SECOND OPINION | Mystery Diagnosis III | BCBS | Full Episode


>>Announcer: “SECOND OPINION IS BROUGHT TO
YOU BY BLUE CROSS/BLUE SHIELD. ACCEPTED IN ALL 50 STATES. BLUE CROSS/BLUE SHIELD — LIVE FEARLESS.>>Announcer: “SECOND OPINION” IS PRODUCED
IN CONJUNCTION WITH UR MEDICINE, PART OF UNIVERSITY OF ROCHESTER MEDICAL CENTER, ROCHESTER, NEW
YORK.>>Dr. Peter Salgo: THIS IS “SECOND OPINION”
AND I’M YOUR HOST, DR. PETER SALGO. THIS WEEK, “MYTH OR MEDICINE?”, DO MORE TESTS
MEAN A BETTER CHANCE OF GETTING A CORRECT DIAGNOSIS?>>Dr. Lisa Harris: TESTS ARE USED BY PHYSICIANS
TO HELP GUARANTEE WHAT WE THINK THE DIAGNOSIS IS.>>Dr. Peter Salgo: AND SPECIAL GUEST LARRY
LUITJENS IS HERE. WE’RE GOING TO PUT OUR “SECOND OPINION” DOCTORS
ON THE SPOT TO SEE IF THEY CAN FIGURE OUT HIS DIAGNOSIS.>>Larry Luitjens: ALL OF A SUDDEN, LOOKED
AT THE RESULTS AND I SEE HIM TAKE OFF AND POOF! JUST LIKE THAT, THERE WERE FOUR NURSES AND
A DOCTOR AROUND ME, HOVERING AROUND ME, STICKING NEEDLES IN ME, AND I HEARD HER SAY “DO YOU
HAVE ANYBODY YOU WANT TO CALL?”>>Dr. Peter Salgo: THANK YOU SO MUCH FOR
COMING, LARRY. IT’S NICE TO MEET YOU. NICE TO DISCUSS YOUR STORY WITH YOU. YOU AND I HAD A LITTLE CHAT BEFORE WE STARTED
AND I WANT TO GET RIGHT TO WORK. I WANT TO INTRODUCE TO YOU THE TWO VICTIMS
— I MEAN THE DOCTORS — WHO ARE GOING TO TRY AND FIGURE OUT WHAT ON EARTH YOU HAD WRONG
WITH YOU. IT’S OUR “MYSTERY DIAGNOSIS” SHOW.I WANT YOU
TO MEET DR. LOU PAPA AND DR. RALPH JOZEFOWICZ, BOTH OF THEM FROM THE UNIVERSITY
OF ROCHESTER MEDICAL CENTER. ALL RIGHT, LARRY. LET’S GO BACK TO THE YEAR 2002. THINGS STARTED TO GO A BIT AWRY. WHAT HAPPENED IN 2002?>>Larry Luitjens: IN 2002. WELL, FIRST — I CAN TELL YOU WHAT HAPPENED?>>Dr. Peter Salgo: YEAH, PLEASE, TELL ME
WHAT HAPPENED IN 2002.>>Larry Luitjens: I DON’T WANT TO GIVE THEM
ANY HINTS, YOU KNOW.>>Dr. Peter Salgo: WELL, THEY GOT TO HAVE
SOMETHING TO GO ON. YOU KNOW, THIS GUY’S PLAYING THE GAME REALLY
WELL.>>Dr. Lou Papa: [LAUGHS] SCARING ME.>>Larry Luitjens: IN 2002, I WAS DIAGNOSED
WITH PROSTATE CANCER.>>Dr. Peter Salgo: OKAY, AND YOU WERE TREATED? HOW WERE YOU TREATED?>>Larry Luitjens: TOMOTHERAPY, RADIATION.>>Dr. Peter Salgo: OKAY. AND THEN, 2003, WHAT HAPPENED?>>Larry Luitjens: I LIVE IN THE BEAUTIFUL
BLACK HILLS OF SOUTH DAKOTA AND I WAS ON MY WAY TO SYLVAN LAKE ON MY BICYCLE AND I GOT
PICKED OFF FROM BEHIND BY A RECREATIONAL VEHICLE.>>Dr. Peter Salgo: AND YOU HAD A SERIOUS
INJURY. WHAT HAPPENED?>>Larry Luitjens: WELL, I HAD DOUBLE CONCUSSION. I CRACKED MY HELMET. GOOD THING I HAD IT ON. AND 8 MULTIPLE BROKEN
RIBS, A PUNCTURED SCAPULA, DISLOCATED SHOULDER, AND A FEW SCRATCHES HERE AND THERE.>>Dr. Peter Salgo: OKAY, AND, WHERE YOU COME
FROM, THAT’S JUST A MINOR INJURY IN A DAY’S WORK?>>Larry Luitjens: JUST A NORMAL DAY IN THE
HILLS.>>Dr. Peter Salgo: LET’S MOVE FORWARD, NOW,
TO 2004. THEN WHAT HAPPENED?>>Larry Luitjens: 2004, I GOT THE RASH AND
I WENT TO SEE A DERMATOLOGIST. AND SHE GAVE ME SOME CREAM TO RUB ON IT AND
TOLD ME TO COME BACK AND I DID AND, WHEN I CAME BACK, SHE SAID “I’LL MAKE YOU AN APPOINTMENT
WITH THERHEUMATOLOGIST.”>>Dr. Peter Salgo: OKAY. AND THE RHEUMATOLOGIST SAW YOU AND SAID…?>>Larry Luitjens: “YOU’VE GOT LUPUS AND SJOEGREN’S”
AND I DIDN’T KNOW WHAT EITHER ONE OF THEM WAS.>>Dr. Peter Salgo: WHAT IS LUPUS? WHAT IS SJOEGREN’S SYNDROME?>>Dr. Lou Papa: WELL, LUPUS AND SJOEGREN’S
ARE BOTH AUTOIMMUNE CONDITIONS. THEY’RE A LITTLE BIT DIFFERENT.>>Dr. Peter Salgo: YOU BECOME IMMUNE TO YOURSELF.>>Dr. Lou Papa: RIGHT, YOUR BODY ATTACKS
YOU AND LUPUS CAN ATTACK A NUMBER OF DIFFERENT SYSTEMS. SJOEGREN’S, THE SAME TYPE OF THING, BUT I’M
