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Dr. Renata Trister DO

The thyroid gland is a butterfly-shaped endocrine gland that is located in the lower front of the neck. The thyroid gland is an important organ of the endocrine system. The thyroid’s job is to make thyroid hormones, which are secreted into the blood and then carried to every tissue in the body. Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working properly. The thyroid makes hormones that control the way every cell in the body uses energy. This process is called metabolism.

Hypothyroidism (underactive thyroid) is a condition in which your thyroid gland doesn’t produce enough of certain important hormones. An underactive thyroid is most common in women and patients over 50.


The major thyroid hormone secreted by the thyroid gland is thyroxine, also called T4 because it contains four iodine atoms. T4 is converted to triiodothyronine (T3) by the removal of an iodine atom. T3 is the active form of thyroid hormone. This occurs mainly in the liver and in the brain. The amount of T4 produced by the thyroid gland is controlled by another hormone, which is made in the pituitary gland located at the base of the brain, called thyroid-stimulating hormone (abbreviated TSH). The amount of TSH that the pituitary sends into the blood stream depends on the amount of T4 that the pituitary sees. If the pituitary sees very little T4, then it produces more TSH to tell the thyroid gland to produce more T4. Once the T4 in the blood stream goes above a certain level, the pituitary’s production of TSH is shut off. In fact, the thyroid and pituitary act in many ways like a heater and a thermostat. When the heater is off and it becomes cold, the thermostat reads the temperature and turns on the heater. When the heat rises to an appropriate level, the thermostat senses this and turns off the heater.

TSH and T4:

The best way to initially test thyroid function is to measure the TSH level in a blood sample. A high TSH level indicates that the thyroid gland is failing because of a problem that is directly affecting the thyroid (primary hypothyroidism). (Low TSH levels usually indicate that the person has an overactive thyroid that is producing too much thyroid hormone.) Occasionally, a low TSH may result from an abnormality in the pituitary gland, which prevents it from making enough TSH to stimulate the thyroid (secondary hypothyroidism).

T4 circulates in the blood in two forms: 1) T4 bound to proteins that prevent the T4 from entering the various tissues that need thyroid hormone and 2) free T4, which does enter the various target tissues to exert its effects. The free T4 fraction is the most important to determine how the thyroid is functioning, and tests to measure this are called the Free T4 (FT4) and the Free T4 Index (FT4I or FTI). Individuals who have hyperthyroidism will have an elevated FT4 or FTI, whereas patients with hypothyroidism will have a low level of FT4 or FTI. Combining the TSH test with the FT4 or FTI accurately determines how the thyroid gland is functioning. The finding of an elevated TSH and low FT4 or FTI indicates primary hypothyroidism due to disease in the thyroid gland. A low TSH and low FT4 or FTI indicates hypothyroidism due to a problem involving the pituitary gland. A low TSH with an elevated FT4 or FTI is found in individuals who have hyperthyroidism.

The most common cause of hypothyroidism is thyroiditis. Swelling and inflammation damage the thyroid gland’s cells.

Thyroiditis is caused by:

The immune system attacking the thyroid gland

Viral infections (common cold) or other respiratory infections

Pregnancy (often called postpartum thyroiditis)

Other causes of hypothyroidism include:

Certain medicines, such as lithium and amiodarone

Congenital (birth) defects

Radiation treatments to the neck or brain to treat different cancers

Radioactive iodine used to treat an overactive thyroid gland

Surgical removal of part or all of the thyroid gland



Increased sensitivity to cold temperature

Fatigue or feeling slowed down

Heavier and irregular menstrual periods

Joint or muscle pain

Paleness or dry skin

Sadness or depression

Thin, brittle hair or fingernails


Weight gain

If untreated:

Decreased taste and smell


Puffy face, hands, and feet

Slow speech

Thickening of the skin

Thinning of eyebrows


Treatment is aimed at replacing the thyroid hormone that you are lacking.

Levothyroxine (also called Synthroid) is the most commonly used medication:

You will be prescribed the lowest dose possible that relieves your symptoms and brings your blood hormone levels back to normal.

Most people with an underactive thyroid will need to take this medicine for life.

When starting your medicine, your dosage may need adjustment and your hormone levels may need to be monitored for 2 to 3 months. Once your hormone levels stabilize, your thyroid hormone levels will be monitored at least once every year.

When you are taking thyroid medicine, be aware of the following:

Do not stop taking the medicine when you feel better. Continue taking it exactly as your doctor prescribed.

If you change brands of thyroid medicine, let your doctor know. Your levels may need to be checked.

Thyroid medicine works best on an empty stomach and when taken 1 hour before any other medications.

Wait at least 4 hours after taking thyroid hormone before you take fiber supplements, calcium, iron, multivitamins, aluminum hydroxide antacids, colestipol, or medicines that bind bile acids.

While you are taking thyroid replacement therapy, tell your doctor if you have any symptoms that suggest your dose is too high, such as:


Rapid weight loss

Restlessness or shakiness



Making dietary changes can be very helpful to your overall health and in addressing hypothyroidism. Many people with hypothyroidism experience crippling fatigue and brain fog, which prompts reaching for non-nutritional forms of energy like sugar and caffeine.

1. Decrease Sugars: Greatly reduce or eliminate caffeine and sugar, including refined carbohydrates like flour, which the body treats like sugar. Reduce grain-based carbohydrates and focus on eating non-starchy vegetables.

2. Add Healthy Proteins: Proteins include nuts and nut butters; quinoa; hormone- and antibiotic-free animal products (organic, grass-fed meats, eggs, and sustainably-farmed fish); and legumes.

