Racketering of the Medical establishment

Published by: YOUNG MEN’S MUSLIM ASSOCIATION P.O BOX 18594, Actonville, 1506 Benoni, Gauteng South Africa 2 A Small Indiana Town Scarred by a Trusted Doctor The New York Times By JULIE CRESWELL © Joshua Lott for The New York Times On a spring evening last year, Debra Davidson flipped on the television to watch the local news. When an item came on about her longtime physician, she perked up and leaned forward. Then she screamed. Her husband rushed into the living room to see if everything was O.K. Everything was not O.K. The report said that her cardiologist, Dr. Arvind Gandhi, had been sued by two former patients who accused him of performing unnecessary operations. Sign Up For NYT Now's Morning Briefing Newsletter Mrs. Davidson had been treated by Dr. Gandhi for more than three decades. She first saw him for an irregular heartbeat when she was 27. For years, she took the medication he prescribed. When Dr. Gandhi said she needed open-heart surgery in 2011, she scheduled it immediately. When he subsequently inserted mesh stents three times to remove blockages from her arteries, she never questioned the procedures. Only last year did she resist one of Dr. Gandhi’s recommendations: to implant a pacemaker. Instead, he inserted a heart monitor under her skin but asked her to reconsider her resistance to a pacemaker. 3 Mrs. Davidson is now one of 293 patients around Munster, Ind., who have filed lawsuits against Dr. Gandhi and two other doctors in his practice claiming that they performed needless procedures. The Indiana state Medicaid program has started an investigation, and one doctor not named in the litigation said he had received a subpoena from the United States attorney’s office and provided the medical charts of several former patients of Dr. Gandhi and his colleagues that he has since treated. Lawyers for Dr. Gandhi and his practice, Cardiology Associates of Northwest Indiana, said they had not received any subpoenas, and the doctors denied any wrongdoing. In recent years, federal officials have brought several prominent cases against cardiologists and hospitals, accusing them of performing unnecessary procedures like inserting stents into coronary arteries. While medical professionals say there is no indication that cardiology has more unnecessary procedures than, say, orthopedics, they do note that the specialty has come under increased scrutiny by regulators because the procedures tend to be reimbursed by Medicare and private insurance at significantly higher levels than those in many other specialties. “Cardiology, whether we like it or not, is generally a big moneymaker for hospitals,” said Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland Clinic and the former president of the American College of Cardiology. “We are still a fee-for-service system, and that creates, in my view, misaligned incentives among some physicians to do more procedures and among some institutions, particularly in areas where there is not tight medical supervision, to turn a blind eye and enjoy the high revenue stream.” While there are various industry and federal guidelines describing when it is appropriate for a patient to undergo certain procedures — Medicare, for instance, says a patient’s arteries must be 70 4 percent blocked to justify the use of a stent — in the real world, interpretations vary. In extreme cases, physicians have been accused of falsifying medical records, saying arteries were more blocked than they really were. Last year, a hospital system in eastern Kentucky paid nearly $41 million to settle allegations, without admitting wrongdoing, that it billed for unnecessary coronary stents and catheterizations after a group of area doctors falsified patient records to justify the procedures. The hospital system, Ashland Hospital Corporation, faces 120 private lawsuits from patients who claim they underwent unnecessary procedures. At Community Hospital in Munster, Ind., Dr. Gandhi was a star. For decades, he ran a prominent practice in the bedroom suburb of 23,000 people about 30 miles southeast of Chicago. He and his partners not only ran the most popular cardiology practice in Munster but were also the highest-paid heart doctors in the state in terms of Medicare reimbursements, records show. The lawsuits against him have divided the town’s medical community, with some doctors finding themselves in the unusual position of speaking against a fellow doctor, working with the medical malpractice lawyers who are their usual foes. Besides the doctors, the malpractice lawsuits also name Community Hospital, through the foundation that oversees its operations, as a defendant. Dr. Gandhi was a high-ranking member of the medical staff at the hospital, and the lawsuits charge that the superfluous procedures were done “with the authority and consent” of Community Hospital, one of the largest and most respected institutions in Munster. Lawyers for the hospital deny any wrongdoing. Some doctors said there had been repeated warnings over the years about Dr. Gandhi’s practice, but those concerns were largely ignored. 