TRYING TO FIGURE OUT THAT LEAP THAT OCCURRED.>>Dr. Peter Salgo: OKAY, ANYTHING TICKLING
YOUR BRAIN STEM, AT THIS POINT, OR ARE YOU JUST SITTING THERE, COLLECTING DATA?>>Dr. Ralph Jozefowicz: WELL, BOTH LUPUS
AND SJOEGREN’S CAN BE ASSOCIATED WITH NERVOUS SYSTEM DISEASE, BOTH CENTRAL AND PERIPHERAL
NERVOUS SYSTEM DISEASE, BUT I NEED TO HEAR MORE OF THE STORY TO FIGURE THINGS OUT. BUT ALSO, WHERE WAS THE RASH?>>Larry Luitjens: IT WAS ON THE ARMS.>>Dr. Ralph Jozefowicz: ANYTHING ON THE FACE?>>Larry Luitjens: NOTHING ON THE FACE, NOTHING
AT ALL.>>Dr. Peter Salgo: IS HE THE 8 MILLIONTH
PERSON TO ASK YOU ABOUT WHETHER YOU HAD THE CLASSIC RASH ON YOUR FACE?>>Larry Luitjens: YES, HE IS.>>Dr. Peter Salgo: PEOPLE WITH LUPUS GET
A BUTTERFLY-SHAPED RASH, WHICH YOU DID NOT HAVE.>>Larry Luitjens: NO, NO.>>Dr. Peter Salgo: THAT BEING SAID, THEY
PUT YOU ON GABAPENTIN AND LYRICA FOR THE LUPUS AND ALWAYS GOING THE WAY IT WAS GOING, UNTIL
LAST FALL. THEN WHAT HAPPENED LAST FALL?>>Larry Luitjens: WELL, EVERY TIME SOMETHING
HAPPENED TO ME, WHETHER I GOT A HEADACHE OR AN INGROWN TOENAIL, NO MATTER WHAT IT WAS,
I IMMEDIATELY SAID “IT’S LUPUS.”>>Dr. Peter Salgo: WERE YOU TAKING ANY MEDICATION
ON YOUR OWN, THAT THE DOCTOR DIDN’T PRESCRIBE, ANY SUPPLEMENTS, ANYTHING?>>Larry Luitjens: OH, YEAH, THEY TOLD ME
THAT I COULDN’T BE CURED FROM LUPUS, SO, WHENEVER I WOULD GET ON THE INTERNET AND THEY WOULD
SAY “BUY THIS. THIS WILL HELP WITH LUPUS” OR WHATEVER, AUTOIMMUNE,
SO, YEAH, I TOOK QUITE A FEW SUPPLEMENTS.>>Dr. Peter Salgo: ALL RIGHT, BUT NOW, WE’RE
ALMOST RIGHT HERE, ALMOST TO THE PRESENT DAY. AND WHAT HAPPENED, THAT CHANGED, THAT GOT
DIFFERENT AND YOU TALKED TO YOUR DOCTOR ABOUT IT?>>Larry Luitjens: WELL, REALLY, THE PAIN
IS PROBABLY THE THING. I WAS AT A BASKETBALL GAME.>>Dr. Peter Salgo: YOU’RE A COACH.>>Larry Luitjens: I’M A COACH, RETIRED HIGH
SCHOOL BASKETBALL COACH. AND WE WERE PLAYING THE TOURNAMENTS AT THE
END OF THE YEAR AND MY GENERAL PRACTITIONER, MY DOCTOR, WALKED BY AND I SAID “DR. JOY” — EVERYBODY, 2,000 PEOPLE IN MY HOMETOWN,
EVERYBODY CALLS HER “DR. JOY”. THEY DON’T CALL HER “DR. FALKENBERG”, THEY CALL HER “DR. JOY”. I SAID “DR. JOY, YOU GOT A MINUTE?” SHE HAD 30. SHE SAT DOWN AND WE VISITED AND SHE SAID “WHY
DON’T YOU COME AND SEE ME SOMETIME?”SHE SAYS “I THINK THAT THERE’S MORE THAN LUPUS. I THINK THAT SOMETHING ELSE IS CAUSING YOUR
PAIN.”>>Dr. Peter Salgo: NOW, FOR THESE GUYS, DESCRIBE
THE PAIN. SUCCINCTLY, BUT TELL THEM WHERE THE PAIN WAS,
WHAT WAS IT LIKE.>>Larry Luitjen: MAINLY IN THE FEET AND LEGS. IT WOULD, YOU KNOW, RANGE FROM KIND OF LIKE
2 ALL THE TIME UP TO THERE’D BE DAYS IT’D BE 9, 10, IT WOULD BE BAD. I WOULDN’T WANT TO DO ANYTHING.>>Dr. Peter Salgo: SO WAS IT ABOVE YOUR KNEE,
BELOW YOUR KNEE, ALL THE WAY AROUND THE LEG?>>Larry Luitjens: MAINLY KNEE ON DOWN. SOMETIMES IN THE THIGHS, BUT MAINLY KNEE ON
DOWN.>>Dr. Peter Salgo: SYMMETRICALLY, BOTH LEGS?>>Larry Luitjens: YES.>>Dr. Peter Salgo: NOW WHAT ARE YOU THINKING?>>Dr. Ralph Jozefowicz: SOUNDS LIKE A PERIPHERAL
NEUROPATHY WOULD BE ONE OF THE THINGS.>>Dr. Peter Salgo: A PERIPHERAL NEUROPATHY
IS “PROBLEMS WITH THE NERVES DOWN AWAY FROM THE CENTER OF THE BODY.”>>Dr. Ralph Jozefowicz: IT’S BASICALLY THE
NERVOUS SYSTEM CONSISTS OF THE CENTRAL AND THE PERIPHERAL NERVOUS SYSTEM. THE CENTRAL NERVOUS SYSTEM IS THE BRAIN AND
THE SPINAL CORD AND THE PERIPHERAL NERVOUS SYSTEM IS ESSENTIALLY ALL THE NERVES THAT
COME OUT OF THE BRAIN STEM AND THE SPINAL CORD AND THESE ARE THE ONES THAT PROVIDE INFORMATION
TO THE MUSCLES, THAT MOVE THE MUSCLES, AND ALSO CARRY INFORMATION FROM THE SKIN, INCLUDING
