• The Glucose Tolerance Test (GTT) is used to diagnose pre diabetes, overproduction of insulin, diabetes (high sugar levels) or hypoglycemia (low sugar levels). You should plan to be in the office two and half to three hours. If the test is done to diagnosed hypoglycemia (three hour test) you will be in the office for three to four hours.

    BEFORE THE TEST

    You will be scheduled to come in at 8 am. You should not to eat or drink for 10 hours prior arrival (fasting), except for water and medications. Be sure you hydrate well and do not do exercise before the test.

    DURING THE TEST

    A "fasting" blood sample will be drawn first. Afterwards you will be given a sweet beverage of 75 gr to 100 gr (depending of the test ordered) of dextrose (carbohydrate) to drink. Your blood will be drawn at 30, 60 and 120 minutes after drinking the beverage ( and 180 min if done to rule out hypoglycemia). During the test you will need to stay in the office all the time, and can not smoke, eat or drink (except for water). After the sweet beverage, some patients may complain of mild dizziness or nausea. You should not have any symptoms during the test. If you do have symptoms, please inform the staff. The provider will see you after the test.

    AFTER RESULTS ARE AVAILABLE

    The provider will schedule an appointment to review the results of the test to determine how your body processes carbohydrates, it will analyze how high the expected peaks are and how quickly the values descend or if they descend at all.

    INTERPRETATION

    A person with Normal Glucose metabolism will start with a glucose level between 60-90. After drinking the beverage, there will be a normal increase in the glucose level between 100-140 in first hour. As the body processes the glucose, the glucose level will drop gradually and at the end of the 2 hours the blood glucose level should returned to normal levels. Glucose levels in a person with Impaired Glucose metabolism will rise during the 30 minute to 90 minute period to over 140 but remain less than 200. A patient with diabetes will have at least one value of 200 and/or values over 180- 200 at 2 hours. The insulin levels vary depending of your glucose levels, however the insulin:glucose ration should < 0.45 at 2 hrs, The provider will explain in detail the insulin during the follow up visit.

  • PPD or TB SKIN TEST

    The tuberculosis skin test determines if someone has developed an immune response to the bacterium that causes tuberculosis (TB). This response can occur if someone currently has TB, if they were exposed to it in the past, or if they received the BCG vaccine against TB (which is not administered in the U.S.).  An incubation period of two to 12 weeks is usually necessary after exposure to the TB bacteria in order for the PPD test to be positive. It is only contraindicated in people who have had a severe reaction to a previous tuberculin skin test.

    Administration of the tuberculosis skin test

    The standard tuberculin test is administered by injecting a 0.1 mL of a liquid containing 5 TU (tuberculin units) of PPD into the top layers of skin (intradermally, immediately under the surface of the skin) of the forearm. A discrete, pale elevation of the skin (a wheal) 6 mm-10 mm in diameter should be produced when the injection is done correctly. This wheal is quickly absorbed.

    You can take showers and baths as you normally do. If the arm itches or blisters, place an ice cube in a washcloth and place it on your arm. DO NOT SCRATCH!

    Understanding your PPD skin test results.

    NEGATIVE: If the area of skin where you received the PPD injection isn't swollen or is only slightly swollen or red 48 to 72 hours after the injection, the test results are negative. A negative result means that you most likely have not been infected with the bacteria that cause TB.

    POSITIVE: If after 48-72 hours of administration you have a raised, hard bump or there's swelling on your arm, you have a positive test. That means TB germs are in your body. But it doesn't always mean you have active tuberculosis disease.  This bump, or induration, will also turn pink or red. The size of the induration, not the redness, is used to determine your results. For those patients with darker skin, please let us know if the area feels swollen, or tender.

    Reading the TB test 48-72 hrs. after administration

    POSITIVE TEST

    -       If you have a positive reaction, please call for an appointment to be seen by a health care provider to confirm the reaction and the size of the induration.

    -       Make a circle around the area of induration with a black marker or pen.

    -       Measure the area of induration with a ruler. The reaction should be measured in millimeters of the induration (firm swelling).

