Ebola, Quarrantine Measures, Politics or Science ? Are the politicians correct?

Politics and Junk Science

The world is not a safe place.  (the truth will set you free?)

The United States has been especially fortunate because of the CDC and it's experience in endemic and epidemic infection. Many third world endemic infection have been controlled, and we have required immunization for diseases prevalent in other countries.

The advent of modern transportation with thousands of people travelling around the world in a matter of hours increases the importance of isolating and containing diseases such as Ebola.  Prevention is less expensive, and treatment on site at the origin of the endemic outbreak is essential.

In areas where endemics occur the population density and the prevalence of the infection increases the liklihood of spread to other locations.

The outbreak of Ebola is a mere test of our CDC's control methods. Far worse could be forthcoming. Politicians are making decisions without accepting recommendations from public health scientists and authorities.  Could they be correct ? The Governors of New York, New Jersey and others have correctly used their authority to protect the public health.

As usual our government reacts slowly.

The major effect has been for  health workers returning from West Africa. Health officials have emphasized repeatedly that direct contact with secretions is required for transmission to non-infected individuals.

This week's NEJM (New England Journal of Medicine) has several articles regarding Ebola, regarding diagnosis, treatment and isolation measures.

Ebola in the United States:  EHRs as a Public Health Tool at the Point of Care    
Ebola and our fragile health system

Despite repeated assurance by the CDC that the transmission of Ebola Virus is not airborne, there are recent articles which report vomitting produces a spray pattern, and protective measures to prevent spread of Ebola Virus.

Ebola Virus Disease and the need for New Personal Protective Equipment.

Ebola, the world's most dangerous virus. (documentary)

Numbers below are time tags and contents of video:

0:00 Introduction to viruses
1:20 Virus anatomy
2:35 Hemorragic fever in Angola (Ebola)
2:56 WHO and GOERM
3:15 WHO and world wide  monitoring
8:25  Infection control and prevention in underdeveloped countries
11:54 CDC
12:00 Biological containment and isolation methods
13:15  Ebola, Marburg virus have no treatments or vaccines. 


25:00 Virology, methodology for research
33:00 Viral Vectors and origins, zoonoses, West Nile Virus
36:00  Threat of bioterrorism
41:00  Limited resources, requiring large volunteer efforts in Africa and elsewere.
45:00  Previous lessons from HIV (25% of Africans had HIV virus leading to AIDS)

Ebola Virus Outbreak 2014 - WARNING

Ebola is named for a river in the Congo where virus first appeared in 1976.

This video is from an active Ebola facility in Western Africa and explains the isolation and containment methods used.

22:23 Health worker evacuation to U.S for treatment.

Experimental Treatment: ZMAPP 

Q: What is this drug?

A: Called ZMapp, it is a cocktail of specially engineered antibodies designed to target and inactivate the Ebola virus.

Q: What do we know about whether it works?

A: Very little. Various antibodies have been tested in small numbers of monkeys, but not people. In one study, 43 percent of treated monkeys survived when the drug was given after the animals showed symptoms.

Mapp Biopharmaceutical now is developing a combination of three antibodies that seemed most promising in those animal studies.

Ebola - What You're Not Being Told  according to reports from Scientific Reports; 

Are you as confused as I am? My education and training in medicine should make me able to discern fact from fiction.

Here are opposing views:

You'll notice if you read virtually any mainstream article on the topic that they make a point of insisting that Ebola is only transferred by physical contact with bodily fluids. This is not true, at all.

A study conducted in 2012 showed that Ebola was able to travel between pigs and monkeys that were in separate cages and were never placed in direct contact.

Though the method of transmission in the study was not officially determined, one of the scientists involved, Dr. Gary Kobinger, from the National Microbiology Laboratory at the Public Health Agency of Canada, told BBC News that he believed that the infection was spread through large droplets that were suspended in the air.
"What we suspect is happening is large droplets; they can stay in the air, but not long; they don't go far," he explained. "But they can be absorbed in the airway, and this is how the infection starts, and this is what we think, because we saw a lot of evidence in the lungs of the non-human primates that the virus got in that way."