SENSATION, AND WHAT A PERIPHERAL NEUROPATHY IS, IT’S A DISEASE OF THESE PERIPHERAL NERVES.>>Dr. Peter Salgo: AH, BUT IS IT LUPUS?>>Dr. Ralph Jozefowicz: LUPUS CAN CAUSE NEUROPATHY,
BUT THERE’S PROBABLY 50-PLUS DIFFERENT THINGS THAT CAUSE NEUROPATHY.>>Dr. Peter Salgo: SO, IN ANOTHER WORDS,
JUST PUTTING THIS IN THE BUCKET OF LUPUS IS A MISTAKE, AT THIS POINT? WHICH YOUR DOCTOR DIDN’T MAKE. SHE WAS ASTUTE AND SHE SAID “OH, IT DOESN’T
SOUND LIKE LUPUS,” RIGHT?>>Larry Luitjens: THAT’S WHAT SHE TOLD ME,
YEAH.>>Dr. Peter Salgo: SO, THEN, SHE SAID, AS
I RECALL, “HOW IS YOUR WALKING?” AND YOU SAID “IT ISN’T THE PAIN,” IT’S…WHAT?>>Larry Luitjens: WELL, I JUST SAID I WAS
WALKING LESS. I HAD BEEN WALKING 4 MILES A DAY AND, ALL
OF A SUDDEN, I WAS DOWN TO WHERE I WOULD ONLY MAYBE BE ABLE TO MAKE ONE MILE AND I WOULD
GET TIRED.>>Dr. Peter Salgo: I UNDERSTAND YOU COULDN’T
MAKE IT TO THE MAILBOX. YOU WERE HAVING TROUBLE. WHY COULDN’T YOU MAKE IT?>>Larry Luitjens: WELL, IT WAS KIND OF UPHILL
WHEN I HAD TO GO BACK TO THE HOUSE.>>Dr. Peter Salgo: WAS IT THE PAIN OR WAS
IT YOUR BREATHING?>>Larry Luitjens: BREATHING.>>Dr. Peter Salgo: YOU COULDN’T BREATHE?>>Larry Luitjens: I DIDN’T BREATHE WELL AT
ALL.>>Dr. Peter Salgo: THAT GETS YOUR ATTENTION,
IF YOU’RE A DOCTOR. SO WHAT DID SHE DO? SHE DO SOME BLOOD TESTS?>>Larry Luitjens: SHE DID SOME BLOOD TESTS.>>Dr. Peter Salgo: AND SHE SENT YOU FOR A
CARDIOGRAM?>>Larry Luitjens: YES.>>Dr. Peter Salgo: AND DESCRIBE WHAT HAPPENED
WHILE YOU WERE GETTING THE CARDIOGRAM.>>Larry Luitjens: WELL, YOU KNOW, IT WAS
KIND OF FASCINATING. THE GAL GIVING ME THE CARDIOGRAM WAS SHOWING
ME EVERYTHING ON THE COMPUTER AND TRYING TO TELL ME WHAT IT WAS AND I, OF COURSE, HAD
NO IDEA WHAT SHE WAS TALKING ABOUT, BUT SHE SAID SOMETHING ABOUT “HAVE YOU HAD AN EKG
LATELY?” AND I DON’T KNOW.>>Dr. Peter Salgo: YOU MEAN AN ECHOCARDIOGRAM?>>Larry Luitjens: ECHO.>>Dr. Peter Salgo: SO THERE ARE TWO KINDS
OF CARDIOGRAMS. ONE LOOKS AT THE ELECTRICAL ACTIVITY IN YOUR
HEART AND, WHILE SHE WAS DOING THAT, SHE SAID “HAVE YOU HAD AN ECHOCARDIOGRAM” –>>Dr. Ralph Jozefowicz: AN ULTRASOUND OF
YOUR HEART.>>Dr. Peter Salgo: A PICTURE OF YOUR HEART. AND YOU SAID NO.>>Larry Luitjens: “I DON’T THINK SO.”>>Dr. Peter Salgo: AND SHE SAID GO GET ONE?>>Larry Luitjens: SHE SAID “IF I COULD” — THIS
IS A SMALL COMMUNITY. SHE SAID “IF I COULD GET ONE LINED UP RIGHT
NOW, WOULD YOU DO IT?” WELL, OF COURSE, YOU KNOW, I DON’T HAVE ANYTHING
TO DO, ANYWAY.>>Dr. Peter Salgo: [LAUGHS] SO YOU GOT ONE?>>Larry Luitjens: I GOT ONE.>>Dr. Peter Salgo: AND WHAT HAPPENED WHILE
YOU WERE GETTING THE ECHO?>>Larry Luitjens: WELL, THE PEOPLE THAT WERE
TESTING ME ALL OF A SUDDEN LOOKED AT THE RESULTS AND I SEE THEM TAKE OFF AND POOF! JUST LIKE THAT, THERE WERE FOUR NURSES AND
A DOCTOR AROUND ME, HOVERING AROUND ME, STICKING NEEDLES IN ME, AND I HEARD HER SAY “DO YOU
HAVE ANYBODY YOU WANT TO CALL?”>>Dr. Peter Salgo: THAT’S NEVER GOOD.>>Larry Luitjens: BOY, THAT DIDN’T SOUND
GOOD AT ALL.>>Dr. Peter Salgo: AND THEN YOU SAID “WHY?” AND THEY SAID ‘CAUSE YOUR HEART RATE WAS…>>Larry Luitjens: 24.>>Dr. Lou Papa: 24?>>Dr. Peter Salgo: DID YOU SEE THE EYEBROWS
GO UP OVER THERE?>>Larry Luitjens: YEAH, I DID.>>Dr. Lou Papa: THAT WOULD MAKE YOU SHORT
OF BREATH, YEAH.>>Dr. Peter Salgo: WE’RE GOING TO PAUSE IN
A MINUTE. BUT NOW, YOU’VE GOT A GENTLEMAN WITH A HEART
RATE OF 24, SHORTNESS OF BREATH, CAN’T GET TO THE MAILBOX, STOCKING-GLOVE DISTRIBUTION. YOU KNOW THIS DIAGNOSIS. IT’S…?>>Dr. Lou Papa: [LAUGHS] INTERESTING.>>Dr. Peter Salgo: ANY IDEAS GOING THROUGH
YOUR MIND HERE?>>Dr. Ralph Jozefowicz: WELL, THERE ARE AUTONOMIC
NERVES THAT, BASICALLY, THEY’RE ALSO PERIPHERAL NERVES, BUT THEY GO TO THE HEART AND TO THE