5 When Dr. Mark Dixon, then the medical director of Community Hospital’s electrophysiology lab, where defibrillators were implanted, raised concerns to a hospital executive in 2005 about whether Dr. Gandhi and other physicians were qualified to implant the devices, he said he was shut down. “The response to me was, ‘I understand your concern, but we have a very large producer here who wants the privilege,’ ” Dr. Dixon said last year in a deposition in a lawsuit. He said he was later told to stop reviewing implants performed at the hospital by the nurse manager of the lab. Dr. Dixon did not return calls seeking comment. In an email responding to questions, the hospital said Dr. Dixon was never told that Dr. Gandhi was a large revenue generator whose practice was too lucrative to curb, nor was he told to stop reviewing the implants. Lawyers for Dr. Gandhi, his practice and the hospital, say the lawsuits are without merit. The legal actions, they say, are being driven by envious physicians eager to take patients from Dr. Gandhi and by greedy lawyers seeking a big settlement. “The physicians at Cardiology Associates have exemplary records as outstanding cardiologists and leaders in their field,” the lawyers said in a statement. Last fall, Dr. Gandhi retired. Dr. Arvind Gandhi moved to Munster in 1981 after completing a cardiology fellowship in Chicago. In more than 30 years of practice in the area, he gained a reputation for an attentive but efficient bedside manner. He did not lack for confidence. His mantra was “I saved your life,” several former patients said. “He was supposed to be the best cardiologist in the area,” said Phil Probus, 86, a retired railroad worker and World War II veteran. In 2013, Mr. Probus had a defibrillator implanted by Dr. Gandhi that a paid consultant later told him was unnecessary, and 6 he is now one of the plaintiffs. “I never questioned anything he did.” Medicare reimbursement records show that Dr. Gandhi and his partners, Dr. Wail Asfour and Dr. Satyaprakash Makam, received nearly $5 million in combined Medicare payments in 2012, making them the three most reimbursed cardiologists in Indiana. How much they earned from treating patients who had private insurance is not in the public record. The partners invested in real estate, including luxury apartments in Chicago, and a local restaurant. Dr. Makam was often seen driving around Munster in a blue Porsche with the license plate “Tick Doc.” “It was a nice car,” said David Wiening, a retired road construction inspector and patient of Dr. Makam’s who is a plaintiff. Over five years, Dr. Makam performed 24 procedures on Mr. Wiening’s legs. Pulling up his pant legs, Mr. Wiening shows off his “ugly walking sticks,” two legs that are bloated and hairless, covered in parts with small lesions. A vascular surgeon paid by the plaintiffs’ lawyers in the case told Mr. Wiening he did not need many of the procedures performed on him. When asked why the three highest-billing Medicare cardiologists in the state would be found in the same town and the same practice, lawyers for Cardiology Associates of Northwest Indiana said the population in the area was older and sicker than in larger Indiana cities. Munster’s population is older than those of Indianapolis and Fort Wayne. But David Malenka, a professor of Medicine at the Dartmouth Institute for Health Policy and Clinical Practice, said an examination done at the request of a reporter by researchers of inpatient and outpatient claims for defibrillator implants, adjusted for age, sex and race, showed that Munster’s rate per capita was in the top 10 percent for the country for 2010, 2011 and 2012. The 7 region showed up with some of Indiana’s highest rates per capita for cardiac catheterizations and coronary angioplasties, procedures that, in many cases, can be elective. When investigators at the Dartmouth Institute studied rates per capita for procedures that must be treated — a hip fracture, for instance — Munster was below average in the state. “What that says is that for procedures that are more discretionary, they are at the top,” Dr. Malenka said. Community Hospital, a nonprofit institution, benefited immensely from the flourishing cardiology practice. As at other hospitals, heart procedures are one of its leading revenue engines, according to the 2012 tax filings for the foundation that oversees the hospital. The foundation that oversaw Community and two other, smaller local hospitals was controlled by one of Munster’s most prominent families. Until his death in April at the age of 95, Donald S. Powers, a local real estate developer, was the foundation’s chief executive. For years, Dr. Gandhi was one of Mr. Powers’s personal cardiologists and treated him after a heart attack. “Dr. Gandhi controlled his medications, did testing and performed several procedures on Mr. Powers,” the hospital said in a statement. The Powers family still oversees the foundation, the Community Foundation of Northwest Indiana. Mr. Powers’s daughter, Frankie Fesko, is the foundation’s chairwoman, and his grandson, Donald P. Fesko, is the chief executive of Community Hospital in Munster. The hospital declined to make any of its executives or members of the Fesko family available for this article. While one of the foundations, doing business as Community Hospital, is named in the malpractice litigation, no members of the Fesko family have been accused of any wrongdoing in the lawsuits. 