Translation: Ebola IS an airborne virus. (as is annotated in the video and below, I am using this term in the layman's sense as TRAVELS THROUGH AIR)

Someone pointed out that in medical terms, if the virus is transferred through tiny droplets in the air this would technically not be called an "airborne virus". Airborne, in medical terms would mean that the virus has the ability to stay alive without a liquid carrier. On one hand this is a question of semantics, and the point is well taken, but keep in mind that the study did not officially determine how the virus traveled through the air, it merely established that it does travel through the air. Doctor Kobinger's hypothesis regarding droplets of liquid is just that, a hypothesis. For the average person however what needs to be understood is very simple: if you are in a room with someone infected with Ebola, you are not safe, even if you never touch them or their bodily fluids, and this is not what you are being told by the mainstream media. Essentially I am using the word "airborne" as a layman term.

The AP's spin on it:
Experts say people infected with Ebola can spread the disease only through their bodily fluids and after they show symptoms.

From CNN:
Ebola spreads through contact with organs and bodily fluids such as blood, saliva, urine and other secretions of infected people.

And from the BBC itself in their article describing the second confirmed case in Nigeria:
The virus spreads by contact with infected blood and bodily fluids - and touching the body of someone who has died of Ebola is particularly dangerous.

To make matters worse, there is something very, very important that the corporate media and public health officials are not telling you regarding this crisis.

You'll notice if you read virtually any mainstream article on the topic that they make a point of insisting that Ebola is only transferred by physical contact with bodily fluids. This is not true, at all.

How Obamacare will effect this year's Medicare Enrollment Period

How to judge Medicare plans

While much of the nation is preoccupied with Obamacare and picking new health insurance at work, older Americans have deadlines of their own coming up — involving Medicare.

We're just a few days away from the two-month period when the nation's 54 million Medicare beneficiaries have a chance to change their Medicare Advantage and prescription drug plans.

Every year, seniors should review their options and compare plans even if they're happy with their current coverage. Experts want people to avoid being surprised after it's too late to change. The deadline is Dec. 7.

The process of shopping can be daunting, and many seniors simply don't heed the advice.

"It's the same advice we give every year, but it's hard to get people off the dime," says Ross Blair, senior vice president of eHealthMedicare.com, which provides tools and information on Medicare insurance issues.

Medicare Advantage plans. Nearly 16 million people — or about 30% of the Medicare population — are enrolled in Medicare Advantage plans. These cover hospitalization, outpatient care and, often, prescription-drug coverage under one plan.

According to the Centers for Medicare and Medicaid Services, the average premium for Medicare Advantage plans will increase less than $3 next year, to $33.90 per month. Residents of Los Angeles County will see average costs of just $13.74 per month. The vast majority of enrollees will face little or no premium increase for next year.

 But out-of-pocket costs, such as deductibles and co-pays, are expected to rise. Looking beyond the monthly premium will be important for shoppers wanting to save money.

Be aware that some Advantage plans will be terminated this year. Be certain yours will continue;

Pay attention to networks, experts stress. Medicare Advantage plans are also reducing the size of their provider networks — in some cases quite dramatically.

If your physician will no longer be participating in your current plan, your insurer is required to send you notice of that fact and help you find another doctor in the network.

Nationwide, the average monthly premium in 2015 will be about $31, the federal government estimates. In California the figures vary, but the average is $58.91.

Although the number of these plans has dropped for 2015, there will still be 1,000 available nationwide. In Los Angeles County, Medicare participants will have 31 plans from which to choose for 2015, down from 34 this year.

As with Medicare Advantage plans, insurers are shifting more costs onto beneficiaries in the form of higher out-of-pocket costs, such as deductibles, co-pays and co-insurance, so you need to look beyond premiums.

Also, many plans have "preferred" status pharmacies, whose costs can be lower than other in-network pharmacies, says Elaine Wong Eakin, executive director of the Medicare advocacy organization California Health Advocates. In fact, 70% of Medicare drug plans had preferred pharmacy networks this year, and the expectation is there will be more in 2015.

Also, pay attention to the ratings. To help consumers determine the value of both Medicare Advantage and prescription drug plans, Medicare created a quality rating system. A plan can receive one to five stars, with five being the best, based on the agency's assessment of medical services and customer satisfaction.

Experts urge consumers to be alert for possible changes since last year's Medicare Advantage and prescription plans.

To review your plan options: Medicare plan finder at http://www.medicare.govor call (800) MEDICARE; eHealthMedicare.com.