LUNGS AND TO THE INTESTINES AND THEY’RE INVOLVED IN COORDINATING A LOT OF THESE MAINTENANCE
FUNCTIONS OF THE BODY AND THEY’RE ALSO AFFECTED IN A PERIPHERAL NEUROPATHY, SO YOU COULD HAVE
NEUROPATHIES THAT, YOU KNOW, CAUSE BLOOD PRESSURE PROBLEMS, CAUSE IMPOTENCE, COULD CAUSE PROBLEMS
WITH HEART RHYTHM AND HEART RATE, AND IT’S SIMILAR NERVES THAT ALSO CARRY SENSATION FROM
THE FEET AND, IF THEY’RE INJURED, THEY CAUSE BURNING AND PAIN.>>Dr. Peter Salgo: NOW, WE KNOW THAT HIS
PRIMARY CARE PHYSICIAN DREW SOME BLOODWORK AND WE ALSO KNOW IT WASN’T BACK, SO WE CAN’T
GIVE YOU THE ANSWER ‘CAUSE SHE DIDN’T KNOW THE ANSWER. WHAT BLOODWORK WOULD YOU HAVE DRAWN?>>Dr. Lou Papa: ONE OF THE THINGS THAT WOULD
BE INTERESTING, ESPECIALLY WITH THE LOW HEART RATE AND THE NEUROPATHY, WE’D LOOK AT THYROID
FUNCTION, THAT’S AN IMPORTANT THING TO LOOK AT. IT’S INTERESTING, WITH THE NEUROPATHY, THERE’S
A COUPLE OF NUTRITIONAL ISSUES THAT CAN AFFECT YOUR JOINT FUNCTION. B12 DEFICIENCY CAN DO THAT, FOLATE DEFICIENCY,
AND I’D BE LOOKING AT THAT.>>Dr. Peter Salgo: ANY OTHER BLOOD TESTS? THEY’RE THINKING HARD, NOW. THERE’S SMOKE COMING OUT OF THEIR EARS.>>Dr. Lou Papa: THAT’D BE INTERESTING. I’D LIKE TO HAVE A LITTLE BIT MORE INFORMATION
BEFORE I START CASTING A BIG NET.>>Dr. Peter Salgo: THAT’S ALL YOU GOT. THAT’S ALL SHE HAD. SHE DID DRAW SOME OTHER BLOOD TESTS AND I
WILL TELL YOU WHAT THOSE BLOOD TESTS WERE WHEN WE GET BACK. STAY RIGHT HERE. WE’RE GOING TO BE RIGHT BACK TO HEAR YOUR
SECOND OPINION. BUT, FIRST, HERE’S THIS WEEK’S “MYTH OR MEDICINE”.>>Announcer: WHEN WE GO TO THE DOCTOR WITH
SYMPTOMS, WE, AS PATIENTS, HAVE COME TO EXPECT A BATTERY OF TESTS TO BE RUN TO FIND OUT WHAT
IS WRONG. DIAGNOSTIC TESTS ARE USED TO RULE IN OR RULE
OUT A DISEASE, SO…>>Dr. Lisa Harris: “MORE TESTS ARE LIKELY
TO LEAD TO A MORE ACCURATE DIAGNOSIS.” THAT IS A MYTH AND I AM GOING TO TELL YOU
WHY. I AM DR. LISA HARRIS, SENIOR VICE PRESIDENT OF MEDICAL
AFFAIRS, PHYSICIAN NETWORK; AND CHIEF MEDICAL OFFICER AND A PRACTICING PRIMARY CARE PHYSICIAN
AT OUR LADY OF LOURDES IN BINGHAMTON, NEW YORK. WE ACTUALLY MAKE A DIAGNOSIS BY TAKING A HISTORY,
PERFORMING A PHYSICAL EXAM, AND THEN DOING THE TESTS TO CONFIRM WHAT WE FOUND ON PHYSICAL
EXAMINATION, THEREFORE TESTS WON’T NECESSARILY LEAD TO AN ACCURATE DIAGNOSIS. IN FACT, IT CAN BE VERY CONFUSING. TESTS CAN BE INCORRECT, THEY MAY BE INACCURATE,
OR THEY JUST MIGHT NOT BE COMPLETE, SO WE MAY NOT KNOW EXACTLY WHAT WE’RE SEEING WHEN
WE GET A TEST RESULT. AND IT CAN CONFUSE THE PICTURE AND MUDDY THE
WATERS, SO WE’RE NOT SURE WHERE TO GO NEXT AND THAT WILL LEAD TO MORE TESTS AND MORE
TESTS AND NOT A SPECIFIC DIAGNOSIS. YOUR BEST BET IS TO — GIVE A GREAT HISTORY,
LET YOUR PHYSICIAN ASK SOME CLARIFYING QUESTIONS, DO A PHYSICAL EXAM TO GENERATE A DIFFERENTIAL
DIAGNOSIS, AND THEN, A FEW CONFIRMATORY TESTS TO SEAL YOUR ULTIMATE DIAGNOSIS. THERE REALLY ISN’T A TEST FOR EVERYTHING. I THINK A LOT OF PEOPLE THINK THAT THERE ARE
TESTS OR X-RAYS OR SOME SORT OF DIAGNOSTIC EXAMINATION FOR EVERYTHING THAT WE DO, BUT
TESTS ARE ACTUALLY VERY LIMITED AND, AGAIN, IT’S IMPORTANT TO REMEMBER THAT YOUR HISTORY
AND PHYSICAL EXAMINATION NARROW THE FIELD AND THE TEST IS JUST THERE TO CONFIRM OR RULE
OUT WHAT WE’RE SUSPECTING. AND THAT’S MEDICINE.>>Announcer: NOT SURE IF IT’S MYTH OR MEDICINE? CONNECT WITH US ONLINE, WE’LL GET TO WORK
AND GET YOU A SECOND OPINION.>>Dr. Peter Salgo: WE’RE BACK WITH LARRY. AGAIN, THANK YOU FOR SHARING YOUR STORY WITH
US AND CONFOUNDING OUR MEDICAL EXPERTS OVER HERE. IN SUM — YOU WERE AN ACTIVE GUY WITH LUPUS
WHO DEVELOPED WHAT LOOKS LIKE A PERIPHERAL NEUROPATHY, SOME NERVE ISSUES IN YOUR LEGS,