3. Good fats: Fat is your friend and cholesterol is the precursor to hormonal pathways; if you’re getting insufficient fat and cholesterol, you could be exacerbating hormonal imbalance, which includes thyroid hormones. Natural, healthful fats include olive oil; ghee; avocados; flax seeds; fish; nuts and nut butters; hormone- and antibiotic-free full fat cheese, yogurt, and cottage cheese (yes, full fat, not skim); and coconut milk products.

3. Nutrients: While nutritional deficiencies may not be the cause of hypothyroidism, not having enough of these micronutrients and minerals can aggravate symptoms: vitamin D, iron, omega-3 fatty acids, selenium, zinc, copper, vitamin A, the B vitamins, and iodine.

It’s commonly believed that hypothyroidism is due to insufficient iodine, but this is not always true true.  Rather than supplements, primary sources of iodine include sea vegetables and seafood. Secondary sources: eggs, asparagus, lima beans, mushrooms, spinach, sesame seeds, summer squash, Swiss chard, and garlic.

Omega-3s, found in fish, grass-fed animal products, flaxseeds, and walnuts, are the building blocks for hormones that control immune function and cell growth, are critical to thyroid function, and improve the ability to respond to thyroid hormones.

4. Address underlying food sensitivities. Just like the body’s attack on the thyroid in the presence of Hashimoto’s thyroditis, the body will also see offending or inflammatory foods as an invader and can induce or exacerbate the autoimmune response. There is much association with gluten sensitivity and various autoimmune disorders. Eating gluten can increase the autoimmune attack on your thyroid. Trying a gluten free diet may be helpful.

5. Do a gut check. A whopping 20 percent of thyroid function depends on a sufficient supply of healthy gut bacteria, so it’s best to supplement with probiotics (friendly intestinal bacteria).

6. Address silent inflammation with whole foods nutrition. Systemic inflammation and autoimmunity often go hand-in-hand.

7. Look at your stressors and practice relaxation. The thyroid is a very sensitive gland and is exceptionally reactive to the stress response.


In most cases, thyroid hormone levels  and symptoms will return to normal with proper treatment. You will likely take a thyroid hormone medicine for the rest of your life.



Hormone Replacement Therapy

Also called: ERT, Estrogen replacement therapy, HRT, Menopausal hormone therapy 

 Renata Trister DO

Menopause is a normal life event that usually occurs between ages 40 and 55. It is defined as 12 months without a menstrual period. Surgical removal of the uterus and ovaries, chemotherapy or other medical interventions and/or trauma can lead to early menopause (younger than 40).

Each woman will experience menopause in her own unique way. Some women may not experience any symptoms at all. For many women, however, the most common symptoms are hot flashes, night sweats, and vaginal dryness. The most effective treatment for these symptoms is hormone replacement therapy (HRT), although other treatments are also available.

HRT commonly refers to two different options:

     If you have a uterus, you may be prescribed combination estrogen plus progestin therapy (EPT). The progestin is added to protect your uterus from cancer that can occur when estrogen is used alone. If you are prescribed a low‐dose vaginal estrogen for treatment of vaginal dryness, you probably will not be prescribed a progestin.

     If you do not have a uterus, you will need only one hormone, estrogen (ET). There are many HRT options available by prescription from your doctor:

     A pill taken by mouth  a patch, cream, gel, or spray that can be applied to your skin  a cream, suppository, tablet, or ring that can be used within the vagina.

Many doses are available to meet your needs. Each of these options has different pros and cons that you can discuss with your healthcare provider.

Bioidentical hormones, which are similar to the hormones naturally made by the ovaries, are available in well‐tested, government‐approved products that can be prescribed by your doctor. Bioidentical hormones are a good option for many women.

In 2002, a large study called the Women’s Health Initiative (WHI) reported an increased risk of breast cancer, heart disease, stroke, and blood clots with the use of HRT. In the ten years since the reporting of those results, we have learned that the type of HRT (Estrogen versus estrogen-progestin therapy), how it is taken, and the timing of starting this treatment (early versus late after menopause) produce different benefits and side effects. The risk of side effects (such as heart attack, stroke, blood clot, or breast cancer) with HRT in healthy women ages 50 to 59 is low. In contrast, using HRT for a long time or starting HRT when you are a number of years beyond menopause is associated with a higher risk of these side effects.

Evaluating the benefits and risks of HRT for you personally is an important discussion for you to have with your physician. Treatment options should be tailored to your needs and your concerns.

HRT remains the most effective treatment available for menopausal symptoms, including hot flashes and night sweats that can interrupt sleep and impair quality of life. Many women can use these therapies safely.

Having a history of blood clots, heart disease, stroke, or breast cancer, make HRT risky, and is only used in special situations.

     The length of time is different for EPT (estrogen-progestin) and ET(estrogen only). For EPT, the time is limited by the increased risk of breast cancer that is seen with more than 3 to 5 years of use. For ET, no sign of an increased risk of breast cancer was seen during an average of 7 years of treatment, a finding that allows more choice in how long you choose to use ET.

     Healthy women under age 60, do not increase risk of heart disease with HRT. The risks of stroke and blood clots in the lungs do increase, averaging to 1 in every 1000 women per year.

     ET delivered through the skin (by patch, cream, gel, or spray) and low‐dose oral estrogen may have lower risks of blood clots and stroke than standard doses of oral estrogen, but all the evidence is not yet available. Research will continue to bring valuable information to help women with their decision about HRT.




Gut Dysfunction and Chronic Disease: “4R GI Restoration Program”

Summary Article Review.