For free personalized counseling services: State Health Insurance Assistance Programs, shipnpr.shiptalk.org or call (800) 677-1116; In Los Angeles, California Health Advocates: http://www.cahealthadvocates.org/HICAP

NY Times Article

Venture capital in healthcare is flowing, but how long will it last?

Despite the lingering slow recovery of the economy one sector that is booming is in health care financing and funding of health information technology, ranging from electronic data storage, evolutionary development of current technology which includes, EHR HIX, telehealth, health information exchanges, and mobile health apps. 

Much of the financing of these are not through conventional funding, but depends upon venture capital and startups from young entrepeneurs just entering the work-force.  Some are triggered by well funded, successful companies such as Google, Microsoft, and Apple.  Apple and Google have recently entered the health space in a more visible manner. Both Apple and Google have already developed many moble health apps,  now both companies are launching a more visible presence as Google Health, and Apple's Healthkit.With so much venture capital being foisted onto the digital health space, it’s beginning to beg the question: how long will this last, can it sustain itself, and what’s an entrepreneur to do? And, what are the implications for emerging companies versus traditional healthcare companies and systems?

Those were just a few of the burning questions discussed at Health 2.0‘s Pre, Post, M&A IPO panel held in Santa Clara.

"In the current landscape, larger-than-average sums of seed and early series funding is available to startups across a wide spectrum within the healthcare space. While that may seem like an obvious benefit, entrepreneurs need to be mindful of what’s reasonable and what’s actually needed, so as not to over-promise with a big initial raise and under deliver with a sub-par series b or c.

“You need to be careful to not overreach on your first round,” said Johh de Souza of MedHelp. “It can be very hard then on the second round. It matters on who the investor is, too.”

Frank Williams, of Evolent, agreed: “ You can overreach and then under deliver, and that creates a lot of issues.”

Sage advice, to be sure, but the entrepreneur should also capitalize on the current market conditions, and shouldn’t necessarily be faulted for the seeming glut of capital being heaped upon healthcare startups, Glen Tullman of 7wire Ventures cordially countered.

“I don’t think you can blame, nor should the entrepreneur be conservative, in terms of how big the raise is,” he said. “It doesn’t matter what you raised at a valuation – either you’re performing or you’re not.”

The venture capital funds are increasingly shifting away from life sciences and biotech and toward the digital health realm, with investors realizing that much less capital is needed to get off the ground for the latter while a return is still enticing, said Milena Adamain of Azimuth Partners.

To that end, on the M&A side, much of it’s a seller’s market, certainly as it relates to digital health, Williams said.

“It’s really hard to buy thinks now,” he said. “Everything is really expensive because of the competition.”

But the overall M&A landscape of healthcare in general will continue to be much more varied, with a good deal of late-comers merging as a means of survival. Yet at the same time, the different types of buyers, including nontraditional players like big consumer companies, bodes well for activity.

“As far as M&A, it looks incredibly attractive because of a broad base of buyers that you’ve never had,” Adamain said.

On the IPO side, everyone still looks to Castlight as what might be, but it’s still too soon to say whether long-term stability can be achieved, the panel said. Although at the moment, being a billion dollar company certainly appears to be working in Castlight’s favor.

“I would say the jury is still out,” Williams said. “Right now it’s a massive success. The question is do they continue to grow.”

So what does that mean for companies pondering the IPO? It’s hard to say exactly, but Tullman, of 7wire Ventures, said one gauge is to see how feasible it is for investors to sell within a year and what sort of return they can get.

All told, while it’s speculative to insist a bubble will burst around the available capital for digital health, and tech in general, the healthcare space is likely big enough to sustain a significant share of investor interest."

“Everyone is looking at something that is a fifth of the economy and so there’s a lot of strategic thinking to get a piece of that,” Williams said.

attributions:  Medcity News, Dan Verel, Marc O'Connor

The Affordable Care Act and the Internal Revenue Service

Part I

In October 2013 enrolllment  for the Affordable Care Act became available.  It's introduction and enrollment were plagued with unanticipated challenges.

It is one year post-enrollment apocalypse. Some are happy, some are not happy, all are confused. Despite problems, and delays almost 7 million people have enrolled.  How many are still enrolled and how many have actually seen a doctor are still unanswered questions.

In addition to the delays the Los Angeles Times reports that 30,000 ACA enrollees from Octobr 2013 were never enrolled or had eligibility issues undetetced at the time of enrollment.