    -       Take 2 clear pictures of the area where the test was placed.

    -       Send the pictures by email and request an appointment.

    - The pictures or the email should have a date and time 48 -72 hrs after administration.  

    -       A patient who does not return or send a picture within 72 hours will need to be rescheduled for another skin test.

    NEGATIVE TEST

    -       Make a circle around the area OF INJECTION with a black marker or pen.

    -       Take 2 clear pictures of the area where the test was placed.

    -       Send the pictures by email.

    - The pictures should have a date and time 48 -72 hrs after administration.  

    -       A patient who does not return or send a picture within 72 hours will need to be rescheduled for another skin test.

  • BENZODIAZEPINES INFORMATION

    Benzodiazepines are psychoactive drugs that help relax muscles and relieve anxiety, insomnia, seizures, and alcohol withdrawal symptoms.

    Some common benzodiazepines include:

    Alprazolam/ Xanax

    Diazepam/ Valium

    Chlordiazepoxide/ Librium

    Lorazepam/ Ativan

    Clonazepam/ Klonopin

    Temazepam/ Restoril

    • Benzodiazepine drugs (also called benzos, Downers, Nerve Pills, Tranks) are habit forming and can lead to addiction. Long-term use also can lead to tolerance, which means that lower doses will become ineffective and patients will need higher doses with time. People who have a history of drug or alcohol abuse are more likely to develop an addiction to these drugs.

    • Benzodiazepines can become addictive - even if you take them as your doctor or health care professional has prescribed. The effects of benzodiazepines may be felt within an hour and can last from hours to several days depending on the type of benzodiazepine (short, intermediate or long acting). Some of the effects that may be experienced with low to moderate doses.

    • If you abuse benzodiazepines you may have adverse effects with symptoms such as:

    • Memory loss, difficulty thinking clearly

    • Confusion, depression, blurred vision • Drowsiness, feeling tired or weak

    • Dizziness, change in balance, falling over • Headache, dry mouth, nausea, vomiting

    • Loss of appetite, diarrhea, constipation

    • Disturbing or vivid dreams

    • Hostility, irritability

    • Amnesia

    IT IS NEVER OK OR ADVISED TO COMBINE BENZODIAZEPINES WITH ALCOHOL OR WITH OTHER DRUGS THAT AFFECT THE CNS

    It's not safe to drink alcohol or take other drugs that have similar effects on the central nervous system (CNS) with the benzodiazepines. These drugs or substances interact with oral benzodiazepines causing additional depression of the brain and respiratory system (breathing difficulties). People who drink alcohol while taking this medicine will feel the effects of alcohol and /or opiates (such as Vicodin, Percocet or heroin) faster.

    DRIVING CAN BE AFFECTED

    Driving ability can be affected by benzodiazepines. You may not notice that your driving is affected until you find yourself in a situation where you need to respond immediately and appropriately such as to avoid an accident. It is recommended to drive only after the effect of the benzodiazepines wears off. You can ask your pharmacist or provider about the length of the effect of this drugs.

    BENZODIAZEPINE SIDE EFFECTS:

    Common side effects include:

    • Lightheadedness

    • Drowsiness

    • Confusion

    • Sedation

    • Memory impairment

    • Improper body balance

    • Increase or decrease in appetite

    • Nausea

    • Vomiting

    • Constipation

    • Weight gain

    • Dry mouth

    • Reduced libido

    • Fatigue


    Serious side effects include:

    • Respiratory depression

    • Dependence and abuse

    • Withdrawal symptoms

    • Jaundice

    • Seizures

    • Suicide

    • Slow heart rate

    • Severe low blood pressure

    • Fainting

    • Akathisia (a movement disorder)

  • Guidelines for a Low Cholesterol, Low Saturated Fat Diet

    A low fat diet should have 20% of calories in fat i.e- eat 20-22 gr fat/1000 cal/day.

    Take Omega 3, 1000 mg daily with at least 500 mg of DHA or EPA.

    Exercise to include 30 min daily aerobic exercise (brisk walking) and strength training 2 times a week.

