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Immune system. Brief review. By Jon Trister MD

The Immune System, brief review

 To defend as form invaders  body has two immune systems:

The first defense system is an innate immune system we are born with. This is a  first defense against any foreigners-microbes, viruses, funguses. This is antigen non-specific defense mechanisms which respond to invaders immediately or within several hours after exposure to every foreigner. Cells associated with innate immune system are Macrophages, Dendritic cells and  B-lymphocytes

 The second defense system is an adaptive immune system (acquired) immunity refers to antigen-specific defense and require  several days to become protective and are designed to react with and remove a specific antigen. Adaptive immunity is the immunity one develops throughout life. Cells associated with adaptive immune system are T- and B-Lymphocytes

One of the function of the innate  immune system is an APC ( antigen presentation cells)-is an identification, isolation  of the antigen-specific protein -epitope-actual portions or fragments of an antigen that react with receptors on B-lymphocytes and T-lymphocytes, as well as with free antibody molecules) and presentation it in the from of complex : MHC I/epitope  or MHC ii/epitope on the surface of the APC ( Macrophages, Dendritic cells, B-Lymphocytes).Epitope is a fragment of the antigen which will provide adaptive immune system a specific  information about invader ( antigen).Without ability to perform this function as an APC innate immune system will be unable to “educate” adaptive immune system about structure of the antigen.

Polysaccharides antigens( 3-4 sugar residuals)  usually have many epitopes but all of the same specificity.

Proteins antigens (5-15 amino acids )usually have many epitopes of different specificities.

Immune responses are directed against many different epitopes of many different antigens of the same microbe.

The body recognizes an antigen as foreign when epitopes of that antigen bind to B-lymphocytes and T-lymphocytes by means of epitope-specific receptor molecules having a shape complementary to that of the epitope.


                     MHC molecules

MHC-I molecules are made by all nucleated cells in the body

MHC-I presents epitopes to T8-lymphocytes; MHC-II presents epitopes to T4-lymphocytes.

MHC-I molecules are designed to enable the body to recognize infected cells and tumor cells and destroy them with cytotoxic T-lymphocytes or CTLs.

CTLs are effector defense cells derived from naïve T8-lymphocytes.

MHC-I molecules are made by all nucleated cells in the body; bind peptide epitopes typically from endogenous antigens; present MHC-I/peptide complexes to naive T8-lymphocytes and cytotoxic T-lymphocytes CTL.


MHC-II molecules are made by antigen-presenting cells or APCs, such as dendritic cells, macrophages, and B-lymphocytes; bind peptide epitopes typically from exogenous antigens; and present MHC-II/peptide complexes to naive T4-lymphocytes or effector T8-lymphocytes that have a complementary shaped T-cell receptor or TCR

Exogenous antigens enter antigen-presenting macrophages, dendritic cells, and B-lymphocytes through phagocytosis, and are engulfed and placed in a phagosome where protein antigens from the microbe are degraded by proteases into a series of peptides. These peptides are then attached to MHC-II molecules that are then put on the surface of the APC.


Cholesterol Conundrum

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.


Medical foods and supplements

Good health maintenance requires the right nourishment to feed the factories in the body’s billions of cells.  The food intake for the cells, tissues and organs often lacks some of the items needed for efficient cell function and energy output.  Brain cells require some different nutrients than the skin or liver, for example.  Prescription drugs are often used to compensate for abnormal cell or organ function or to suppress symptoms, but they may be inefficient and accompanied by more symptoms and side affects.

Medical foods and supplements furnish the missing ingredients for specific cell function and correction of the deficiencies and symptoms.  There are many supplements and natural ingredients that cannot be duplicated by pharmaceuticals and can correct many of the causes of disease and even prevent most viral infections altogether.

Inherited genetic defects are often related to the body’s inability to produce or utilize certain nutrients, vitamins or minerals.  Disease is inevitable in these conditions, unless the correction can be made by using the specific medical food or supplement.  We are able to see that the inherited condition is compensated for and when the gene expression is prevented, the disease condition is prevented.