California's health insurance exchange is vowing to fix enrollment delays and dropped coverage for about 30,000 consumers before the next sign-up period this fall.

Covered California said it failed to promptly send insurance applications for 20,000 people to health plans recently, causing delays and confusion over their coverage.

Another group of up to 10,000 people have had their insurance coverage canceled prematurely because they were deemed eligible for Medi-Cal based on a check of their income, officials said.

C alifornia's health insurance exchange is vowing to fix enrollment delays and dropped coverage for about 30,000 consumers before the next sign-up period this fall.

Covered California said it failed to promptly send insurance applications for 20,000 people to health plans recently, causing delays and confusion over their coverage.

Another group of up to 10,000 people have had their insurance coverage canceled prematurely because they were deemed eligible for Medi-Cal based on a check of their income, officials said.

At a time when many taxpayers have lost faith in the IRS' ethics do we let the IRS be involved in our health care?

An unlikely partnership, will it work, and do we have a choice?

In transition

Todd Park, the former CTO in the Obama administration has been replaced by Megan Smith, following his resignation several months ago.  Todd, during the rapid growth of HIT including Health Information Exchanges, and in conjunction with the Office of the National Coordinator of HIT (ONCHIT) was responsible for the successful role out of Health Information Exchanges, and later with the challenge of implementing Health.gov .

Megan Smith Named CTO of the United States!

Today +Megan Smith (formerly VP at Google[x]) joins President +Barack Obama as the Chief Technology Officer of the United States of America. Megan co-founded Women Techmakers in 2012 with +Stephanie Liu, and seeing the potential for building on the movement to empower women in technology, Megan and I created my current role as Google's Women in Technology Advocate. Megan has been an advisor to Women Techmakers despite her busy schedule advocating for women and children globally, and I'm honored to have worked side-by-side with her to enact change. I'm proud of my friend and mentor, and look forward to seeing the impact she'll make in her new role.

More from +Barack Obama and the White House blog http://goo.gl/xqbs10.

Covered California Executive Director Gets $52K Bonus for Role in Exchange Launch

Tuesday, August 26, 2014

RELATED TOPICS:

• Covered California

Covered California has announced it will give Executive Director Peter Lee a one-time,  $52,528 bonus related to the launch of the state's health insurance exchange. Anne Gonzales, a spokesperson for the exchange, said that an estimated 1.2 million state residents enrolled in coverage through the exchange during its first open enrollment period.

• "Covered California's Peter Lee Nets Bonus, Obamacare Site Nets 1.2 Million Enrollees" (Rauber, 

Comments:

DISGUSTING.

$52,528 for his role in launching the Golden State's exchange? That's tax payer money, folks, and, you know what, I would have thought that the roll-out of the exchange would be part of the job description of the director, and his annual salary would cover that. Furthermore, the roll-out wasn't without its problems, though not as bad as the federal exchange. Just imagine, if it had been that bad, Mr. Lee might have had to be content with just his meager $262,644 pay packet.

You will find additonal information about Covered California 2015 on Digital Health Space today

A Black Box for the Operating Room

Surgical 'black box' could reduce errors According to Dr. Chethan Sathya, Special to CNN ;

Airliners have them, trains have them, and now,even automobiles have them. How many 

times have we heard about the search for the black box?

It may be coming to an operating room near you.

Researchers in Canada have created a surgical "black box" that tracks surgeons' movements during an operation

  So far, Grantcharov's black box has been tested on about 40 patients undergoing laparoscopic weight-loss surgery.  Teodor Grantcharov, a minimally invasive surgeon at St. Michael's Hospital in Toronto. Unlike the so-called black boxes in aviation, which are used after disasters occur, the surgical black box Grantcharov is creating will be used proactively to prevent major patient complications.

 Inside the operating room, video cameras track every movement. Outside, a small computer-like device analyzes the recordings, identifying when mistakes are made and providing instant feedback to surgeons as they operate.

Read the entire article 

A work in progress

Grantcharov's black box is a multifaceted system. In addition to the actual box, it includes operating room microphones and cameras that record the surgery, the surgeon's movements and details about team dynamics.

It will allow surgeons to hone in on exactly what went wrong and why.