BUT THEN, YOU GOT SHORT OF BREATH, THEY GOT A CARDIOGRAM, ECHOCARDIOGRAM, YOUR HEART RATE
WAS, AS THEY SAY IN BOSTON, WICKED LOW, AND YOUR DOCTOR, EXCELLENT DOCTOR THAT SHE WAS,
DREW A WHOLE BUNCH OF BLOOD TESTS. AND, DURING THE BREAK, OUR IMMINENT EXPERTS
HAVE BEEN DEEP IN COLLOQUY. ANY OTHER BLOOD TESTS YOU’D LIKE?>>Dr. Ralph Jozefowicz: WELL, WE BOTH TALKED
ABOUT LYME DISEASE. I DON’T KNOW, IN THE BLACK HILLS, IF IT’S
ENDEMIC. I KNOW IT’S ENDEMIC ACROSS THE COUNTRY.>>Dr. Peter Salgo: SO YOU WANT A LYME TITER. ANYTHING ELSE?>>Dr. Ralph Jozefowicz: THYROID AND A VITAMIN
B12 ASSAY.>>Dr. Peter Salgo: IN THE MEANTIME – BECAUSE
THEY DREW A COUPLE MORE THAT ARE GOING TO BE CRITICAL — WHILE YOU’RE THINKING –>>Dr. Ralph Jozefowicz: ELECTROLYTES.>>Dr. Peter Salgo: ELECTROLYTES WERE FINE. WHILE THEY’RE THINKING, YOU’RE IN AN AMBULANCE. BECAUSE HIS HEART RATE’S 24.>>Dr. Lou Papa: SO CAN I ASK — ON THE HEART
RATE, DID THEY SAY IT WAS JUST BRADYCARDIA OR WAS THERE EVIDENCE OF HEART BLOCK?>>Dr. Peter Salgo: I CAN TELL YOU. I SAW THE CARDIOGRAM AND THERE’S A LONG PR
INTERVAL, A LONG QT INTERVAL, AND I CAN TELL YOU THAT HIS EJECTION FRACTION ON THE ECHO
— I CHEATED. I READ THIS –>>Larry Luitjens: THAT’S GOOD.>>Dr. Peter Salgo: WAS ABOUT 75%. IT’S NOT BAD. SO HIS HEART’S FUNCTIONING OKAY, IT’S BEATING
OKAY, BUT THERE IS SOME CONDUCTION PROBLEM WHICH IS SLOWING IT DOWN.>>Dr. Ralph Jozefowicz: WERE ANY OF THE SUPPLEMENTS
THAT HE WAS TAKING CONTAINING ANTICHOLINERGICS?>>Dr. Peter Salgo: WE DON’T KNOW. YOU DON’T KNOW WHAT WAS IN THOSE, DO YOU?>>Larry Luitjens: NO. HAVEN’T HEARD.>>Dr. Peter Salgo: BUT NOW THAT YOU’RE ON
THE SUBJECT OF SUPPLEMENTS, ANYTHING ELSE YOU WANT, ANY OTHER BLOOD TESTS?>>Dr. Lou Papa: ANY OTHER BLOOD TESTS OF
SUPPLEMENTS?>>Dr. Peter Salgo: AH, THEY’RE THINKING. OKAY. YOU GET TO THE HOSPITAL IN RAPID CITY. THEY PUT IN A PACEMAKER, OKAY?>>Larry Luitjens: YEP.>>Dr. Peter Salgo: FINE. ANY OTHER BLOOD TESTS YOU WANT?>>Dr. Ralph Jozefowicz: DIGITALIS LEVEL.>>Dr. Peter Salgo: HE WASN’T TAKING DIG AND
IT WASN’T IN HIS SUPPLEMENTS, BUT I CAN TELL YOU THAT THERE WERE SOME OTHER BLOOD TESTS
THAT THEY DREW AND I HAVE A LIST OF THEM. THE AUTOIMMUNE PANEL WAS REPEATED. FOLATE, THEY GOT. B12, HEAVY METALS, A METABOLIC PANEL, AND
THAT’S WHAT THEY DREW. OKAY.>>Dr. Lou Papa: AND I’M ASSUMING THAT WAS
ALL NORMAL.>>Dr. Ralph Jozefowicz: ZINC LEVEL.>>Dr. Peter Salgo: ASSUME NOTHING! SO YOU WANTED ZINC. ANYTHING ELSE?>>Dr. Ralph Jozefowicz: I’M TRYING TO THINK
WHAT BASICALLY SLOWS THE HEART AND CAUSES PERIPHERAL NEUROPATHY?>>Dr. Peter Salgo: YOU GOT THE BLOODWORK
DONE. YOU GOT THE PACEMAKER IN. AND I CAN TELL YOU
THEY DREW A BIG HEAVY-METAL PANEL. OKAY. AND, WHEN YOUR DOCTOR CAME TO YOU, WHAT ON
EARTH DID SHE TELL YOU?>>Larry Luitjens: I’M DIVORCED. SHE SAID “YOUR EX-WIFE ISN’T TRYING TO KILL
YOU, IS SHE?”>>Dr. Peter Salgo: STOP. WHAT DID THEY FIND?>>Dr. Ralph Jozefowicz: ARSENIC.>>Dr. Peter Salgo: ARSENIC!>>Dr. Lou Papa: INTERESTING.>>Dr. Peter Salgo: ISN’T THAT INTERESTING? THE QUESTION IS WHY?! YOU KNOW, I MEAN, ARSENIC IS FOUND EVERYWHERE,
IT’S A VERY COMMON ELEMENT. BUT, FOR SOMEONE TO HAVE A VERY HIGH ARSENIC
LEVEL — YOUR LEVEL WAS 75 AND, FOR THOSE OF US WHO DON’T KNOW THE NORMS, THAT WOULD
INCLUDE ME, WE LOOKED IT UP. 35 IS NORMAL, SO 75 IS MORE THAN TWICE NORMAL AND, WHEN
YOU ACTUALLY LOOK THAT UP, IT IS ASSOCIATED WITH CONDUCTION PROBLEMS IN THE HEART, AMONG
OTHER THINGS, PERIPHERAL NEUROPATHIES AS WELL. SO THE QUESTION IS WHERE DOES ARSENIC COME
FROM? YOU LIVE IN CUSTER. SO YOU DRINK BOTTLED WATER, YOU TOLD ME.>>Larry Luitjens: I DRINK BOTTLED WATER. I DON’T DRINK THE WATER, SO.>>Dr. Peter Salgo: OKAY, BUT COULD IT HAVE