8 A whistle-blower lawsuit brought by a physician and a hospital employee against the hospital, Dr. Gandhi and his practice in 2008 raised similar accusations that the hospital had billed for unnecessary defibrillator and pacemaker implantations that were performed by doctors without the proper credentials to implant the devices. But the suit, eventually joined by the United States attorney’s office in Hammond, Ind., just north of Munster, was settled without anyone admitting wrongdoing. The hospital paid a $48,942 settlement. The hospital and the doctors say that the settlement shows that the issues have been investigated and that they have been absolved of many of the same allegations contained in the current malpractice suits. A little more than a decade ago regulators expanded approval for a combination pacemaker-defibrillator device that, overnight, practically made pacemakers obsolete. Since then, there has been a growing battle over the qualifications necessary to implant the device, which is connected with electrodes to the heart and can send electrical pulses to restore a normal heart rhythm. A study published in 2009 showed about 71 percent of the new defibrillators were implanted by electrophysiologists — cardiologists who have received specific training in the rhythms of the heart. But, like other hospitals, Community Hospital allowed its medical staff to set credentialing requirements, and it allowed doctors who were not electrophysiologists to implant the devices. “It’s quite questionable to have complex electrophysiology procedures being done by people who are not formally trained,” said Dr. Nissen, who said he was not aware of the particulars in Munster. In 2005, after Dr. Gandhi had obtained privileges to implant combination pacemaker-defibrillators, Dr. Mark Dixon, then the 9 director of the electrophysiology program at Community, reviewed some of Dr. Gandhi’s cases. He found several cases in which the patient’s indications, or test readings, did not meet national guidelines for necessity, according to a deposition Dr. Dixon provided last fall for one of the patient lawsuits. Dr. Dixon said he reported Dr. Gandhi to the hospital’s quality assurance committee. That committee, according to the hospital, had been set up to improve documentation, but not to question whether procedures were necessary. In its statement, the hospital said Dr. Dixon never brought any complaints regarding Dr. Gandhi’s quality of care or appropriateness of implants to the quality committee’s attention. “None of the records were being reviewed for medical necessity of the implant,” the hospital said. Sitting in the corner of a Starbucks near Community Hospital, Dr. Scott Kaufman nervously sipped a Frappuccino. An electrophysiologist, Dr. Kaufman had concerns about Dr. Gandhi dating back more than seven years when he encountered Gloria Sargent in an emergency room of a nearby hospital. Ms. Sargent was in rough shape, vomiting and with a sustained rapid heart rate. In late 2006, Dr. Gandhi upgraded Ms. Sargent’s pacemaker- defibrillator device from a more basic one implanted by another doctor just a few months earlier. Dr. Kaufman turned off the device’s pacing, which sends an electrical shock to the heart to convert it to a normal heartbeat. He studied her electrocardiogram in the emergency room, and it showed she had normal electrical impulses going to her heart’s lower chamber. “She did not qualify for the upgrade and all of the surgeries she went through,” Dr. Kaufman asserted. Ms. Sargent became patient zero in the litigation against Dr. Gandhi. Last fall, after the plaintiffs’ lawyers handling her case began holding news conferences and running ads in the local 10 newspaper, former patients of Dr. Gandhi began trickling into Dr. Kaufman’s office. So he began working with a group of medical malpractice lawyers, the same lawyers who had twice sued him. Those cases were settled; the Indiana Medical Review Panel found that Dr. Kaufman had done nothing wrong. “I’m O.K. with working with these guys,” Dr. Kaufman said. “I just want this to stop.” © Joshua Lott for The New York Times Angela Webb, 52, had a pacemaker implanted by one of Dr. Gandhi’s associates when she was in her 40s. A new doctor removed it, and her condition improved markedly. “I was so happy to have it out,”… Dr. Kaufman says that of the 15 former patients of Dr. Gandhi and the Cardiology Associates doctors he has seen, at least 11 did not need the various procedures performed on them. One of those is Angela Webb, 52, who had a pacemaker implanted by one of Dr. Gandhi’s associates when she was in her 40s. After Dr. Kaufman observed her for a few months, he removed it. “When they took the pacemaker