Dr. Trister has had extensive training in this field and makes it a regular part of his practice. He completed his training at the Institute for Functional Medicine under direction of Doctor J. Bland


FAQ about Prolotherapy and PRP

Am I a candidate for Prolotherapy and PRP?

A: Many problems related to musculoskeletal conditions are can be successfully treated with Prolotherapy (Regenerative Injection Therapy):
1.Degenerative Joint Diseases (Osteoarthritis)-OA:all locations:
neck, TMJ, shoulders, scapulaes, clavicles, ribs, elbows, wrists, fingers, thoracic and lower back pain, “disc’s problems”, hips, knees, ankles, feet, toes.
2.Consequences of ligamentous, cartilagenous and tendinous injuries (with some limitations). Partial tears of tendons, muscles and ligaments can be successfully treated with combining various techniques :
Prolotherapy + PRP (Platelets Rich Plasma)
Prolotherapy + Mesenchymal stem cells + PRP
Prolotherapy + Neural prolotherapy.
3.Some form of arthritis may have infectious, allergic, autoimmune or metabolic causes. In such cases we will order special diagnostic tests to help patient in selection of appropriate treatment.
4.Patients with infected joints,non-healing wounds around joints,cancerous spread into the bones(metastasis,multiple myeloma, leukemias) ARE NOT A CANDIDATES FOR PROLOTHERPAY.
5.Elderly and debilitated patients may not respond well to prolotherapy.
6.Degree of joint damage (stage of the OA), age, weight, smoking status, nutritional status, use of certain medication (Steroids , NSAID) will negatively affect prognosis of the treatment.
6. Patients with illnesses related to medico-legal problems (Motor Vehicle and industrial Accidents) must have official pre-authorization from their insurances or Court order for treatment.
7. Other factors may play role too: anticoagulation therapy, anti-platelets therapy etc
During initial consultation we will perform detailed physical examination, review imaging tests, and available laboratory tests,will perform diagnostic musculoskeletal ultrasound in the office .
This will help us select right strategy for treatment.

How much does it cost?

A.: The initial evaluation cost depends on the complexity of the problem and how much time is needed to do the evaluation.  One hour is usually the time set aside for the first visit.  A few first visits are less complex, taking 30 minutes, while a few may require 90 minutes.  A call to the office will allow us to give an estimate of a consulation/evaluation fee.

When treatment is given during the office visit, there will be an additional charge for the treatment.  Charges vary according to the area(s) treated.

Will my insurance pay for this treatment?

A.:  Insurance companies vary a lot. Most insurances including Medicare and Medicaid DO NOT pay for this services. Some pay well for prolotherapy treatments.  Some pay part of the time and not other times.  Some companies will not pay for it at all. Please contact your insurance and ask this question . CPT code for Prolotherapy  is “ M0076 “

How many treatments will I need?

A.:  It is not possible to tell ahead of time how many treatments a patient might need before they are pain-free.  The doctor will give  an estimated range of the number of treatments that you will need, depending on the severity of your condition.

How far apart are the treatments?

A.:  Treatments are usually given at three-four weeks intervals.  There are exceptions to this, depending on other circumstances.

How soon after treatment can I work out or play sports?

A.:  If your sports or work-outs involve the area that is being treated, you will get the best results with treatment when you avoid exercising or stressing the area until 3 or 4 weeks after the last treatment.  If you must continue to exercise the treatment area, it may take a lot more treatments to get the desired result.  You may continue to re-injure it with the exercise or sports activity, preventing it from getting strong enough to protect it.

What is in the medicine that is used in the injections?

A.:  There is no cortisone used in prolotherapy.  The solution is normally a mixture of a very concentrated dextrose (glucose) with a local anesthetic like lidocaine.  A small amount of sodium morrhuate ( a water soluble form of cod liver oil) is added for extra stimulation of the healing reaction in some cases.

What is the success rate with prolotherapy?

A.:  Prolotherapy generally has about a 70% good to excellent response among the doctors across the country that keep track of their patients’ responses to treatment.  About 10% of the patients are in the poor response, or less than 50% improvement category.

Is there a guarantee that prolotherapy will work for me?

A.:  There is nothing in medicine that is guaranteed.

How do I contact the office for an appointment?