BEEN IN THE SUPPLEMENTS? WHAT DO WE KNOW ABOUT WHAT’S IN SUPPLEMENTS?>>Dr. Lou Papa: WE KNOW NOTHING THAT’S IN
SUPPLEMENTS. THAT’S PART OF THE PROBLEM. SUPPLEMENTS ARE AN UNREGULATED FIELD, SO YOU
DON’T KNOW WHAT YOU’RE GETTING.>>Dr. Peter Salgo: AND, THAT BEING SAID,
WE KNOW THAT IT’S UNREGULATED. YOU WERE CHEWING ANYTHING THAT THE INTERNET
RECOMMENDED.>>Larry Luitjens: ANYTHING, ANYTHING.>>Dr. Lou Papa: OH, JEEZ.>>Dr. Peter Salgo: I ACTUALLY HEARD THAT
1/3 OF ALL THE SUPPLEMENTS DON’T EVEN CONTAIN WHAT THE LABEL SAYS THEY CONTAIN.>>Dr. Lou Papa: THAT’S CORRECT. EVEN WITHIN THE SAME COMPANY, EVEN THE SAME
COMPANY, NEXT TO ONE ANOTHER.>>Dr. Peter Salgo: SO THIS IS INTERESTING
BECAUSE, POSSIBLY — WE’LL NEVER KNOW, RIGHT? — THE SUPPLEMENTS HAD IN THEM HEAVY METAL,
ARSENIC. WHAT DOES ARSENIC DO, NEUROLOGICALLY? CAN IT ACCOUNT FOR HIS SYMPTOMS?>>Dr. Ralph Jozefowicz: ONE OF THE SIGNS
YOU SEE IS MEES’ LINES, IS BASICALLY ON THE NAILS, YOU COULD SEE A WHITE LINE ON THE NAILS. THE OTHER THING IT CAUSES IS PERIPHERAL NEUROPATHY
AND, DEFINITELY, THE HEAVY METALS THAT CAUSE PERIPHERAL NEUROPATHY ARE LEAD, ARSENIC, ZINC,
AND MERCURY, AND THOSE ARE THE ONESTHAT WE TYPICALLY SCREEN FOR, IF WE’RE CONCERNED ABOUT
HEAVY METAL. AND THERE’S TWO TYPES OF INTOXICATION. THERE COULD BE AN ACUTE INTOXICATION, SO,
IF YOU HAVE A MASSIVE OVERDOSE; OR CHRONIC, LOW-LEVEL INTOXICATION, SO, IN THIS CASE.>>Dr. Peter Salgo: NEITHER OF THEM IS VERY
GOOD.>>Dr. Ralph Jozefowicz: YEAH, NEITHER IS
VERY GOOD, BUT IT CAUSES A PERIPHERAL NEUROPATHY, WHICH BASICALLY MEANS IT WOULD CAUSE NUMBNESS,
BURNING, WEAKNESS, AS WELL AS IT COULD INVOLVE THE AUTONOMIC NERVES.>>Dr. Peter Salgo: SO THE NEXT QUESTION IS,
NOW THAT THEY’VE FOUND ARSENIC AND IT MIGHT ACCOUNT FOR YOUR SYMPTOMS, DID THEY DO ANYTHING
ABOUT IT? BECAUSE THERE ARE TREATMENTS FOR ARSENIC,
CALLED CHELATING AGENTS, WHICH CAN GRAB ARSENIC OUT OF YOUR BODY AND GET RID OF IT. DID THEY DO THAT FOR YOU?>>Larry Luitjens: NO, THEY DIDN’T.>>Dr. Peter Salgo: SO THEY DIDN’T DO CHELATION. INSTEAD, THEY JUST WATCHED? WITH THE PACEMAKER IN PLACE. BY THE WAY, AFTER THE PACEMAKER WENT IN, HOW
DID YOU FEEL?>>Larry Luitjens: OH, MY GOODNESS. I CAN’T TELL YOU HOW MUCH BETTER I FELT. I MEAN, I FELT REALLY, REALLY GOOD. I MEAN, I’M BACK OUT, WALKING AGAIN AND YOU
KNOW, I CAN BREATHE.>>Dr. Peter Salgo: AND WAS THAT RIGHT AWAY,
AFTER THE PACEMAKER WENT IN?>>Larry Luitjens: YEP.>>Dr. Peter Salgo: SO AT LEAST PART OF HIS
SYMPTOMS HERE WERE DUE TO THE LOW HEART RATE AND LOW CARDIAC OUTPUT. SO THEY DIDN’T GIVE YOU CHELATING THERAPY
AND THEY JUST LET IT GO AND I GUESS THE THEORY WAS, EVENTUALLY, IF YOU STOP TAKING ARSENIC,
THE BODY WILL CLEAR THE ARSENIC. WOULD YOU HAVE CHELATED?>>Dr. Ralph Jozefowicz: WELL, THERE’S TWO
TYPES OF TOXIC EXPOSURES. ONE IS WHEN YOU HAVE AN ACUTE EXPOSURE AND
THIS COULD CAUSE COMA, MASSIVE MEDICAL PROBLEMS, AND DEATH; OR THE SORT OF CHRONIC, LOW-LEVEL
EXPOSURE, THAT COULD LEAD TO THINGS LIKE NEUROPATHY AND THE HEART BLOCK, ET CETERA. NOW, THEY SOLVED THE HEART PROBLEM BY PUTTING
THE PACEMAKER IN AND YOU FELT BETTER IMMEDIATELY. THE NERVE PROBLEM, THE NEUROPATHY, NO MATTER
WHAT YOU DO, IT’S GOING TO TAKE A LONG WHILE FOR THAT TO GET BETTER. THE IMPORTANT THING IS TO STOP THE SUPPLEMENTS.>>Dr. Peter Salgo: SO, AGAIN, WITH FINGERPOINTING
HERE, THE SUPPLEMENTS. YOU CAN GET INDUSTRIAL EXPOSURE TO ARSENIC,
WHICH IS ONE OF THE MAJOR WAYS YOU GET IT. THERE ARE SOME METALWORKERS AND CONSTRUCTION
WORKERS AND PEOPLE LIKE THAT. OR YOU CAN GET IT FROM THE SOIL. YOU CAN GET IT IN DIFFERENT WAYS. OR WATER. BUT HERE, LOW-LEVEL. SO YOU WOULDN’T HAVE CHELATED, AS LONG AS