out, they couldn’t understand how I recovered so quickly,” said Ms. Webb, who said she could finally pick up her grandson and have the magnetic resonance imaging tests needed to treat her multiple sclerosis. “I was so happy to have it out.” Lawyers for Cardiology Associates say Ms. Webb’s lawsuit and others are riddled with errors, including, in her case, pages of accusations against Dr. Gandhi, who was not her physician, and lists of procedures that she did not undergo. When asked how her pacemaker could have been removed without medical problems, they said that in cases where devices had been removed because of infection, the devices did not need to be reimplanted in 25 percent of the cases. The lawyers also note that Dr. Kaufman and Dr. Dixon work together at a practice owned by another hospital. 11 It will take years for the lawsuits to wend their way through the legal system. In Indiana, each individual case must first go through a medical review panel, a process that can take more than two years. So far, however, the first two cases heard by the panel of physicians, including Ms. Sargent’s case, found Dr. Gandhi and Cardiology Associates “failed to comply with the appropriate standard of care” and that conduct “was a factor in the patient undergoing unnecessary procedures.” The panel did not find Community Hospital negligent. Debra Davidson is still searching for answers. Doctors and medical consultants paid for by the malpractice lawyers have now told her she did not need the many angiograms or stents because her heart had no blockages. When she stopped taking the medication she had been on for decades, she lost 30 pounds and began to feel better, she said. “But did I need this?” she asked, her hand hovering over the five- inch scar on her breastbone where surgeons entered for her open-heart surgery. Mrs. Davidson was sitting in her kitchen, and one of the lawyers present responded with a sad shrug. A physician who had reviewed her medical charts said it is unclear. It does not appear a stress test was done, which could have indicated whether her heart was getting adequate blood flow and whether the surgery was necessary. She now has advice for friends and family with medical problems. “If they have a feeling that they don’t believe what the doctor is doing for them is for the best, don’t do what I did and depend on the doctor,” Mrs. Davidson said. “Get a second opinion.” ADVICE OF A GOOD DOCTOR Note from Katie: I am so excited to post this interview with Dr. William Davis, MD, a preventive cardiologist whose unique approach to diet allows him to advocate reversal, not just prevention, of heart disease. He is the founder of the Track Your Plaque program, and wrote the book Wheat Belly: Lose the Wheat, Lose the Weight, and Find Your Path Back to Health 12 Enter Dr. Davis: How did you come to the conclusion that wheat is harmful in its current form? I learned just how bad wheat was when I asked patients in my cardiac practice to remove it from their diet. I did this because 80% of people I’d meet for the first time were diabetic or pre-diabetic, situations that double or triple heart disease risk. In an effort to minimize this situation, I applied a very simple fact: Two slices of whole wheat bread raise blood sugar higher than 6 teaspoons of sugar, higher than a Snickers bar. (Most people are unaware that the glycemic index of whole wheat bread is among the highest of all foods.) I asked everyone to remove wheat to observe the blood sugar effects. People would come back after a 3-6 months and, indeed, their blood sugars and HbA1c (a measure of prior 60 days blood sugar) would be much lower, even to the point at which some diabetics were no longer diabetic. But people told me plenty more: They lost 30 pounds, lost 4 inches from their waist, felt better than they had in 20 years with more energy, less moodiness and deeper sleep. They told me how they experienced complete relief from acid reflux, irritable bowel syndrome, migraine headaches, hand and finger arthritis and joint pain, sinus congestion and chronic sinus infections. They told me about how their asthma improved so much that they threw away three inhalers, their rheumatoid arthritis was so much better they were in the process of reducing medication, their ulcerative colitis and Crohn’s had improved so much that no medication was required any longer, their leg edema had disappeared and rashes were gone. At first, I dismissed it as pure coincidence. But the effects became so frequent and consistent that the conclusion became unavoidable: Wheat was the underlying cause for an incredible array of health problems and weight gain, and that eliminating was key to astounding health. And note that this was not gluten avoidance for the gluten-sensitive; this was wheat avoidance for everybody, as it was a rare person who didn’t experience at least some measurable improvement in health, if not outright transformation. I now recommend complete wheat avoidance for all my patients, as well as anyone else interested in regaining control over health and weight. How is wheat