A.:  Please call our office at 508-754-9950 for an appointment.  The staff will be happy to schedule your appointment and give you further information.

What are the office hours?

A.:  Our office hours are 8:00 AM to 12:00 NOON and 1:00 PM to 5:00 PM, Monday through Friday.

What should I bring to the doctor’s office for the initial evaluation?

A.:  Please bring the completed paper work that the office sends to you and any X-ray or films of any other studies that you may have had.

What happens at the first visit?

A.:  Medical assistant will greet you, collect your paper work and take you to the examination room.  The doctor will review your paper work, ask you questions about your problem, examine you, read your X-rays and explain them to you, give you his opinion about what he believes is causing your pain or other problems, order any new studies that may be needed and make recommendations for treatment.  He will explain the treatment and answer your questions. You will be given Consent form for treatment and estimated cost. No treatment will be performed during consultative visit.

Will I need a driver?

A.:  Most of the time patients do need a driver. You will receive a treatment which may affect your ability to drive safely for 12-24 hours.

Will I need to be off work after the treatment?

A.:  Most patients do not need to be off work the day after the treatment if it is sedentary work.

What are the risks with prolotherapy?

A.:  There are risks with all treatments and medications, not just prolotherapy.  If the doctor feels that you are a candidate for prolotherapy, he will explain the risks to you and try to answer all of your questions.


Intravenous therapy (Myers Cocktail)

Anti-aging efforts for looking and feeling younger, being healthier and living longer are all part of an anti-aging program.

Youthful vitality is noted by freedom from pain, returning to normal activities, enjoying more energy, having better and happier relations with your loved one and family, having better sex, improving your memory and being happier with yourself.  Anti-aging treatment benefits both men and women.

Everything that we do in this office is directed toward these anti-aging goals.

Bio-identical hormones are often useful in the anti-aging program.  A physical examination is done in the office.  Mammograms and pap smears may be ordered.  Special laboratory test are ordered see if there are any medical problems and to determine the type and amount of hormones that should be prescribed.  Natural supplements may be used to enhance the hormones or to benefit other anti-aging needs.

Memory and brain function are strengthened by a number of the natural supplements and medical foods.  The memory can be enhanced with nutritional supplements for people who are in college to people of Medicare age.  There are supplements that increase the rate of growth of the connections between the cells of the brain, that improve the chemical functions at the cell junctions in the brain, that increase the circulation in the brain and that help Alzheimer’s disease by helping to reduce the amyloid tissue that is developing in the brain.  Amyloid deposits are seen in the brain MRI’s of these patients as white spots.  It is believed that the brain connections are lost wherever these deposits are found.  Alzheimer’s disease can be prevented in offspring of Alzheimer patients by the use of some of these supplements.

Weight loss is often an important aspect of the anti-aging program.  Good health and good appearance are both important.  Weight loss treatment is supported by diet, nutritional supplements, safe and natural appetite suppressants and advice on an appropriate exercise program.

Nutritional Intravenous Vitamin and Mineral Protocol

About the Therapy

“Myers’ Cocktail,” an intravenous vitamin nutrient supplement, was formulated more than 30 years ago by John Myers, MD, a Baltimore physician. This potent solution contains a specially balanced combination of vitamin and minerals. It is given intravenously to help the treatment of a range of ailments and increase energy. In the last few years, Alan R. Gaby, MD, president of the American Holistic Medical Association, has modified the ingredients and popularized the protocol.

The standard Myers’ Cocktail consists of magnesium, calcium, vitamin B-5 (dexpanthenol), vitamin B-6 (pyridoxine), vitamin B-12 (hydroxycobalamin), vitamin B complex, and an average of 25 grams of Vitamin C. Two time Nobel Laureate Dr. Linus Pauling was a staunch supporter of Vitamin C for healing a wide variety of health problems. Vitamin C is an important antioxidant that helps the immune system ward off bacterial and viral infections. It also makes certain metabolic processes in work better. Other vitamins or ingredients may be added to the Myers’ Cocktail protocol, depending on the patient’s diagnosis and overall health as well as the condition being treated.

