the patient and one that they are willing to repeat," said David A. Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine. He also is an ACG past president.

Dr. Leung's upcoming projects will look at colonoscopy techniques, such as using water infusion without air insufflation, to reduce the discomfort related to the procedure and allow more patients to have it done without or with less sedation.

The print version of this content appeared in the Jan. 19, 2009 issue of American Medical News.

Washington -- The Food and Drug Administration is asking the manufacturers of new drugs and biologics for type 2 diabetes to be more diligent in determining if their therapies pose cardiovascular risks.

Until now, manufacturers had only to show that their drugs reduced blood sugar levels.

"We need to better understand the safety of new antidiabetic drugs," said Mary Parks, MD, director of the agency's Division of Metabolism and Endocrinology Products at the Center for Drug Evaluation and Research. She released a guidance document outlining the agency's recommendations for doing such an assessment Dec. 17, 2008.

More than 23 million people in the U.S. have been diagnosed with type 2 diabetes, which places them at a two- to four-times greater risk of heart disease than their nondiabetic counterparts. None of the currently approved antidiabetic therapies has been proven convincingly to reduce that risk, the FDA said.

The guidance, which is effective immediately, asks that phase II and III clinical trials demonstrate that new therapies do not increase cardiovascular risk in comparison with existing therapies.

More than 23 million people in the U.S. have type 2 diabetes.

The FDA also recommends to manufacturers that any cardiovascular events occurring in their trials be analyzed by committees of outside cardiologists.

The FDA already has placed black-box warnings on one class of type 2 diabetes drugs, thiazolidinediones, or TZDs, after they were found in postmarketing studies to increase the risk of heart failure. Two drugs, Avandia, or rosiglitazone, and Actos, or pioglitazone, are in that class.

Alarms about Avandia's association with increased heart risks were raised in a May 2007 New England Journal of Medicine article by Steven Nissen, MD, chair of Cleveland Clinic's Dept. of Cardiovascular Medicine. At the time, Dr. Nissen noted that because of this risk, Avandia is not a drug he recommends to patients.

GlaxoSmithKline, the manufacturer of Avandia, strongly disagreed with the conclusions in the NEJM article, faulting the authors' reliance on a meta-analysis rather than on long-term trials that Glaxo said showed no increased cardiovascular risk associated with Avandia.

Meanwhile, in a study published online Dec. 10, 2008, by the Canadian Medical Assn. Journal, researchers found that the risk of fractures doubled among older women who take TZDs for one year or more to control their diabetes.

"We knew going into this study there was an association between thiazolidinediones and fracture risk. However, the magnitude of the risk had not been evaluated," said Sonal Singh, MD, MPH, an assistant professor of internal medicine at Wake Forest University School of Medicine in Winston-Salem, N.C., and a co-researcher for the study.

Glaxo responded that the bone fracture risk had been reported previously and is noted on the Avandia label. A study to evaluate the effects of the drug on bone in women with type 2 diabetes is now enrolling participants, a spokesman said.

But in a commentary published online Dec. 10, 2008, in the CMA journal, Lorraine L. Lipscombe, MD, an adjunct researcher at the Institute for Clinical Evaluative Sciences in Toronto, recommended that TZDs not be considered a first-line therapy for type 2 diabetes.

"If a patient is unable to take other therapies or if other therapies have failed, there may be a role for thiazolidinediones in carefully selected patients duly informed of the potential adverse effects," she wrote.

The print version of this content appeared in the Jan. 19, 2009 issue of American Medical News.

Inhalers such as Serevent Diskus and Foradil Aerolizer, which contain only a long-acting beta agonist, are not good choices for treating asthma. The reason: The chance they will be used without an inhaled corticosteroid is too great, according to three Food and Drug Administration advisory committees that gathered in December 2008. The benefits of inhalers that deliver both types of medicines -- Advair Diskus and Symbicort -- are worth the risks.

"The single agent, long-acting beta agonists should no longer be approved for use in the treatment of asthma. The combination dispensers should continue to be approved for all age groups," said Marsha Rappley, MD, chair of the FDA's Pediatric Advisory Committee and dean of the College of Human Medicine at Michigan State University. Members of the Pulmonary-Allergy Drugs as well as the Drug Safety and Risk Management advisory committees were also in attendance.

The agency is not required to follow its advisory panels' recommendations but generally does.

This is the latest in the checkered history of long-acting beta agonists. Several studies showed that these medications increase the risk of severe exacerbations. Because they seem to reduce symptoms without addressing inflammation, treatment guidelines urge that they be used only with inhaled corticosteroids, which appear to mediate their negative effects. The beta agonists also are not recommended for patients able to control their illnesses on other medications. Prior FDA advisory committee deliberations have led to the drugs remaining on the market, but with stronger warnings about possible adverse events.

Most asthma specialists received news of the latest action with trepidation. On one hand, the combination products are far more commonly prescribed than the inhalers with only a long-acting beta agonist. Also, even if the single products lose an indication for asthma, they are still expected to be labeled for chronic obstructive pulmonary disease -- so they could still be used off-label for asthma patients.

On the other hand, physicians worried about losing the single-drug products as an option or the possibility that all products containing a long-acting beta agonist drug would be pulled from the market. Many physicians view these drugs as very valuable.

"I think their conclusions were conservative and consistent with trying to optimize the safety and the use of these medications. I can see their rationale. But I'm a bit concerned that they're overcautious about the safety signal," said Stanley Szefler, MD, head of pediatric clinical pharmacology at National Jewish Health in Denver. He was speaking personally, although he testified at the joint advisory committee meeting on behalf of the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma & Immunology.

Concern also stemmed from the idea that this move might limit patient access and affect the cost of treating asthma. These drugs in two inhalers are less expensive than are the combined products.

"From a clinical standpoint, it's nice to have more options. And, from a patient standpoint, I'm concerned about cost. These medications are fairly expensive," said Richard Gower, MD, president of ACAAI. "We live in an imperfect world. All drugs have potential benefits and side effects."

Manufacturers cheered the conclusion that the benefits of combination products outweighed the risks but disagreed with the conclusion that those with only a long-acting beta agonist should no longer be used for asthma.

Statements issued by these companies said these products provided more dosing flexibility and were safe when used as directed.

"We welcome the committee's endorsement of Advair as a safe and effective treatment for asthma. ... Serevent, when used with an [inhaled corticosteroid], is an important treatment option for some patients as outlined in national guidelines," said Ellen Strahlman, MD, chief medical officer for GlaxoSmithKline.

The advisory panels also called for more studies to determine the safety of the combination products in children.

The print version of this content appeared in the Jan. 19, 2009 issue of American Medical News.