consumption linked to heart health? Wheat consumption causes heart disease. It’s not cholesterol, it’s not saturated fat that’s behind the number one killer of Americans; it’s wheat. The nutrition community has been guilty of following a flawed sequence of logic: If something bad for you (white processed flour) is replaced by something less bad (whole grains) and there is an apparent health benefit, then a whole bunch of the less bad thing is good for you. Let’s apply that to another situation: If 13 something bad for you—unfiltered Camel cigarettes—are replaced by something less bad—filtered Salem Cigarettes—then the conclusion would be to smoke a lot of Salems. The next logical question should have been: What is the health consequence of complete removal? Only then can you observe the effect of whole grains vs. no grains . . . and, from what I witness every day, you see complete transformations in health. Consumption of wheat, due to its unique carbohydrate, amylopectin A, triggers formation of small, dense LDL particles more than any other common food. Small, dense LDL particles are the number one cause for heart disease in the U.S. The majority of adults now have an abundance of small LDL particles because they’ve been told to cut their fat and “eat plenty of healthy whole grains.” This situation of excessive small LDL particles can appear on a conventional cholesterol panel as higher levels of LDL (“bad”) cholesterol, along with low HDL cholesterol and higher triglycerides that often leads to statin drugs. When more sophisticated lipoprotein testing is obtained, then the explosion of small LDL particles becomes obvious. Compound this with the increased appetite triggered by the gliadin protein in wheat that acts as an appetite-stimulant, and you gain weight. The weight gained is usually in the abdomen, in the deep visceral fat that triggers inflammation, what I call a “wheat belly.” Wheat belly visceral fat is a hotbed of inflammation, sending out inflammatory signals into the bloodstream and results in higher blood sugar, blood pressure, and triglycerides, all adding up to increased risk for heart disease. Say goodbye to wheat and small LDL particles plummet, followed by weight loss from the wheat belly visceral fat. Inflammation subsides, blood sugar drops, blood pressure drops. In short, elimination of wheat is among the most powerful means of reducing risk for heart disease. What other conditions have you seen to be associated with wheat consumption? A shorter list might be what conditions have not been associated with wheat consumption. Gastrointestinal consequences of wheat consumption include the common conditions of acid reflux and irritable bowel syndrome symptoms of gas, cramps, and diarrhea. People with inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease experience improvement and, sometimes, complete relief from cramps, pain, diarrhea, and bleeding. Brain and nervous system effects range from mood disruption, such as depression, to behavioral outbursts in children with ADHD and autism, to triggering of hallucinations in people with schizophrenia and mania in people 14 with bipolar illness. Wheat can also inflict direct damage on the brain and nervous system and show up as a condition called cerebellar ataxia, the progressive loss of balance and bladder control, and peripheral neuropathy, the loss of feeling, usually in the feet and legs. A British research group, for instance, has found that 50% of unexplained peripheral neuropathy can be blamed on wheat. There’s also the recent detailed description of gluten encephalopathy, or dementia from wheat by the Mayo Clinic; diagnosis is usually made at autopsy. Joint pain and swelling are common accompaniments of wheat consumption. The most common form involves the wrist and fingers. Others experience relief from back pain and hip and knee pain with eliminating wheat, especially if weight loss from the abdomen develops, since this belly fat serves as a repository for inflammation; lose the wheat belly, inflammation subsides. Skin conditions commonly improve or disappear with wheat elimination. Common conditions like acne improve, as well as a long list (enough to fill four pages) of other skin conditions from granuloma annulare, to allergic dermatitis, to gangrene. From the head down to the toes, there is no body system not affected by consumption of wheat. What are the most important things to understand when it comes to wheat consumption? I believe one of the most crucial aspects of the wheat conversation for people to understand is that the gliadin protein in wheat acts as an appetite-stimulant. People who consume the gliadin protein in wheat consume, on average, 400 more calories per day. People who eliminate the gliadin protein of wheat consume 400 calories less per day, even if calories, fat grams, or portion sizes are unrestricted. I think that this fact has been used to advantage by Big Food. Put wheat flour, and thereby gliadin, into every product you can, you increase appetite, increase consumption, increase sales. I believe this explains why