The black box will eventually assess everything from how surgeons stitch to how delicately they handle organs and communicate with nurses during high-stress situations. Error-analysis software within the black box will help surgeons identify when they are "deviating" from the norm or using techniques linked to higher rates of complications.

So far, Grantcharov's black box has been tested on about 40 patients undergoing laparoscopic weight-loss surgery.

The surgical black box will be tested in hospitals in Canada, Denmark and parts of South America in the next few months. Talks are also under way with a number of American hospitals.

If doctors accept it, implementation in U.S. hospitals could happen quickly since the surgical black box isn't considered a medical device and doesn't require approval from the U.S. Food and Drug Administration.

But the litigious medical environment may make its implementation problematic. If the recordings were used in court, they could open the floodgates to a new wave of malpractice concerns, which would be counterproductive to surgeons and patients, Grantcharov says.

"We have to ensure the black box is used as an educational tool to help surgeons evaluate their performance and improve," he says.

Bottom line, Grantcharov says, is that even after years of practicing medicine, the black box "made me a safer surgeon and a better teacher."

Read the entire article 

Hidden Costs of the Affordable Care Act

HEALTHCARE.GOV COST $1.7 BILLION

"The federal government issued sixty contracts from 2009 to 2014 in efforts to build Healthcare.gov, the federal insurance marketplace. According to a report issued today by the inspector general (OIG) of the Department of Health and Human Services (HHS), the government had already paid out just under half a billion dollars by February 2014, five months after the beginning of open enrollment. The government is already under obligation for another $300 million, and the estimated value of the sixty contracts totals $1.7 billion. The OIG provided a summary of its findings:
“The 60 contracts related to the development and operation of the Federal Marketplace started between January 2009 and January 2014. The purpose of the 60 contracts ranged from health benefit data collection and consumer research to cloud computing and Web site development. The original estimated values of these contracts totaled $1.7 billion; the contract values ranged from $69,195 to over $200 million. Across the 60 contracts, nearly $800 million has been obligated for the development of the Federal Marketplace as of February 2014. As of that date, CMS had paid nearly $500 million for the development of the Federal Marketplace to the contractors awarded these contracts.”
A few familiar names appear on the list of contracts, such as Northrop Grumman and Lockheed Martin. Also appearing are CGI Federal, widely blamed for the botched roll out of the site last October, and Accenture Federal Services, which has taken over for CGI in hopes that this year’s open enrollment will go better than 2013.

An Analysis of the Affordable Care Act Enrollments

Health insurance exchanges in 2015: 



Health Insurance exchanges are very new in to the marketplace. Previous exchanges were largely private and individualized without strict guidelines.  The Affordable  Care Act mandated a total revision and set rigid giuidelines for these exchanges and  great emphasis was placed on the initial enrollment deadline without a mature online registration system.  The rush led to frustration, disappointment, and worse, a total lack of faith and trust in the Affordable Care Act.

How to boost success

We must thank those volunteers who were and still are essential to this process. Many are from non-profit organizations who were not  formerly involved with healthcare.  Our government placed much of the enrollment process on volunteers.

Health Train Express will outline plans to improve enrollment and the functioning of health exchanges

A Webinar sponsored by Enroll America #soe2014 and supported by  

State of Enrollment: Getting America Covered 2014

More than 800 health coverage leaders came together for our State of Enrollment: Getting America Covered conference in June 2014 to share, learn, and plan after the first open enrollment period under the Affordable Care Act.

We took a critical look at what worked, what barriers consumers continue to face, and how we could all work together to sustain and build momentum for the ongoing effort to get America covered (click here to download the full conference program).

A compilation of resources for Getting America Covered 2014

Watch the Plenary Webcasts

Click here to watch recordings of the five plenary sessions.

Download Slides from the Workshop Presentations

Volunteers Matter: Building and Sustaining a Volunteer Program

Health Insurance Literacy: Helping Consumers Understand Their Coverage Options As it turned out this was one of the most important issues for a previously uninsured population totally unfamililar with terms and the workings of health insurance coverage 

Evaluate Your Outreach: Efforts to Improve Results

Referral Networks: Essential for Enrollment Success

Using Personal Stories to Motivate Consumers

Phonebank Your Way to Success: Consumers Need to Hear from You Over the Phone

Getting to Yes: Resources, Tips, and Lessons for an Effective Fundraising Pitch

Facilitating Productive Coalition Communication – The North Carolina Model

Outside the Box: Innovative Ways Tax Preparation Can Maximize Enrollment

Equipping Enrollment Assisters to be Successful

Keys to Enrollment: Leading States Speak Out

Effective Outreach and Organizing Strategies in an Open Enrollment Environment

Strategies to Fast-Track Medicaid Enrollment

What Worked and How Do We Know?