THAT PACEMAKER WAS IN?>>Dr. Ralph Jozefowicz: I ALWAYS LIKE TO
TREAT THE PATIENT AND, IF YOU’RE DOING WELL WITH THE PACEMAKER AND THE NEUROPATHY SOUNDED
LIKE IT WAS MAINLY PAINFUL, BUT YOU DIDN’T HAVE PARALYSIS FROM IT, THIS IS SOMETHING
THAT WILL GET BETTER WITH TIME, OVER MONTHS, IF YOU STOP THE SUPPLEMENTS.>>Dr. Peter Salgo: SO HIS DOC DID IT RIGHT.>>Dr. Ralph Jozefowicz: YEAH.>>Dr. Peter Salgo: NOW, LET’S TALK ABOUT
SUPPLEMENTS. HE WAS TAKING SUPPLEMENTS. ARE THERE ANY SUPPLEMENTS IT’S OKAY TO TAKE?>>Dr. Lou Papa: THE PROBLEM WITH THE SUPPLEMENTS
IS THAT THERE HASN’T BEEN ANY GOOD EVIDENCE THAT THEY DO ANYTHING BETTER THAN A PLACEBO
AND THERE’S SOME EVIDENCE COMING OUT THAT A LOT OF THEM DO HARM.>>Dr. Peter Salgo: ONE CASE IN EXAMPLE…>>Dr. Ralph Jozefowicz: RIGHT, AND THERE
IS HARM FROM TAKING TOO MANY VITAMINS AND TOO MANY SUPPLEMENTS. TOO MUCH VITAMIN A, VITAMIN D, CAUSES PROBLEMS. TOO MUCH VITAMIN B6, IN THE UNITED STATES,
CAUSED NEUROPATHY BECAUSE THERE WAS SOME IMPURITY IN THE SUPPLEMENTS FOR THE VITAMIN B6.>>Dr. Peter Salgo: AND I’LL ASK A DELIBERATELY
LOADED QUESTION, BUT — THE FDA IS LOOKING AT ALL THESE SUPPLEMENTS –>>Dr. Lou Papa: THEY’RE NOT!>>Dr. Peter Salgo: AREN’T THEY?>>Dr. Lou Papa: NO, THEY’RE NOT, AND THAT’S
THE PROBLEM. THEY FOUND A LOOPHOLE. THEY’RE NOT CONSIDERED PHARMACEUTICALS, THEY’RE
CONSIDERED FOOD ADDITIVES, SO, AS A RESULT, THEY’RE NOT BEING MONITORED, THEY’RE NOT TESTED
FOR ACCURACY, THEY’RE NOT EVEN TESTED FOR RELIABILITY FROM ONE TO THE OTHER. THESE ARE INDIVIDUALS THAT HAVE FOUND THE
INTERNET, HAVE FOUND PEOPLE WHO ARE INTERESTED IN FINDING SOMETHING OUT ABOUT THE DISEASE
THAT’S ABOVE AND BEYOND THE CONVENTIONAL, AND ARE VERY HAPPY TO SELL IT TO YOU.>>Dr. Peter Salgo: THE QUESTION I HAVE IS
THIS. IT COULD’VE BEEN FROM THE SUPPLEMENTS. YOU STOPPED TAKING THE SUPPLEMENTS, RIGHT?>>Larry Luitjens: YEP.>>Dr. Peter Salgo: AND I KNOW THAT YOUR LEVEL
OF ARSENIC — ‘CAUSE SHE TESTED. GOOD DOCTOR, BY THE WAY.>>Larry Luitjens: SHE IS VERY GOOD.>>Dr. Peter Salgo: HIS LEVEL WENT DOWN TO
ZERO. AND YOU’RE BETTER, THIS IS NOT PROOF POSITIVE
THAT IT WAS (a) THE SUPPLEMENTS OR NECESSARILY THE ARSENIC, BUT IT’S PRETTY STRONG EVIDENCE. DOES IT MATTER? AS LONG AS YOU DON’T TAKE ANY MORE SUPPLEMENTS
AND YOU DON’T KNOW WHICH ONE WAS THE BAD ACTOR. DOES IT MATTER IF WE KNOW WHICH SUPPLEMENT
IT WAS, AS LONG AS HE’S FEELING BETTER?>>Dr. Lou Papa: WELL, I THINK, FROM A PUBLIC
HEALTH PERSPECTIVE, IT SURE AS HELL MATTERS, YOU KNOW. THE SCARY THING IS SUPPLEMENTS ARE BAD ENOUGH,
IF YOU GO TO A LOCAL NUTRITIONAL STORE, BUT, IF YOU GET IT OFF THE INTERNET, THEY’RE EVEN
MORE OF THE WILD WEST, SO, YOU KNOW, THAT’S THE TYPE OF STUFF THAT, YOU KNOW, THE FDA
WANTS TO KNOW ABOUT, SO THEY CAN SEND A CEASE AND DESIST LETTER.>>Dr. Peter Salgo; BY THE WAY, WE LEFT A
LITTLE TIME HERE. THIS IS A MOMENT WHEN YOU CAN ASK THESE FOLKS
FOR THEIR OPINION OR ANY INFORMATION YOU WANT. THIS IS YOUR MOMENT FOR A SECOND OPINION. SO FIRE AWAY, IF YOU HAVE ANYTHING YOU’D LIKE
TO KNOW.>>Larry Luitjens: GO BACK TO LUPUS, YOU KNOW,
AND I’VE BEEN TOLD, YOU KNOW, THAT IT’S NOT CURABLE AND I DON’T BELIEVE THAT. I HAVE A PRETTY POSITIVE ATTITUDE AND I BELIEVE
THAT I’M GOING TO BE CURED, BUT I DO, I FEEL SO MUCH BETTER THAN I DID. IS THE LUPUS GETTING
BETTER?>>Dr. Lou Papa: LUPUS IS A WAXING AND WANING
DISEASE. IT’S A CHRONIC DISEASE. YOU DON’T GET CURED. SO THE ISSUE IS YOU CONTROL IT, THE SAME WAY
YOU WOULD CONTROL HYPERTENSION, YOU CONTROL OTHER CONDITIONS, SO IT IS A CONTROLLABLE
DISEASE. IT HAS A LOT OF MANIFESTATIONS. IT’S SEVERE IN SOME PEOPLE, IT CAN BE MORE