Many people who have benefited from this protocol claim that the intravenous shots of vitamin B12 in Myers’ Cocktail are even more beneficial than Vitamin B-12 intramuscular injections in restoring their energy and stamina. Intravenous treatments are more effective than oral therapy for increasing blood levels of nutrients. According to some experts, intravenous delivery may improve the transport nutrients from the blood into the cells

The standard ingredients in Myers’ Cocktail

* Vitamin B complex 100 (B complex)

* Vitamin C

* Magnesium

* Vitamin B5 (Dexpanthenol)

* Calcium (Calcium gluconate)

* Vitamin B12 (Hydroxocobalamin)

* Vitamin B6 (Pyridoxine hydrochloride)

Conditions that may be improve with Myers’ Cocktail

* Chronic Fatigue Syndrome with or without Epstein-Barr virus

* Chronic depression

* Acute or chronic muscle spasm

* Fibromyalgia

* Migraine headaches- often within minutes

* Tension headaches

* Narcotic withdrawal

* Seasonal allergic rhinitis

* Respiratory problems

* Acute of chronic asthma

* Sinusitis

* Bronchitis

* Cardiovascular disease

* Ischemic vascular disease

* Congestive heart failure

* Athletes who need quick recovery for athletic events

* Acute viral illness/colds

* Acute infections

What is the duration of Treatment?

Patients vary in the number of treatments needed, but most require infusions 1 to 2 times per week. Some patients experience improvement after only one treatment, and many report significant healing by the fourth infusion. People who have chronic conditions may need ongoing treatment of several IV’s per week, or periodically every few weeks to regain their energy.

How is the protocol given?

Dr. Trister mixes all the ingredients with 200mL sterile water in an IV bag. It is infused slowly over a period of 30 to 45 minutes. There is another version of the which can be completed in 15-20 minutes.

Is It Safe?

Myers’ Cocktail is a safe, effective, and minimally invasive therapy that is well tolerated by most people. It carries a low risk of serious adverse side effects. if the protocol is administered quickly there may be a sensation of warmth and flushing. This is due to the rapid rise of magnesium. Some patients may also have the taste of vitamins in their mouth shortly after they are given the infusion. Potassium level should be checked periodically.

Patients taking digoxin (Lanoxin®) or potassium-depleting drugs should be cautious and should inform Dr. Trister that they are using these medications before beginning the Myers’ Cocktail protocol.


Platelet rich plasma (PRP) therapy

New Treatment Provides Lasting Musculoskeletal Pain Relief

Platelet rich plasma (PRP) therapy is a revolutionary new treatment that relieves pain by promoting long lasting healing of musculoskeletal conditions. This rapidly emerging technique is showing exciting potential with osteoarthritis of the knee, shoulder, hip and spine, rotator cuff tears, chronic plantar fasciitis, anterior cruciate ligament (ACL) injuries, pelvic pain and instability, back and neck injuries, tennis elbow, ankle sprains, tendonitis, and ligament sprains. How does PRP therapy help?

The body’s first response to soft tissue injury is to deliver platelet cells. Packed with growth and healing factors, platelets initiate repair and attract the critical assistance of stem cells. PRP therapy’s natural healing process intensifies the body’s efforts by delivering a higher concentration of platelets. To create PRP therapy, a small sample of your blood is drawn (similar to a lab test sample) and placed in a centrifuge that spins the blood at high speeds, separating the platelets from the other components. The concentrated platelet rich plasma (PRP) is then injected into and around the point of injury, jump-starting and significantly strengthening the body’s natural healing signal. Because your own blood is used, there is no risk of a transmissible infection and a very low risk of allergic reaction.

How long does it take?

The procedure takes approximately one to two hours, including preparation and recovery time. Performed safely in a medical office, PRP therapy relieves pain without the risks of surgery, general anesthesia, or hospital stays and without a prolonged recovery. In fact, most people return to their jobs or usual activities right after the procedure.

How often should this procedure be done?

Up to three injections may be given within a six-month time frame, usually performed two to three weeks apart. You may, however, gain considerable to complete relief after the first or second injection.

What are the expected results?