    Fat

    • Limit total intake of fats and oils.

    • Avoid butter, stick margarine, shortening, lard, palm and coconut oils.

    • Limit mayonnaise, salad dressings, gravies and sauces, unless they are homemade with low-fat ingredients.

    • Limit chocolate.

    • Choose low-fat and nonfat products, such as low-fat mayonnaise, low-fat or non-hydrogenated peanut butter, low-fat or fat-free salad dressings and nonfat gravy.

    • Use vegetable oil, such as canola or olive oil.

    • Look for margarine that does not contain trans fatty acids.

    • Use nuts in moderate amounts.

    • Read ingredient labels carefully to determine both amount and type of fat present in foods. Limit saturated and trans fats.

    • Is better to eat "good fats", however the daily total portion and total fat content is important. For example: avocado (1/4 to 1/2 of an avocado/day), nuts (15 nuts/day ) and olive oil (2 tsp/day).

    • Avoid high-fat processed and convenience foods.


    Meats and Meat Alternatives

    • Choose fish, chicken, turkey and lean meats.

    • Use dried beans, peas, lentils and tofu.

    • Limit egg yolks to three to four per week.

    • If you eat red meat, limit to no more than three servings per week and choose loin or round cuts.

    • Avoid fatty meats, such as bacon, sausage, franks, luncheon meats and ribs.

    • Avoid all organ meats, including liver.

    Dairy

    • Choose nonfat or low-fat milk, yogurt and cottage cheese.

    • Most cheeses are high in fat. Choose cheeses made from non-fat milk, such as mozzarella and ricotta cheese.

    • Choose light or fat-free cream cheese and sour cream.

    • Avoid cream and sauces made with cream.

    Fruits and Vegetables

    • Eat a wide variety of fruits and vegetables.

    • Use lemon juice, vinegar or "mist" olive oil on vegetables.

    • Avoid adding sauces, fat or oil to vegetables.

    Breads, Cereals and Grains

    • Choose whole-grain breads, cereals, pastas and rice.

    • Avoid high-fat snack foods, such as granola, cookies, pies, pastries, doughnuts and croissants.

    Cooking Tips

    • Avoid deep fried foods.

    • Trim visible fat off meats and remove skin from poultry before cooking.

    • Bake, broil, boil, poach or roast poultry, fish and lean meats.

    • Drain and discard fat that drains out of meat as you cook it.

    • Add little or no fat to foods.

    • Use vegetable oil sprays to grease pans for cooking or baking.

    • Steam vegetables.

    • Use herbs or no-oil marinades to flavor foods.

  • CORTISOL TESTING INSTRUCTIONS

    The first step is to complete the Salivary Cortisol testing and the 24 hrs urine collection for cortisol (if ordered). The second part of the test is the measurement of cortisol levels after taking a medication called Dexamethasone ( This test is the last test to be done because dexamethasone lowers the cortisol levels and can affect the results of other tests).

    Saliva samples are to be collected at 10pm, 12am-Midnight and 8 am.

    Urine specimen is collected during a 24 hrs period.

    The Dexamethasone pill is taken at 11 PM.

    These samples should be stored in the refrigerator and dropped off early morning the day after you take the Dexamethasone.

    No preparation is needed for these tests. Avoid excess caffeine intake before and during the collection period. Minimize emotional and physical stresses and vigorous exercise.

    Please see instructions below.

    For example: You can start the 24 hrs Urine collection on Saturday morning and do the Salivary cortisol collection on Saturday night (store collected sample containers in the refrigerator). On Sunday night, take the Dexamethasone pill at 11 PM and return to the office on Monday, between 8 and 9 AM, with the Salivary cortisol containers, Urine containers and to have your blood drawn.

    INSTRUCTIONS FOR THE 24 HRS URINE COLLECTION

    1) Place your name on the containers using a waterproof pen. You will be given one or more containers for collecting and storing your urine. You can use a pan, smaller container that fits in the toilet or a urinal to collect the urine. You will need to transfer the urine from the collecting container to the storage container. You will need to keep it cold.