MILD IN OTHER PEOPLE, BUT IT WAXES AND WANES.>>Dr. Peter Salgo: SO, NO, BUT, AS LONG AS
YOU’RE FEELING BETTER, DO YOU CARE? IS THE REAL ISSUE. AND, BY THE WAY, YOU LOOK GREAT. AND I DO WANT OUR VIEWERS TO KNOW THAT YOU
JUST RETIRED AFTER COACHING BASKETBALL FOR 47 YEARS AND YOU HOLD THE RECORD FOR THE MOST
WINS FOR ANY BASKETBALL COACH IN SOUTH DAKOTA.>>Larry Luitjens: AND?>>Dr. Peter Salgo: AND?>>Larry Luitjens: THE RECORD FOR THE MOST
LOSSES.>>[ LAUGHTER ]>>Dr. Peter Salgo: AND I THINK THAT YOUR
MENTAL ATTITUDE IS EXACTLY WHY YOU COACHED SO WELL.>>Larry Luitjens: THANK YOU.>>Dr. Peter Salgo: IT WAS A PLEASURE MEETING
YOU. I’M DELIGHTED YOU’RE FEELING BETTER. SO THANK YOU SO MUCH FOR SHARING YOUR STORY
WITH US. AND, PANEL, THANK YOU FOR BEING GOOD SPORTS
AND HANGING IN THERE. THIS WAS AN INTERESTING CASE. AND I WANT TO THANK YOU FOR WATCHING US. I’D LIKE TO KNOW WHAT YOU THINK ABOUT TODAY’S
DISCUSSION AND LARRY’S SECOND OPINION, BY TWEETING US OR COMMENTING ON OUR FACEBOOK
PAGE. AND, NOW, FOR THE LAST WORD ON YOUR ROLE IN
GETTING A BETTER DIAGNOSIS, HERE’S THIS WEEK’S “SECOND OPINION 5.”>>Dr. Ingrid Watkins: HELLO. I’M DR. INGRID WATKINS AND I’M HERE TO SHARE WITH
YOU 5 THINGS YOU CAN DO TO HELP YOUR DOCTOR DIAGNOSE YOU THE FIRST THING YOU CAN DO IS BRING UP WHAT IS MOST CONCERNING TO YOU AT THE BEGINNING OF YOUR DOCTOR VISIT PATIENTS OFTEN BRING UP WHAT IS MOST IMPORTANT
TO THEM AT THE VERY END OF THEIR DOCTOR’S APPOINTMENT. IF THE DOCTOR DOESN’T KNOW, AT THE BEGINNING
OF THE VISIT, WHAT PROBLEM IS MOST CONCERNING TO YOU, YOUR DOCTOR WON’T HAVE TIME TO ADEQUATELY
ADDRESS THAT PROBLEM. THE NEXT THING IS TO MAKE SURE YOU ARE HONEST WITH THE DOCTOR. EVEN WHEN IT COMES TO SENSITIVE TOPICS, OUR
JOB IS NOT TO JUDGE OUR PATIENTS. SO IF YOU’RE HAVING HOME OR WORK STRESSORS,
EXPERIENCING ABUSE, DRINKING TOO MUCH, USING DRUGS, OR SMOKING, YOUR DOCTOR WANTS YOU TO
TELL THEM ABOUT IT, NOT SHY AWAY FROM IT. THIRDLY, IT IS VERY HELPFUL TO YOUR PHYSICIAN
IF YOU WRITE DOWN YOUR SYMPTOMS AND BE SPECIFIC ABOUT THEM YOUR DOCTOR NEEDS TO KNOW HOW LONG YOU’VE
HAD CERTAIN SYMPTOMS, WHAT MAKES THEM BETTER OR WORSE, AND THE NATURE AND INTENSITY OF
THE SYMPTOMS. YOU SHOULD ALSO HAVE WRITTEN DOWN YOUR PAST
MEDICAL HISTORY, INCLUDING PAST SURGERIES, FAMILY HISTORY, AND ALL YOUR MEDICATIONS AND
THE DOSAGES. YOU SHOULD BRING THIS INFORMATION WITH YOU
TO EACH DOCTOR THAT YOU SEE.WHEN YOU SEE YOUR PRIMARY CARE PHYSICIAN, BRING ALL YOUR MEDICATION
BOTTLES WITH YOU TO THE VISIT, EVEN YOUR OVER-THE-COUNTER AND HERBAL SUPPLEMENTS. LASTLY, KNOW WHAT TESTS YOU HAD PREVIOUSLY AND KNOW WHERE YOU HAD THEM DONE. MAKE SURE YOU GET A COPY OF THE RESULTS,
AND BRING THEM TO YOUR DOCTORS’ VISITS. HAVING A FOLDER OR A BINDER WITH ALL YOUR
MEDICAL INFORMATION, INCLUDING ANY LAB TESTS, X-RAYS, CT SCANS, OR MRI RESULTS IS VERY HELPFUL. AND THAT’S YOUR “SECOND OPINION 5.”>>Dr. Peter Salgo: THANK YOU SO MUCH FOR
WATCHING, AND REMEMBER, YOU CAN GET MORE SECOND OPINIONS AND PATIENT STORIES ON OUR WEBSITE. THAT’S SECONDOPINION-TV.ORG. YOU CAN SEND US YOUR SHOW IDEAS, SHARE YOUR
OWN STORY, AND MAYBE WE’LL INVITE YOU TO BE WITH US RIGHT HERE ON THE SHOW. YOU CAN CONTINUE THIS CONVERSATION ON FACEBOOK
AND TWITTER, WHERE WE ARE LIVE, EVERY DAY, WITH BREAKING HEALTH NEWS. I’M DR. PETER SALGO AND I’LL SEE YOU NEXT TIME FOR
ANOTHER “SECOND OPINION.”>>Announcer: “SECOND OPINION” IS BROUGHT
TO YOU BY BLUE CROSS/BLUE SHIELD, ACCEPTED IN ALL 50 STATES. BLUE CROSS/BLUE SHIELD — LIVE FEARLESS.>>Announcer: “SECOND OPINION” IS PRODUCED
IN CONJUNCTION WITH UR MEDICINE, PART OF UNIVERSITY OF ROCHESTER MEDICAL CENTER, ROCHESTER, NEW
YORK.

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