Renata Trister DO

Gastrointestinal (GI) symptoms are one of the leading causes for visits to the primary care physician and the emergency room.  Over 70 million Americans are suffering from some form of serious GI disorder.  Assessment and proper support of the gastrointestinal (GI) system may provide benefit for patients with a variety of chronic ailments.   There is an association between impaired GI function and some chronic conditions, such as gastritis, peptic ulcers, colon cancer, inflammatory bowel disease, irritable bowel syndrome, rheumatoid arthritis, asthma, eczema, metabolic bone disease, allergies, nutrient malabsorption, and esophageal reflux (GERD). Many factors are associated with impaired GI function including food allergies, excessive stress, and the use of non-steroidal anti-inflammatory (NSAIDS) drugs and corticosteroids.  Fortunately, the constant renewal of intestinal cells provides a great opportunity for healing.

Recent work has been compiled in order to define a systematic approach for the support and optimization GI function. Based on the concepts of Remove, Replace, Reinoculate, and Regenerate, the 4R GI Restoration Program promotes overall GI health by removing unhealthy bacteria from the intestinal tract and allergenic foods from the diet, replacing supportive stomach acids and digestive enzymes, reinoculating the intestine with healthy bacteria (probiotics), and regenerating the intestinal lining with targeted nutritional support.

GI Restoration and the 4R Program

Remove focuses on eliminating harmful bacteria, viruses, fungi, parasites, and other environmentally derived toxic substances from the GI tract. An oligoantigenic or “elimination” diet is important to this step of the 4R GI Restoration Program, since foods to which a patient is intolerant or allergic can worsen GI dysfunction and stimulate negative immune and inflammatory responses.

It is important to keep in mind that even a healthy GI tract may permit pathogens, food proteins and environmental toxins to reach the circulation system. Therefore, removal of offending substances and microorganisms is a critical component in GI restoration.

Replace refers to the replacement of enzymes and other digestive factors lacking or in limited supply in an individual’s GI environment. These include digestive enzymes, such as pepsin, proteases, lipases, and saccharidases, as well as hydrochloric acid (HCl) and intrinsic factor.

HCl is particularly important to consider, especially in individuals older than 60, since inadequate levels (hypochlorhydria) are often associated with GI dysfunction. HCl is necessary for proper digestion, nutrient absorption, and the breakdown of protein for further digestion in the small intestine. HCl has been shown to effectively kill harmful organisms in the GI tract—which results in the decreased likelihood and severity of certain bacterial and parasitic intestinal infections.

Nutritional deficiencies can also impact GI function, protection, and health. Extensive evidence suggests a strong association between Helicobactor pylori infection and vitamin C deficiency. H. pylori is a bacteria that can cause peptic ulcers and stomach inflammation (chronic gastritis). Since vitamin C may help eradicate H. pylori, this deficiency, when coupled with poor intake of vitamin C, may increase both the colonization of H. pylori and the threat to the GI tract. In addition, zinc deficiency is known to worsen inflammatory bowel disease, delay GI restoration, and cause a variety of functional problems, including interruption of protein synthesis and reduced cell-mediated immunity.

Reinoculate refers to the reintroduction of desirable bacteria (or probiotics) into the intestine to restore the balance of the GI tract. Probiotics are “friendly” bacteria that serve a variety of functions in the GI tract.  For example, they prevent colonization by harmful bacteria and help break down toxins. Lactobacillus acidophilus and Bifidobacterium lactis are examples of probiotics.

Prebiotics may also be useful in supporting a healthy bacterial balance. Prebiotics are non-digestible food ingredients that selectively stimulate the growth of friendly bacteria without supporting pathogenic flora. Some prebiotics include fructooligosaccharides, soluble rice fibers, some soy fibers, and arabinogalactans.

Regenerate refers to providing support for the healing and growth of the GI mucosa. Part of the support for healing comes from promoting healthy microflora and removing impediments that continually re-injure or irritate the mucosa. In addition, appropriate nutritional support is crucial to overall health and responsible for reversing GI dysfunction and eliminating the chronic diseases associated with it. Important nutrients for support of GI regeneration include vitamins C and E and the carotenoids, for their antioxidant effects, and zinc and vitamin B5 (pantothenic acid), due to their roles in supporting the healing mechanisms. In addition, the following dietary factors are particularly helpful for the healing and regeneration of the GI tract.

Plantain Fruits The mucus coating in the GI system is important in protecting the body from microbes such as H. pylori and other ulcer causing substances (NSAIDS, alcohol) Plantains contain botanical phytonutrients that support the upper GI mucus layer.  Plantains contain lectins and flavonoids, which promote mucus thickening and protect the gastric layer from damage by exogenous agents. For these reasons plantains can be used therapeutically.

Phosphatidylcholine Recent studies show that consumption of phosphatidylcholine (lecithin) with potential ulcer-causing substances like aspirin or bile salts protects the gastric layer from damage and promotes healing.

L-Glutamine The amino acid glutamine is considered a preferred fuel for the rapidly replicating cells of the GI mucosa. Glutamine may promote production of glutathione (an important antioxidant) in the GI cells, which supports healing and provides additional protection from free radical damage during inflammation. Dietary glutamine is important for maintenance of GI mucosa during stress, injury, inflammation, and sepsis—a serious, severe illness caused by infection of the bloodstream. Furthermore, glutamine deficiencies are often associated with degenerative changes in the small intestine following intestinal injury, infection, surgery, or radiation.