wheat flour can be found in the most improbable places like tomato soup and licorice. The gliadin protein in wheat exerts this effect on the human brain because it is degraded to a group of compounds called exorphins, or exogenous morphine- like compounds; these effects that can be blocked with administration of opiate- blocking drugs. Yes, the appetite-stimulating effect of wheat can be completely disabled by administering the same drugs that heroine addicts take to block their “high.” Studies in volunteers have demonstrated that people administered opiate-blocking drugs have much reduced desire for cake, cupcakes, and cookies. A drug company filed its application in early 2011 for the drug 15 naltrexone for weight loss; in clinical trials, naltrexone was successful, with participants losing 22 pounds per month by reducing calorie intake 400 calories per day. As long as wheat remains a part of your diet, you will not have full control over impulse and hunger. Calorie consumption is higher, especially for carbohydrate foods. Weight accumulates, particularly around the middle. Eliminate wheat, on the other hand, and you regain normal physiologic control over hunger. 5. If a person decides to eliminate wheat, should he/she turn to “gluten free” alternatives or what type of diet have you found to be optimal? First, I believe we should return to real, unprocessed foods as often as possible. It means eating vegetables, raw nuts, meats, fish, eggs (including the yolks), cheese, healthy oils like extra-virgin olive and coconut. I do not believe that we should count or limit calories, especially after we’ve eliminated the potent appetite stimulant, wheat. If you miss baked goods, I provide recipes in the Wheat Belly book, as well as on The Wheat Belly Blog. These recipes for chocolate chip cookies and cheesecake, for example, are wheat-free, nearly sugar-free, low-carbohydrate and are generally healthy enough to eat anytime with none of the adverse health consequences like weight gain or bloating. I strongly urge people to avoid commercial gluten-free products. This is because, in place of wheat flour, these products, such as gluten-free whole grain bread, are made using cornstarch, rice starch, tapioca starch, and potato starch. These powdered starches are among the few foods that increase blood sugar higher than even whole wheat. It means these foods trigger weight gain in the abdomen (“gluten-free belly”), increased blood sugars, insulin resistance and diabetes, cataracts, and arthritis. They are not healthy replacements for wheat. Ok, a tough one… can you give us a 10-15 second elevator speech that can help us explain the reasons to avoid wheat to doubting friends and relatives? Sure. The American public needs to be aware that agribusiness and Big Food companies have sucker punched you. They have learned how to use this Trojan horse, wheat, harboring its hidden gliadin protein that increases appetite. Wheat is a weak opiate. Eat wheat, you want more wheat, you want more carbohydrates. The gliadin of wheat is converted to exorphins, morphine-like compounds that can be blocked with opiate-blocking drugs. Even worse, we’re advised by our own government agencies like the USDA and Health and Human Services that whole grains are good for us and we should eat more. Eat more “healthy whole grains,” we eat more, we gain weight, we acquire all the health consequences of wheat and weight gain such as 16 hypertension, high cholesterol, arthritis, acid reflux, and diabetes. Big Food makes out, Big Pharma makes out; we all pay the price. The epidemic of diabetes and obesity has been blamed on us. We’re told that Americans are overweight and diabetic because we are gluttons and we’re lazy. I don’t buy it. I believe the majority of Americans are fairly health-conscious and try to get at least some exercise. I do not believe we are that different from, say, the people of 1950 or 1960. I think we’ve been duped into blaming ourselves, when all along a big part of the blame should be placed on this corrupt product of genetics research, propagated by agribusiness, and put to profitable use. … If you haven’t already, check out Dr. Davis’ book Wheat Belly. I’ve found that it is a great resource, especially for friends and relatives who have trouble grasping how “heart-healthy-whole-grains” could possibly be bad. About the author: Dr. William Davis, MD, is a preventive cardiologist whose unique approach to diet allows him to advocate reversal, not just prevention, of heart disease. He started recommending a wheat free diet with his patients because wheat products raise the blood sugar more than a snickers bar. Besides blood sugar improvements, he was surprised to see his patients also experience weight loss of 25 to 30 lbs over several months, marked improvement or total relief from arthritis, improvement in asthma sufficient to chuck 2 or 3 inhalers, complete relief from acid reflux and irritable bowel syndrome symptoms, disappearance of leg swelling and numbness. Most reported increased mental clarity, deeper sleep, and more stable moods and emotions.