Because the goal of PRP therapy is to resolve pain through healing, it could prove to have lasting results. Initial improvement may be seen within a few weeks, gradually increasing as the healing progresses. Research studies and clinical practice have shown PRP therapy to be very effective at relieving pain and returning patients to their normal lives. Both ultrasound and MRI images have shown definitive tissue repair after PRP therapy, confirming the healing process. The need for surgery can also be greatly reduced by treating injured tissues before the damage progresses and the condition is irreversible.


Natural Therapies for Rheumatoid Arthritis and Other Chronic Inflammatory Conditions

Natural Therapies for Rheumatoid Arthritis and Other Chronic Inflammatory Conditions
Renata Trister DO
Chronic inflammatory conditions are affecting a growing number of people, especially in “Western/developed” countries. Rheumatoid arthritis (RA) is one of these chronic inflammatory illnesses. Rheumatoid arthritis (RA) is an autoimmune disease in which your body’s immune system – which protects your health by attacking foreign substances like bacteria and viruses – mistakenly attacks your joints. The abnormal immune response causes inflammation that can damage joints and organs, such as the heart. The body mistakenly attacks its own tissue as if it is an invading pathogen. Although one true cause of RA has not been identified, multiple factors such as infection, genetics and immune dysfunction may contribute to the development of this condition.
Rheumatoid arthritis typically affects the small joints in your hands and feet. Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of your joints, causing redness; warmth and painful swelling that can eventually result in bone erosion and joint deformity. Research suggests that one possible underlying cause of this disease may be an autoimmune reaction to antigens originating from the intestinal tract. An antigen is any substance that causes your immune system to produce antibodies against it. An antigen may be a foreign substance from the environment such as chemicals, bacteria, viruses, pollen and certain “inflammatory foods”. Antigens may also be formed within the body, as with bacterial toxins or tissue cells. Exposure to these antigens and “inflammatory” foods can increase the activity of the intestinal immune system. These reactions can then cause systemic inflammation that is associated with a variety of chronic diseases. Many people are intolerant to the proteins in foods such as wheat and dairy (or fats found in corn or peanut oil), and this can initiate an inflammatory cascade that starts in the gut but can have far-reaching, systemic effects consequences.
Elimination diet or anti-inflammatory diet program can reduce exposure to these “inflammatory foods”. This can thereby reduce immune system stimulation and help improve symptoms in some patients with RA. The most common examples of inflammatory foods are dairy, wheat, trans fats and refined carbohydrates. Furthermore adding certain natural foods and substances can help to protect joint tissues and relieve RA symptoms by controlling inflammation, reducing the associated free radical damage, and supporting the integrity of the intestinal tract.
Modulating the Inflammatory Response Naturally
The anti-inflammation diet is comprised of healthy, wholesome, unprocessed foods.
Anti-inflammatory fats are a cornerstone of this diet. Foods high in omega-3 fatty acids, such as wild salmon, sardines, herring, anchovies, flaxseed, hempseed and walnuts. In addition, other anti-inflammatory fats include extra-virgin olive oil, avocado oil, flaxseed oil, hempseed oil and walnut oil. Omega-6 and omega-3 fatty acids are essential nutrients as well as precursors to both inflammatory and anti-inflammatory molecules. A balanced consumption of each group helps maintain a healthy balance of these molecules. Unfortunately, the consumption of omega-6 fatty acids far outweighs that of omega-3 in the standard American diet, which can result in an overproduction of inflammatory molecules. In RA patients, supplementation with fish oils (omega-3) has resulted in a reduction of pro-inflammatory molecules approaching 90%, and at least 11 double blind, placebo-controlled studies have shown beneficial clinical effects.