Lactoferrin and Lactoperoxidase These proteins are found in milk and other secretions and play important roles in the intestinal immune system. They have have antimicrobial and antiviral properties, stimulate the immune system, and promote healing of the GI tract.

Arabinogalactans are non-starch polysaccharides found in many vegetables and grains. They are considered a fiber, but also have prebiotic functions that promote healthy intestinal bacteria, and can support the immune system.

Summary of the 4R GI Restoration program:

1. Remove any of the factors that may be causing GI dysfunction. Pathogens include “bad” bacteria, viruses, fungi and parasites.  Identify and remove foods to which the individual is sensitive.

Clinical approaches may include:

Elimination diet

Botanical antimicrobials and phytonutrients

1. Replace digestive enzymes and restore normal pH of the stomach.

2. Reinoculate with “good” bacteria or probiotics along with prebiotics.

3. Regenerate by providing nutritional support for healing and growth of normal GI mucosaMicronutrients especially important for GI support include

Vitamin C, Vitamin E and carotenoids for their antioxidant abilities

Zinc and Vitamin B5 for their roles in healing.

The key to successful regeneration is providing the nutrients necessary for the mucosal epithelial cells to proliferate.  A diet that is high in nutritional value and low antigenicity provides a basis for the regeneration of the GI tract.


Androgen Deficiency of Aging Male (ADAM) and Hormone Replacement

Dr. Renata Trister DO

Male hypogonadism, or testosterone deficiency syndrome (TDS), results from a failure of the testes to produce adequate androgen. Patients have low circulating testosterone in combination with clinical symptoms such as fatigue, erectile dysfunction and body composition changes. The cause may be primary (primary testicular failure due to genetic anomaly, infection, chemotherapy/radiation) or secondary (defect in hypothalamus or pituitary), but often presents with the same symptomatology. In the older patient, androgen deficiency of the aging male (ADAM) is an important cause of secondary hypogonadism because testosterone levels decline progressively after age 40. Hypogonadal patients have alterations not only in sexual function and body composition, but also in cognition and metabolism. Regardless of the cause, hypogonadal patients who are both symptomatic and who have clinically significant alterations in laboratory values are candidates for treatment. The goal of hormone replacement therapy in these men is to restore hormone levels to the normal range and to alleviate symptoms suggestive of hormone deficiency. This can be accomplished in a variety of ways, although most commonly testosterone replacement therapy (TRT) is employed.

Androgen deficiency of the aging male (ADAM) is a cause of secondary hypogonadism that often goes unrecognized. This phenomenon of hypogonadism due to aging has also been described as testosterone deficiency syndrome, late-onset hypogonadism, and andropause. Symptoms of this condition resemble those of ‘normal’ aging and include changing body composition (osteopenia, increased adiposity, decreased muscle mass), decline in energy and stamina, decreased cognitive function, decreased libido, and erectile dysfunction. On a metabolic level, men with lower androgen levels have demonstrated higher glucose and insulin levels, higher rates of obesity, and an increased incidence of type 2 diabetes. Several studies have shown a significant improvement in insulin sensitivity in diabetic men treated with supplemental testosterone. Studies have also suggested a link between hypogonadism and cardiovascular disease, which is not surprising given the relationship with hypogonadism and  metabolic syndrome. Testosterone levels in men begin to decline in the late third or early fourth decade and diminish at a constant rate thereafter.

Validated questionnaires have been developed to assess symptoms associated with androgen deficiency, such as the ADAM questionnaire and the Aging Male Survey.

Androgen Deficiency of the Aging Male (ADAM) Questionnaire. The ADAM questionnaire is considered positive if the patient answers ‘yes’ to questions 1 and 7, as well as two to four of the other items [Morley et al. 2000].

1.Do you have a decrease in libido or sex drive?

2.Do you have a lack of energy?

3.Do you have a decrease in strength and/or endurance?

4.Have you lost weight?

5.Have you noticed a decreased ‘enjoyment of life’?

6.Are you sad and/or grumpy?

7.Are your erections less strong?

8.Have you noticed a recent deterioration in your ability to play sports?

9.Are you falling asleep after dinner?

10.Has there been a recent deterioration in your work performance?

Many positive responses in the questionnaire may be indicative of other conditions such as depression. It is therefore important to combine the results of these questionnaires and laboratory measurements of androgen levels and other clinical symptoms to formulate a diagnosis of hypogonadism.

Once the diagnosis is established, several methods of testosterone replacement treatment (TRT) are available. The goal of hormone replacement therapy in hypogonadal men is to restore hormone levels to the normal range of young adult males and to alleviate symptoms suggestive of hormone deficiency. Restoration of normal testosterone levels with replacement therapy can improve muscle mass, prevent osteoporosis, maintain mental acuity, and restore libido, especially in elderly males. While these benefits of TRT in hypogonadal men are well described, not all hypogonadal patients receive only testosterone as a means of hormone replacement. In general, treatment is either in the form of direct androgen replacement with testosterone therapy, or in the form of replacement of pituitary gonadotropins to stimulate endogenous androgen production. Treatment of hypogonadism needs to be tailored to the underlying cause. Since most men over the age of 50 have declining levels of testosterone (a so-called ‘relative hypogonadism’), such men should only be considered candidates for hormone therapy if they have clinical manifestations of ADAM in addition to low testosterone.

TRT modality

Dosing regimen

Intramuscular injection Testosterone enanthate/cypionate: every 2-3 weeks
Transdermal gels/patches Androderm: 5mg/day
Testoderm: 40cm2 scrotal patch (1 patch/day)
Gels (Testim/Androgel): 5–10mg/day
Subcutaneous pellets Testopel: 75mg pellets; 6–12 pellets (450–900mg) Q3–6 months




Gastrointestinal Physiology

By Jon Trister, MD

Gastrointestinal Physiology.
It is important to understand GI function.