    2) Don't save the urine from the first time urinating. Flush this first specimen, but note the time. This is the start time of the 24-hour period. The collection may start at any time during the day after you first urinate.

    3) All urine, after the first flushed specimen, must be saved, stored, and kept cold. This means keeping it either on ice or in a refrigerator for the next 24 hours.

    4) Next day, try to urinate again around the same time you flushed the urine, 24 hours after the start time, to finish the collection process. If you can’t urinate at this time, it is OK. Keep specimen cold till you bring back the specimen.

    INSTRUCTIONS FOR THE SALIVARY CORTISOL TEST

    Times of collection are: 10pm, 12am-Midnight and 8 am.

    1) Label the exterior tube of the Salivary collection device using a waterproof pen with your first and last name, as well as the date and time collected.

    2) Remove the stopper of the container to expose the swab. Do not remove the insert from the tube. This is necessary for processing the specimen.

    3) Place swab directly into the mouth by tipping the tube so the swab falls into the mouth. The swab should be placed under the tongue or allowed to move freely across the tongue. Do not place the swab between cheek and gum. Gently chewing of the swab is acceptable.

    4) Keep the swab in your mouth for two to three minutes. Be sure the swab is completely saturated with saliva; this will ensure that enough volume is collected.

    5) Return the swab back into the insert. Do not touch the swab with your fingers. Do not remove insert from tube.

    6) Replace the stopper, ensuring that the cap is tight (the cap should click when inserted properly).

    INSTRUCTIONS FOR THE CORTISOL AFTER DEXAMETHASONE TEST - (THE LAST TEST)

    1) Take dexamethasone at 11pm.

    2) Return to the office between 8 to 9 AM to have your blood drawn for cortisol levels.

    If applicable, bring the other specimens with you.

  • BRAT DIET FOR DIARRHEA AND VOMITING

    • Stop eating for a few hours to let your stomach settle.

    • Sip liquids, such as a sports drink or water, to prevent dehydration. Drinking fluids too quickly can worsen the nausea and vomiting, so try to take small frequent sips over a couple of hours, instead of drinking a large amount at once.

    • Take note of urination. You should be urinating at regular intervals, and your urine should be light and clear. Infrequent passage of dark urine is a sign of dehydration. Dizziness and lightheartedness also are signs of dehydration. If any of these signs and symptoms occur and you can't drink enough fluids, seek medical attention.

    • Ease back into eating. Try to eat small amounts of food frequently if you experience nausea. Otherwise, gradually begin to eat bland, easy-to-digest foods, such as soda crackers, toast, gelatin, bananas, rice and chicken. Stop eating if your nausea returns. Avoid milk and dairy products, caffeine, alcohol, nicotine, and fatty or highly seasoned foods for a few days.

    • Consider acetaminophen (Tylenol, others) for relief of discomfort, unless you have liver disease.

    • Get plenty of rest. The illness and dehydration can make you weak and tired.

  • Gout is an arthritis caused by a buildup of uric acid. The uric acid can form crystal in your joints, leading to extremely painful gout attacks or flares. Gout usually starts in the large joint of the big toe, but can occur in other joints. Pain, swelling and redness may last from hours to weeks.

    Uric acid is produced when the body breaks down a chemical called purine. Purine occurs naturally in your body, but it's also found in certain foods. Uric acid is eliminated from the body in urine.

    A "gout diet" may help decrease uric acid levels in the blood. While a gout diet is not a cure, it may lower the risk of recurring painful gout attacks and slow the progression of joint damage. Medication also is needed to manage pain and to lower levels of uric acid.

    Gout has been associated with overindulgence of meats, seafood and alcohol.

    The general principles of a gout diet are essentially the same as recommendations for a balanced, healthy diet:

    • Weight loss. Being overweight increases the risk of developing gout, and losing weight lowers the risk of gout.

    • Complex carbs. Eat more fruits, vegetables and whole grains, which provide complex carbohydrates. Avoid foods such as white bread, cakes, candy, sugar-sweetened beverages and products with high-fructose corn syrup.