Fruits and vegetables are high in inflammation-reducing antioxidants. Fruits and vegetables high antioxidants are important, especially onions, garlic, peppers and dark leafy greens, These are high in inflammation-fighting carotenoids, vitamin K and vitamin E.
Herbs and spices include compounds to fight inflammation. Turmeric, oregano, rosemary, ginger and green tea contain bioflavonoids and polyphenols that reduce inflammation and limit free radical production. Some of the most potent anti-inflammatory vegetables are peppers and the spices derived from them, such as cayenne pepper. All chili peppers include capsaicin (the hotter the pepper, the more capsaicin it has), which is a potent inhibitor of substance P, a neuropeptide associated with inflammatory processes.
Niacinamide & N-acetylcysteine (NAC) Niacinamide has been shown to be effective in relieving symptoms of RA and osteoarthritis in both human and animal models. Niacinamide inhibits the synthesis of a pro-inflammatory molecule that plays a decisive role during the development of RA. NAC also stimulates the synthesis of glutathione, a principal defense within the body against free radicals.
The Role of Free Radicals and Antioxidants
The excessive free radical production associated with immune overreaction and inflammation is an area of concern in RA and similar conditions. Free radical damage may be responsible for the degradation in the rheumatoid joint. Therefore, vitamins E and C and superoxide dismutase may be beneficial in reducing free radical injury to joint tissues. Vitamin E supplementation at levels from 200-600 IU per day can also provide some pain relief in RA patients, and vitamin C supplementation is needed for collagen production.
Gut Ecology
Alterations in the bowel flora and its activities are now believed to be contributing factors to many chronic and degenerative diseases. Irritable bowel syndrome, inflammatory bowel disease, rheumatoid arthritis, and ankylosing spondylitis have all been linked to alterations in the intestinal microflora. The intestinal dysbiosis hypothesis suggests a number of factors associated with modern Western living have a detrimental impact on the microflora of the gastrointestinal tract. Factors such as antibiotics, psychological and physical stress, and certain dietary components have been found to contribute to intestinal dysbiosis. Substances that support the proper intestinal flora include probiotics and prebiotics.
Probiotics Bifidobacterium lactis and Lactobacillus acidophilus are two common species of “friendly” bacteria. These microorganisms help with digestion and offer protection from harmful bacteria, just as the existing “good” bacteria in your body already do. Supplementation with these friendly bacteria may support healthy gut ecology and keep undesirable bacteria in check.
Prebiotics are nondigestible carbohydrates that act as food for probiotics. When probiotics and prebiotics are combined, they form a synbiotic. Fermented foods are considered synbiotic because they contain live bacteria and the fuel they need to thrive.
Nutritional Support of Gut Integrity
Above and beyond sustaining healthy gut ecology, supporting the structure and function of the intestinal lining is critical for proper barrier function and intestinal health.
L-Glutamine is an essential amino acid that is anti-inflammatory and necessary for the growth and repair of your intestinal lining. L-glutamine acts a protector and coats your cell walls, acting as a repellent to irritants.
Deglycyrrhizinized Licorice (DGL) is an extract of licorice (Glycyrrhiza glabra). DGL enhances the resistance of the gastric mucosa against the eroding action of bile, promotes growth of cells that line the stomach, and enhances protective mucus production and secretion.
Aloe Vera (Aloe barbadensis) helps in healing of the epithelial cells of the gastrointestinal lining. Aloe has been shown to reduce inflammation.
The integrity and health of the gastrointestinal system plays a significant role in modulating RA and other chronic inflammatory conditions. Taking the above steps can attenuate symptoms of RA and improve quality of life.