Neurological consideration.
Glossopharyngeal nerve (Cranial nerve IX): mixed, sensory and motor nerve.
Sensory function:Oropharynx,Eustachian tube,Middle ear,Posterior third of the tongue,Carotid sinus, Carotid body, Taste to posterior third of the tongue, Supplies parasympathetic fibers to the parotid gland via otic ganglion,contribute to the pharyngeal plexus.
Motor function: Stylopharyngeus muscle.

Vagus nerve (Cranial nerve X):
a)Parasympathetic control of the heart, lungs, gastrointestinal tract.
b)Sympathetic control of the peripheral chemoreceptors.
Dorsal nucleus of the vagus nerve:Parasympathetic output to the intestines;
Nucleus ambiguus:Parasympathetic output to the heart;
Solitary nucleus:Receives afferent taste information and afferent info from visceral organs.
Spinal trigeminal nucleus:afferent impulses arising from the outer ear, the dura of the posterior cranial fossa and mucosa of the larynx.

Accessory nerve ( Cranial nerve XI):Originates in the C1-C2 segments): Innervates sternocleidomastoid and trapezius muscles.
It enters the scull via foramen magnum, travels along the inner wall toward jugular foramen and leave the scull again fia Jugular foramen together with IX and X nerves.

Cranial nerves IX-X-XI provide neurological regulation of the gastrointestinal function.
They pass through jugular foramen which has very complex anatomy.JUgular foramen is formed by the anterolateral part of the temporal bone and posteromedial part of the occipital bone.
Its subdivided into larger posterolateral compartment ( pars venosa) containing the jugular bulb and tenth and eleventh cranial nerves and a smaller anteromedial compartment ( pars nervosa) containing the ninth cranial nerve.These two parts are usually separated by a fibrous bridge connecting the jugular spine of the petrous temporal bone to the jugular process of the occipital bone.This bridge could be osseos or fibrous.
Size of the right jugular foramen is usually larger than the left.
Dura over the jugular foramen had a two perforations forming a glossopharyngeal meatus through ninth nerve passed to enter the pars nervosa and vagal meatus through which vagus and accessory nerves entered the anteromedial part of the pars venosa and jugular bulb.The glossopharyngeal and vagal meati consistently separated by a dural septum.(Albert Rhoton etc, J.Neurosurgery/Volume 42/May 1975).

This complex anatomical entity is a subject to somatic dysfunction as the result of trauma, congenital abnormalities, tumors,dural strains, inter- and intraosseous strains of the temporal and occipital bones.
Those pathologies may alter anatomical relationship of the structures occupying the jugular foramen and subsequently to their physiological dysfunction.

Digestion begins with imaginary stimulation: thinking , seeing and smelling food send signals to the brain via afferent nerves. In the brain processing of information is occurs and efferent pathway-parasympathetic- glossopharyngeal nerve is activated to stimulate salivary glands to produce saliva rich in digestive enzymes-amylase ( initial breakdown of carbohydrates) and lipase (initial breakdown of triglycerides).
Glossopharyngeal nerve ( IX)
[originates in upper medulla, passes through the Jugular foramina]: Stimulate salivary glands.
Vagus (X) [Originate in medulla oblongata and passes through the Jugular foramina] Control digestive tract from the esophagus to the mid-colon.
Accessory nerve (XI) [Originate at the junction of medulla oblongata and spinal cord and passes via jugular foramen with IX and X nerves]
1.Mastication stimulates production of the saliva by oral salivary glands (IX).Mastication stimulates gastric secretion of Pepsin and water (X). 
Stomach:Distention of the esophagus stimulates the oral salivary glands.Distention of the gastric fundus stimulates secretion of the Pepsin,HCL, Intrinsic Factor and water.
Distention of the antrum stimulates Gastrin secretion. In addition, the cells lining the stomach secrete a thick mucus coating that protects the stomach from acid and pepsin.
Distention of the duodenum stimulates secretion of the Pepsin, HCL, Intrinsic Factor and water. Pepsin is active in acidic environment. Pepsin is very specific in digestive capability: it break down only [protein linkages containing certain amino acids : tryptophan , tyrosine, Methionine and leucine.
The presence of food stimulates the vigorous contraction of the muscles of the stomach wall, mixing of the food particles with digestive juices and push semi digested food into duodenum.
Antral drainage inhibit secretion of the  Pepsin, HCL, Intrinsic Factor and water