    • Water. Keep yourself hydrated by drinking water.

    • Fats. Cut back on saturated fats from red meats, fatty poultry and high-fat dairy products.

    • Proteins. Limit daily proteins from lean meat, fish and poultry to 4 to 6 ounces (113 to 170 grams). Add protein to your diet with low-fat or fat-free dairy products, such as low-fat yogurt or skim milk, which are associated with reduced uric acid levels.

    Specific recommendations for foods or supplements include the following:

    • High-purine vegetables.  A healthy diet based on lots of fruits and vegetables can include high-purine vegetables, such as asparagus, spinach, peas, cauliflower or mushrooms. You can also eat beans or lentils, which are moderately high in purines but are also a good source of protein.

    • Organ and glandular meats. Avoid meats such as liver, kidney and sweetbreads, which have high purine levels.

    • Selected seafood. Avoid the following types of seafood: anchovies, herring, sardines, mussels, scallops, trout, haddock, mackerel and tuna.

    • Alcohol. The metabolism of alcohol in your body is thought to increase uric acid production, and alcohol contributes to dehydration. Beer is associated with an increased risk of gout and recurring attacks, as are distilled liquors. The effect of wine is not as well-understood.

    • Vitamin C. Vitamin C may help lower uric acid levels. Take 500 milligram vitamin C supplement daily.

    • Cherries. There is some evidence that eating cherries is associated with a reduced risk of gout attacks.

  • SAFE USE OF OPIOIDS

    If you are taking opioids or talking with your doctor about this treatment option, now is the time to plan for safe use and disposal of these medications. Practicing caution can mean the difference between life and death for you, your loved ones and even your neighbors.

    Opioid painkillers are highly addictive. After just five days of prescription opioid use, the likelihood that you'll develop long-term dependence on these drugs rises steeply -increasing your risk of eventual addiction and overdose. And you don't need a prescription to be at risk. In fact, most people who misuse prescription painkillers report getting them from a family member or friend. Find out what steps to take to keep you and your loved ones safe. Your medical history, family history and personal history of substance use all help determine whether opioids are safe for you to try.

    Medical conditions that increase your risk of dangerous side effects from opioid medications include:

    • Sleep apnea

    • Obesity

    • Anxiety or depression

    • Fibromyalgia

    Mental health and substance abuse problems that increase your risk of opioid abuse and addiction include:

    • History of severe depression or anxiety

    • Heavy tobacco use

    • Prior drug or alcohol rehabilitation

    • Family history of substance abuse

    • Personal history of substance abuse

      Following the CDC's recommendations for safe prescribing of opioid medications your doctor will:

    • Prescribe the lowest effective dose, for the shortest period needed, when treating acute pain. In most cases, acute pain — such as pain that follows surgery or a bone fracture — is not severe enough to require opioids for more than three days.

    • Avoid or delay prescribing opioids for chronic pain. These medications are not often safe or effective for chronic pain unrelated to cancer or cancer treatments. Your doctor should help you evaluate many other therapies — including nonpharmacological treatments and nonopioid medications — before considering a trial of opioids.

    • Work with you to establish realistic treatment goals. Your doctor should help you determine how much pain relief you need in order to gain improvements in your ability to function and quality of life. There's no cure for chronic pain, even with drugs as powerful as opioids, and there are risks associated with all pain medications. You and your doctor should be partners in maximizing your enjoyment of life while minimizing medication-related health risks.

    • Ask you to sign an opioid therapy agreement before you start a long-term course of opioid medications. Typically, these agreements clearly state your responsibilities while using opioid medications. You'll agree to use opioids only as prescribed and to obtain painkillers from only one physician and one pharmacy. You'll acknowledge that you won't receive additional medication until your current prescription runs out, even if your medication is lost or stolen.

    • You may be asked to submit to periodic urine tests and pill counts. You'll agree to maintain all aspects of your treatment plan — such as physical therapy or behavioral medicine — and to keep all scheduled follow-up appointments. Violation of any of these terms may prompt termination of opioid therapy.