History of vitamin D

Vitamin D
Dr. Renata Trister DO

History of vitamin D

Vitamin D was categorized as a vitamin when it was discovered in 1922. It is not a true vitamin because an ongoing nutrient source is not required to sustain normal levels in the body. Vitamin D is properly classified as a secosteroid (derived from steroid) hormone precursor. A hormone is a chemical substance produced by one organ and then transported in the bloodstream to a target organ, where it causes a specific biological action.
D-metabolites: 25-D and 1,25-D
Vitamin D has several metabolites (forms). This summary is limited to two metabolites: 25-D and 1,25-D.
25-D (also known as calciferol, 25-hydroxycholecalciferol) increases calcium absorption in the gut and at high levels, acts as an antagonist on the Vitamin D Receptor. 25-D is produced in the liver and synthesized in the cells of the skin in reaction to sunlight. 25-D dietary sources (fish, fish oils, eggs), foods that are supplemented with vitamin D (dairy products, cereals.) and vitamin supplements.
 25-D is the major circulating form of vitamin D. It is used in the production of (1,25-D) in the kidneys.
1,25-D (also known as calcitriol or 1,25-dihydroxycholecalciferol or 1,25-dihydroxyvitamin-D3) is a potent secosteroid paracrine mediator and virtually affects all cellular activity.
1,25-D is primarily formed in the kidneys; but may also be formed skin, macrophages and other tissues.
Vitamin D dysregulation
1,25-D can 1nduce the innate immune system. Elevated levels can be found in patients with chronic conditions.
25-D can suppress the innate immune system.
Normally, production of 1,25-D is tightly controlled by the kidneys in response to a complex system of hormonal regulation. However, when nucleated cells are infected with bacterial pathogens, 1,25-D is generated by the inflammatory response. This causes the level of 1,25-D to exceed the upper limit normally controlled by the kidneys.
It is essential to measure both 25-D and 1,25-D to evaluate vitamin D levels and dysregulation. The low level of 25-D doesn’t directly reflects the deficiency. Low D- 25 could be a result of down regulation of its production in the liver by high 1.25 D.
Patients with Th1/Th17 inflammation often have a low level of 25-D while the level of 1,25-D is high. T helper 17 cells (Th17) are a subset of T helper cells producing interleukin 17 (IL-17) discovered in 2007. They are considered developmentally distinct from Th1 and Th2 cells and excessive amounts of the cell are thought to play a key role in autoimmune disease such as multiple sclerosis, psoriasis, autoimmune uveitis, juvenile diabetes, rheumatoid arthritis, and Crohn’s disease.


Visual postural examination


Posterior and anterior tilt

Lateral Shift

Oblique tilt

Pelvic rotation

Pelvic torsion


Shape of Gluteus Maximus muscles:

Observe symmetry. Look at the level of gluteal folds- asymmetry indicates inhibition or weakness of the ipsilateral side, which will be lower.

Slight asymmetry indicate inhibition or weakness-look at the upper external quadrant.In this case it will be flat on palpation as the result of decreased of the muscle tone.

Asymmetry of the pelvis will cause changes to lower back extensors and hamstrings.

Weakness of Gluteus Maximus will lead to lowering of gluteal fold on the same side.

Than look to the lumbar and thoracolumbar area.Look for scoliosis, rotation or kyphosis which may influence the shape of the muscles.

Than compare muscles at the lower lumbar region to the muscles at the thoracolumbar junction. Atrophy at the lower segment of the lumbar muscles will require stabilization and  lead to the hypertrophy of the muscles at the thoracolumbar segment.

Normally, lumbar segment is symmetrical and flatter than thoracolumbar segment which is slightly more prominent but still symmetrical.

Than proceed to the upper part of the body:

Shoulder blades can be protracted, retracted, shifted upward or abducted.

Look at the stabilizers: lower stabilizer (lower trapezius) interplays with upper stabilizers (upper trapezius,m. levator scapulae)

Interscapular region:

This area will be flat in the case of muscular inhibition. Weakness or inhibition of the serratus anterior will lead to winging of the scapulae.

If you see atrophy of the lower stabilizers (lower trapezius) than observe upper stabilizers (upper trapezius and m. levator  scapulae) which will be compensatory hypertrophic, which will lead to abduction and weaning of the scapula.

To look closely to the quality of the upper trapezius and levator scapulae focus on the reference  line  from the occiput/lateral neck and the Acromion . This line normally should have “S” shape.When levator scapulae and trapezius are overactive this line became straight.This called “Gothic shoulders”.

Another example of insufficient scapular stabilization will be protracted scapulae due to inhibition of the medium and lower trapezius, rhomboids and overactive serratus anterior.

Upper trapezius in this cases usually overactive which lead to superior shift of the scapulae.

Observation of the anterior shoulder provide information about humeral control:

flattening of the deltoid abductors indicate deltoid atrophy, altered pattern of the shoulder’s muscles and impaired  proprioception from the shoulder joint.


In the assessment of the lower extremity first view the subject general posture.

E/Rotation of the feet exists  may indicates problem with the muscles or the joint of the hip.