Gastrin amplifies antral production of the HCL, Intrinsic Factor, Pepsinogen and water
Gastrin amplifies duodenal secretion of Cholecystokinin
Gastrin is produced by G cells of antrum, in the duodenum, small intestine and pancreas.
HCL inhibit production of Gastrin.HCL stimulates secretion of Secretin by duodenum
Duodenum very complex process and regulated by nervous system and hormones:
Gastrin stimulate the formation of the Cholecystokinin.Lipids in the jejunum stimulate secretion of the Cholecystokinin.Carbohydrates and HCL in duodenal bulb stimulate secretion of the Cholecystokinin.Cholecystokinin induce gallbladder contraction and opening of the hepato-pancreatic ampulla.
Cholecystokinin stimulates production of the Insulin, HCO3, Glucagon in the pancreas
Cholecystokinin inhibit antral secretions and bulbar acidity.Secretin reduce HCL production and stimulate HCO3 production by pancreas which protect duodenal bulb from acid.Secretin stimulate Insulin release and inhibit Glucagon release.Duodenum also secretes mucus for protection from destructive effect of HCL.
Hypertonic Glucose solutions, Acidity in the bulb, Lipids in the jejunum limit the formation of the HCL and diminish gastric motility.If Lipids, proteins and carbohydrates evacuated at the same time disturbing of digestive function might occurs.
Enterokinase in duodenum convert into Trypsin and inhibit Action of the biliary salts.Biliary salts (weak concentration) stimulate Lipase secretion and inhibit (strong concentration) Lipase secretion. 
Gastrin Stimulates: HCL and Water secretion by stomach; secretion of Pepsin, Secretion of Intrinsic Factor, Secretion of Cholecystokinin in the duodenum.
HCL: Inhibits secretion of Gastrin; Stimulates secretion of Secretin; Stimulates production of pepsin from pepsinogen.Anti-bacterial function; Converts Ferric iron to Ferrous iron(absorbable)
Cholecystokinin: Stimulates action of biliary salts, Contraction of Gallbladder, dilatation of choledocho-pancreatic ampula,inhibit gastrin and HCL production; stimulates HCO3, insulin and glucagon release
Secretin: Inhibit HCL, Glucagon, stimulate Insulin release ,stimulates HCO3 production by Pancreas

Endocrine function:
Alpha cells produce and secrete Glucagon, which pancreas release in response to low blood sugar in the serum.Glucagon stimulates breakdown of glycogen ( liver and muscles) to glucose , which is released into bloodstream to serve as a source of cellular energy.
Beta cells secrete insulin in response to high glucose level in the serum.Insulin ( among other functions) drive glucose into muscles and liver to store in the form of glycogen.
Delta cells produce and secrete somatostatin , a complex hormone that is also produced by intestinal lining cells as well as certain neurons in the brain.In the pancreas somatostatin can inhibit release of insulin and glucagon (!?!) to help maintain blood sugar level in a very narrow range.

Exocrine function:
The cells of exocrine pancreas arranged in acini- special clusters along the network of channels forming pancreatic duct-to secrete pancreatic enzymes.
Proteolytic enzymes:Trypsin, Chymotrypsin, Carboxypeptidase A, Carboxypeptidase B,Elastase, Amynopetodases, Dipeptidases, Tripeptidases,Pepsin.

Each of these enzymes has precise and specific function.
Trypsin will break down a protein only at amino acid linkages containing either arginine or lysine.
Chymotripsyn will break down a protein at amino acid linkages containing tryptophan,phenylalanine, tyrosine.
DIpeptidase will break down a protein consisting two amino acids
Tripeptidase will break down a protein consisting three amino acids
All of these enzymes are produced in in-active forms to prevent self-destruction:
Trypsinogen, Chymotripsynogen,Procarboxypeptidase,Prodipeptidases,Protripeptidases
The acing cells also secrete multiple lipases and amylases.
The acinar cells store the inactive precursors in little sacs, or vacuoles, in the cytoplasm, until they are needed for digestion.As ling as these pre-enzymes remain in their inactive form, they pose no threat to the pancreas themselfs.
The body has a remarkable mechanism for signaling the acinar cells of the pancreas to begin manufacturing and secreting stored precursor enzymes.
First, the presence of the food in the mouth and in the stomach stimulate vagal nerve to release its neurotransmitter-Acetylcholine which stimulate release of pre-enzymes into the common space of cul-de-sac.
The presence of food in duodenum stimulates lining cells of duodenum to secrete the hormone Cholecystokinin into bloodstream. This hormone like vagus nerve stimulates the acinar cells to produce and release stored enzymes into duct of Wirsung and than empty pre-enzymes into the duodenum via Vater papilla.
The cells lining the small intestine produce proteolytic enzyme calle enteropeptidase, whose function is specifically to cleave off the six-amino-acid tail of trypsinogen, leaving the active and very powerful trypsin.
Trypsin activates other proteolytic enzymes making them active, to digest protein-cascade reactions.
This semiliquid food boluses that make their way from the stomach to intestine are extremely acidic, from stomach HCL.But Trypsin and Chemotrypsin can perform their digestive function only in an alkaline environment.To solve this problem, lining cells of small intestine sense the load of incoming food, they release another hormone, Secretin into the bloodstream.Secretin stimulate pancreas to produce NaHCO3, powerful antacid quickly neutralizes acid produced earlier by stomach.Now, the activated Enzymes have an ideal environment in which to begin digestive work.


Clinical, biomechanical and pathological correlation in Orthopaedic Medicine

Physicians practicing Orthopaedic Medicine must be able to utilize different clinical findings for identification of the pathological processes.

Restriction of the ROM, pain, changes in the texture of the structures, autonomic manifestations ( sweating, temperature, color changes, etc) will indicate the involvement of different structures in the pathological process. All of these processes indicate disruption of Bio-tensegrity.