    • Schedule regular checkups while you're taking opioids. Expect your doctor to require a follow-up appointment one to four weeks after you start opioid therapy, to evaluate the benefits and risks of these medications for you so far. If you continue taking opioids, your doctor will need to continue seeing you frequently for as long as you use these drugs. These visits may include urine tests.

    • Help you minimize withdrawal when you stop opioids. If you've taken opioids for chronic pain and determine it's time to stop, your doctor should help you slowly and safely taper off these drugs to avoid potentially severe side effects.

    Take these steps with your health care providers:

    • Tell all of your providers about all of the drugs you're taking. Opioids interact dangerously with many medications. For example, combining opioids with medications used to treat anxiety or sleep issues can be very harmful, or even deadly. If you see different doctors, each of them needs to be aware of all the medication you're taking — including over-the-counter medications, such as aspirin, allergy medicine and nutritional supplements. Be honest about your alcohol use and any illegal substances you use.

    • Order all your medications through the same pharmacy whenever possible. The pharmacy has systems in place that alert pharmacists to potentially dangerous interactions between the drugs you're taking.

    • Read the instructions and warnings on the drug safety information sheet stapled to your prescription. These instructions notify you about potential side effects and help you understand how to check your response to the medication.

    • Report side effects to your doctor right away. If you have any side effects, such as constipation, nausea, mood changes or confusion, contact a member of your health care team immediately.

    • Check the expiration date on your pill bottle. Medication loses its effectiveness after a certain amount of time, and its effects become unpredictable. When a medication has expired or you've stopped using it, dispose of it properly.

    • Don't leave unused opioids in your medicine cabinet "just in case." A large part of the opioid abuse crisis is driven not by the people who were originally prescribed the drugs, but by people taking medications that don't belong to them. If you're done with your painkillers, it's very important to dispose of them as quickly and properly as possible.

    • Don't give your unused medications to your friends and don't throw them away. While some types of prescription drugs can be disposed of in your household trash, the FDA says that opioids are too dangerous to go out with your garbage because even one dose to the wrong person can sometimes be fatal.

    To pass your medications into safe hands, contact an organization with an authorized take-back program, such as:

    • Your local law enforcement agency. Many have medicine take back programs.

    • Your trash and recycling service. Ask about medication disposal options and guidelines for your area.

    • The Drug Enforcement Administration (DEA). DEA staff can point you to an authorized site that collects unused medicines. This may include retail, hospital or clinic pharmacies, law enforcement locations, or even mail-back programs.

    • Flushing your unused opioid medication is also recommended in some cases. According to the the U.S. Food and Drug Administration (FDA), flushing should be considered when a medication cannot be safely and securely stored until disposal via a take-back program, or when there are risks in waiting to do so. The FDA's "flush list" includes oxycodone, hydrocodone, fentanyl and many other opioids. Fentanyl patches can be deadly to small children and should be flushed as soon as you take them off your skin. Fold the sticky sides together before flushing. If your medication isn't on the FDA's flush list and there's no takeback program in your area, consult your pharmacist for guidance.

    Opioids can affect your thinking and judgment. Even when you take an opioid medication as prescribed, you might make decisions too quickly, without thinking things through. You may think you're OK and you're making good decisions when you're not. You may take risks and put yourself and others in danger. These are signs that you need to make a plan with your doctor to safely taper off your medications. If you or a loved one is currently taking opioid medications, stay on the lookout for signs of trouble.

    Signs of opioid abuse include:

    • Regularly taking more than the prescribed dose of medication

    • Taking pain medication "just in case," even when you're not in pain

    • Mood changes

    • Borrowing medication from other people, or using medication prescribed for someone else.

    • If taking opioids becomes the center of your life, tell your doctor how the medication is affecting you. Don't try to go off opioids cold turkey, on your own. That's a recipe for failure and puts you at risk of serious health consequences. If you've become dependent on opioids or prefer to stop using them, ask your doctor to help you taper off. There are many non opioid alternatives to help you manage your pain.