The Conference Agenda: (Downloadable pdf)

All or most of these actions took place during the initial enrollment period of  2013-2014. The next open enrollment period will beginning October 2015.

Supported  by   

Doctors would rather be Penalized than go along with Meaningful Use

 HHS defines Meaningful use              Wikipedia defines Meaningful Use


Meaningful use is a term (MU) coined by CMS and HHS to describe their mandated information system for analysis of electronic health records.   Meaningful use has nothing to do with patient care or the usefulness of electronic health records for care givers. The term is highly misleading, implying something which it is not, nor designed to accomplish. In additon, it's mandated use is required to gain incentive patients for purchasing electronic medical record systemsThe main components of Meaningful Use are:

• The use of a certified EHR in a meaningful manner, such as e-prescribing.
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care.
• The use of certified EHR technology to submit clinical quality ot

In other words, providers need to show they're using certified EHR technology in ways that can be measured significantly in quality and in quantity.^[131]

The meaningful use of EHRs intended by the US government incentives is categorized as follows:

• Improve care coordination
• Reduce healthcare disparities
• Engage patients and their families
• Improve population and public health
• Ensure adequate privacy and security

The Obama Administration's Health IT program intends to use federal investments to stimulate the market of electronic health records:

• Incentives: to providers who use IT
• Strict and open standards: To ensure users and sellers of EHRs work towards the same goal
• Certification of software: To provide assurance that the EHRs meet basic quality, safety, and efficiency standards

The detailed definition of "meaningful use" is to be rolled out in 3 stages over a period of time until 2017. Details of each stage are hotly debated by various groups.^[132

Thousands of eligible providers are working diligently toward EHR incentive payments, but some practices are choosing a different route: abandoning meaningful use altogether in favor of their own solutions, and finding ways to make up for the penalties they’ll incur down the road.

Some 6 percent of physicians, in fact, will be “abandoning meaningful use after meeting it in previous years,” according to the Medscape report on EHR use in 2014. In surveying nearly 20,000 doctors, Medscape found another 16 percent admitting that they would never be attesting to meaningful use in any capacity. 

More about Meaningful Use and why physicians find it counterproductive and a barrier to patient care.
The Barriers to Meaningful Use  

Arguments about Physician Reimbursement

Medpage Today posted an interesting commentary about how Physicians are reimbursed. Their conclusion was that physicians can make more money speaking,and/or consulting for pharmaceutical companies, as well as in executive positions. Why treat patients?

CardioBuzz: Toward the $500 an Hour Physician

How does an ULTRA-MARATHON sound to you?

A new and growing challenge for extreme sports is the  ultramarathon.  A normal marathon which is just over 26 miles long is a piddling distance compared to the ultramarathon, that is four times as long. The most common distances are 50 kilometres (31.069 mi), 100 kilometres (62.137 mi), 50 miles (80.4672 km), and 100 miles (160.9344 km), although many races have other distances. The 100 kilometers is recognized as an official world record event by the International Association of Athletics Federations (IAAF)

A recent ultramarathon which attracted about a dozen runners lasted 24 to 48 hours as well as an elevation change of 17,000 feet.

A standard typical marathon presents some dangers to unconditioned athletes. Extending the distance increases the liklihood of serious complications. These include  hyponatremia, edema of the extremities and life threatening pulmonary edema.  These are caused by a fluid shift from the extracellular space to the cell resulting in swelling of the cells.

There is some evidence that extreme runs can produce some heart scarring, however suprisingly joints seem to do well. Each runner must develop their skill carefully and tailored to the feedback they receive from their body.  Fluid balance and caloric intake are critical. Some runners experience gastrointestinal cramping during runs.

Science Friday Podcast:

There have been no long term studies on the effects of these extreme runs.  So if you are bored with it all, ramp things up after studying the longer events. However, extend your distances gradually, allowing your physiology to condition itself .

Try to keep up with me.....hehehe


                                                                                                  Pedal Edema= Swelling of Ankles