I will present several examples:


Entrapment of the sciatic nerve may occur at various areas along its course and may be difficult to differentiate from a herniated disc.Detailed history and examination may give a clue  to the source of the problem.In most cases, sciatica develops at the area of pelvic musculo-tendinous junction.
Piriformis syndrome is an example of the above.
The sciatic nerve may have a high division and may pass through the Piriformis muscle.
In such cases compression of the nerve by surrounding musculature may give rise to neuropathy.
The following muscles can contribute to the symptoms of “Sciatica”
Attachments:Sacrum & greater trochanter.Function: lateral rotation.Innervation : L5-S1S2
Quadratus femoris.Attachments: Ischial tuberosity & intertrochanteric crest
Function: lateral rotation
Innervation:L4-L5-sacral plexus
Gemelli inferior.
Attachments: Ischial tuberosity &
Obturator interns tendon.Function:lateral rotation.Innervation:L4-L5
Gemelli superior.
Attachments: Ischium spine & Obturator interns tendon
Function: lateral  rotation
Obturator internus.
Attachments: Ischiopubic ramus & Greater trochanter.Function: Lateral rotation
Inneravation: L5-S1-S2
All of the above muscles go into contractual state as the result of ligamental instability of the pelvic ligaments: the most important include: sacro-iliac , sacro-tuberous, ilio-lumbar  ligaments, as well as the posterior ligamentous and tendinous structures of the hip.
Clinical symptoms of muscular involvement/ compensation will be pain, restricted mobility and external rotation of the leg.
Ligamental relaxation develop as the result of various etiologies including: trauma, overuse, metabolic /infectious processes resulting in muscle contractures. (Clinical manifestation of the ligamental laxity and examination pearls described in details in G.Hackett Prolotherapy text).
This lead to compression of the neighboring  neuro-vascular structures by the muscles and tendons: initially only capillary network, leading to chronic ischemia of the corresponding nerves and later to compression of the nerves with symptoms of neuropathy.
Fascial distortion leads to fascial shifts and mechanical injury of the cutaneous nerves and neurogenic inflammation.Contractures of surrounding musculature are secondary to ligamental laxity of the joint leading to a decrease in range of motion of the corresponding joints, which are “aiding” in its stability.
The major concept of Prolotherapy and Orthopaedic medicine is stabilization of the joints via restoration of the ligaments. This will lead to restoration of muscle, blood flow, & nerve decompression thereby restoring its function.In the case of sciatica the targets of Prolotherapy will be Ilio-lumbar, sacroiliac, sacro-tuberous, sacro-ischial ligaments and posterior hip capsule.
Osteopathic manipulative therapy may facilitate normal anatomical realignment .
Peri-neural subcutaneous injection of the D5W (Neuroprolo) will help to reduce neurogenic inflammation and restore fascial distortion.Acupuncture will also assist in regulation of the viscera-somatic aspects of ligamental laxity.Similar principle will be applicable in the other anatomical areas:
Lateral elbow pain:
Laxity of the annular radial ligament and resulting increase in superior translation of the radius  will lead to compensatory spasms and contractures of the proximal forearm muscle; the most important-supinator.
These will lead to compression of the posterior interosseous nerve at the Arcade of Frohse.
Thoracic outlet syndrome in some cases is a manifestation of ligamental laxity. It occurs as a result of abnormal  muscle tone, postural changes, and compression of the neurovascular structures.
These examples indicates the importance of the  meticulous clinical examination and imaging studies for confirmation of the possible pathological processes.
Orthopaedic medicine is a life long affair. Please, be persistent and patient.

Jon Trister MD


Cholesterol Conundrum

By Renata Trister, DO

Most people who are even a little bit concerned about their cholesterol know that there is a“good/Healthy cholesterol” – known as HDL, and a “bad/Lousy cholesterol”  – known as LDL. Although, research shows that the higher the amount of HDL and the lower the amount of LDL in the blood, the less likely a person is to suffer a heart attack or stroke, the “causal” relationship between cholesterol and these illness has not been determined.  Roughly one in six Americans with “unhealthy” cholesterol levels. In the past 15 years, prescriptions of cholesterol lowering medications has soared.  In 2011, 260 million prescriptions were dispensed in US alone.


Scientific opinions differ on cholesterol issues, and there is contrary evidence to theories. Two major clinical trials in the past three years have greatly complicated the picture. The first study, from 2008, shows that lowering LDL levels does not always decrease the risk of having a heart attack. Similarly, results from the second study, show that raising HDL levels does not always translate into fewer heart attacks or strokes. These perplexing findings do not mean that people should stop taking their cholesterol medications. The results have, however, underscored the danger of indulging in a common logical shortcut – assuming that artificially producing normal test results in a patient is the same as conferring good health on that patient. For one thing, drugs typically do not mimic normal conditions perfectly. For another, heart attacks and strokes occur after a complex series of processes that may take years to unfold. Simply altering one of these processes does not necessarily fix the whole problem.

Understanding Cholesterol Testing and its Functions.

Cholesterol is a crucial building material in the body. It helps maintain the structure of cells and vessels, improving overall health and function in the body.


About 80% of cholesterol is produced in the body. Liver, brain and other cells produce cholesterol. About 20% of cholesterol comes from food.

The cholesterol screening test that is usually performed is a blood test called a lipid profile. Results of a lipid profile will come in the forms of numbers. The values of LDL, HDL, trigycerides and total cholesterol are measured.

There is no such thing as “bad cholesterol”.

HDL and LDL are actually proteins that carry cholesterol. Cholesterol can’t dissolve in the blood (like oil and water). It has to be transported to and from the cells by carriers called lipoproteins – HDL, LDL.  These carriers have different and crucial functions, they are not “good” or “bad”. Low-density lipoprotein, or LDL carries cholesterol made in the liver to other tissues.  The liver synthesizes cholesterol based on need. High-density lipoprotein, or HDL carries cholesterol from peripheral tissue back to the liver.

The following is a few vital functions of cholesterol:

–        Cholesterol is a precursor to important sex hormones like testosterone, estrogen, androgen and progesterone. It is also a precursor to corticosteroids, hormones whose primary function is to protect the body against stress and disease.


–        Used as an insulator around nerves, cholesterol is absolutely essential for brain function.


–        Bile salts are made from cholesterol, adequate cholesterol is needed for proper digestion.


–        Cholesterol is a precursor to vitamin D, an important nutrient which supports a healthy immune and nervous system, reproduction, insulin production and the metabolism of minerals.


–        Serotonin receptors in the brain require cholesterol in order to function properly. Serotonin is an important neurotransmitter, low levels of serotonin are linked to depression.




Triglycerides make up about 95% of your body’s fat and are the chemical form in which most body fats exist. The fat produced from triglycerides is used for energy production, provides your body’s organs with insulation, and is a central component in the structure of cell membranes.  Unused triglycerides are transferred to fat cells for storage.  When energy is needed, hormones can cause the release of the stored fats.  Excess triglycerides increase the risk of stroke, heart attacks, fatty liver, pancreatitis and obesity.


Since triglycerides are part of a serum lipid blood test, and lipids are fats circulating in the blood, most people assume high fat diets increase triglycerides.  They are surprised to learn sugars, refined grains, and fruit sugars cause elevated triglycerides.


High blood sugar levels lead to high triglycerides levels. Sugars and refined grains stimulate insulin production.  Insulin stimulates the liver to produce triglycerides. Triglycerides in the blood are not made from dietary fats but made in the liver from excess sugar, which has not been used for energy.  Eating more calories than your body can use for energy contributes to higher triglycerides.


Vascular Damage  

The LDL cholesterol is made in response to damage and stress. When blood vessels are damaged, LDL-carried cholesterol “patches up” the arterial lining with a buildup of fatty material, or atherosclerotic plaque. Much of the time the plaque stabilizes without creating too many immediate problems, but sometimes it bursts, triggering blood clots that lead to heart attacks and strokes if the clots prevent blood from delivering critical oxygen to heart or brain tissue. Without oxygen, the affected tissue dies.

People with high LDL levels may form arterial plaques that are more likely to burst. Some people develop extremely high LDL levels because of a genetic disease called familial hypercholesterolemia that severely limits their ability to clear cholesterol from their blood. They suffer heart attacks in their thirties or forties, which is several decades earlier than the average for the general population. On the positive side, those who maintain normal cholesterol levels (LDL less than 100 milligrams per deciliter of blood and HDL cholesterol levels greater than 40 mg/dL) throughout their life without medication are much less likely to suffer heart attacks or strokes.

A Shortcut ?

With all this evidence linking heart disease to cholesterol levels, it is no wonder that researchers in general and pharmaceutical companies in particular reached a fairly straightforward conclusion: anything – such as a medication – that reduces LDL levels and raises HDL levels must also reduce heart disease risk. By the 1980s the drug industry began marketing a whole family of cholesterol-lowering drugs called the statins, which work by blocking a liver enzyme that is essential for forming cholesterol. Clinical studies proved that statins do in fact reduce the number of heart attacks in people with high cholesterol.  Might statins provide benefits unrelated to cholesterol reduction? There is some evidence that they also decrease inflammation. (When inflammation occurs in the arteries, it is thought to increase the risk of heart disease.) A 2008 study called the JUPITER trial tested statins in about 18,000 people with normal LDLs but elevated C-reactive protein, a measure of inflammation. Statins reduced the risks of heart attack and stroke. That led proponents to conclude that by working through an additional mechanism—lowering inflammation, not just LDL—statins were helping even people with normal LDL levels. Cholesterol lowering drugs also have anti-inflammatory properties Inflammation is strongly suspected of contributing to atherosclerosis.

To some extent, as long as the statins were working, few people worried too much about why they were helping. But statins are not for everyone. Some people cannot tolerate the drugs’ multiple side effects, including muscle pain and, more rarely, liver damage. Others cannot lower their LDL levels enough simply by taking a statin. In addition, at least one in five people whose LDL levels are well controlled by their medications still experience heart attacks or strokes.

Food and Lifestyle:


Elevated blood cholesterol may be a response to stress and injury (damage repair, cell formation, hormones production…). Trans fats, refined sugars, artificial sweeteners, industrial meats, genetically modified foods can cause total and LDL cholesterol rise because they stress and injure tissues. Therefore, diet and lifestyle changes can be very beneficial.

Weight loss. Even a modest amount of weight loss can lower cholesterol levels.

Reduce the amount of sugar and flour in your diet. Recent evidence indicates that added sugar – in the form of table sugar (sucrose) or high-fructose corn syrup – is probably a greater contributor to heart disease than is consumption of saturated fat. This suggests that the inflammatory hypothesis may in fact have more validity than the conventional lipid hypothesis, although the debate is far from settled. As a general rule, avoid processed sugars, particularly soft drinks and highly processed snack foods, which can cause rapid spikes and dips in blood sugar levels. The result can be overeating, obesity and heart disease.

Avoid trans-fatty acids.

These heart-damaging fats can reduce HDL (“good”) cholesterol levels and raise levels of LDL (“bad”) cholesterol. The tip-off that trans-fatty acids are present in foods is the listing of “partially hydrogenated oil” on a food’s ingredient list. Trans-fats are found in many brands of margarine and in most heavily processed foods, as well as in snack foods such as chips, crackers and cookies, and in the oils used to cook fast-food French fries, doughnuts and movie popcorn.

Decrease toxic load by eating fresh organic foods when possible.

Exercise. Daily aerobic exercise can help increase HDL levels.

Don’t smoke. Smoking itself is a risk factor for heart disease. It can also significantly lower HDL cholesterol.

Stress. Emotional stress may prompt the body to release fat into the bloodstream, raising cholesterol levels.