Look at the knee joints: varus , valgus or hyperextension

Correlate limb alignment with calcaneal bone and the position of the forefoot.

Varus leg deformity associated with pronation of the foot and flattening of the foot.


Than estimate the shape of each individual muscle groups.

First, look at the Hamstrings: note if the size of the hamstrings is symmetrical

Usually if gluteal muscle is weaker ipsilateral hamstring compensatory stronger.

Hamstrings best seen in the medium and upper thirds of the thigh.

The second important group of the thighs are ADDUCTORS

In general, there are two groups of adductors: Short (cover upper and middle thigh)and Long(cover entire thigh).

Normally, from posterior view adductors create very shallow letter “S”

If upper adductors are in spasm than upper portion of the “S” will be bulkier. As a compensation of this process lower portion of the “S” will be flat -hypotrophy,-hollow just above the knee.

Than look at the calfs: shape and symmetry. Estimate the tightness of hypotrophy of the m.soleus  muscles in the relation to gastrocnemius muscles

If the solei are tight and short, the muscle belly is evident at the medial border just superior to the Achilles tendon. (The m.soleus is located just underneath the gastrocnemius, and together these two muscles form the Achilles tendon. Since these are the 2 biggest muscles in the calf, they provide the majority of the push off when walking, running, and jumping)

If m.Soleus is tight than Achilles tendon become slightly thicker and shorter.

observation of the heel.

No symmetrical person.No specific norms.

Variation of the muscle

anterior view:

ASIS and umbilicus

Rectus abdominis: Upper quadrants more active than lower quadrants. But left and right are symmetrical.

Observe the groove on the lateral edge of the rectus abdominis: it reflects quality of interplay between m.rectus abdominis and m.obliqus abdominis externus. The more prominent this groove -the stronger m.obliqus abdominis externus and m.Rectus abdominis is inhibited.

Next, look at the lateral edge of the waist, which is normally concave. If it become flat or convex shape- sign of weakness of m.transversus abdominis which stabilize abdominal wall and spine properly.

In the upper trunk look at the symmetry of the muscles and respiratory movement of the chest wall. Focus mainly on the pectoralis major.

Compare muscular folds on both sides.The pectoralis muscle is more prominent on the dominant side. Positions of the nipples. If pectoralis is tighten, nipple will be displaced superiorly and laterally. In female, asymmetry of breasts may indicate m.pectoralis tightness.


Observe neck: SCM muscle, which under normal circumstances will be almost invisible.

Usually we only see insertion in the sternoclavicular region. If the muscle belly is pronounced it indicates muscle hypertrophy.

Groove in the area medial to SCM (between SCM and Scalenus muscles )

The more prominent this groove the weaker (hypoactive)the Scalenus muscle


Facial scoliosis”-asymmetry of face

4 points:

These points must be symmetrical. Also observe lateral bending and rotation of the head.

Observe hip, knee and feet position.

First look at the tensor fascia latae. normally this muscle is invisible. If muscle is visible it indicate hypertonus of the MTFL.

Than look at the position of the patella: Symmetry, presence of the shift: if quadriceps is tight than patella shifted superiorly

if MTFL is tight patella will shift supero-lateraly and tilt

If vastus medialis is hypertrophied you will see muscle bulk medially to patella

It is usually sign of overstressed knee joint

When proprioception of the knee is altered patella will move in irregular manner from intermittent activity of the m.quadriceps to improve stability of the knee joint.

This vertical translation of the patella is an important sign of poor proprioception of the knee joint.

Look at the lower leg, primarily tibias anterior.

If M.tibialis anterior (anterolateral aspect of the lower leg, just below the knee) is weak than it’s fibers become flat or even they develop groove-early sign of L4-L5 irritation.

Look at the toes.

Unquiet foot” irregular twitching movement of the tendons of the toes in the different directions-sign of impaired proprioception and the more demanding effort to maintain the balance.



Lateral view: Look at the presence of anterior or posterior tilts.

Look at the lumbar, thoracic and cervical curvatures:The interrelationships of which may depend on the balance between  hips flexors and extensors or abdominal muscles and back extensors.

Look at the position of the head, particularly “push forward head position”

Observe line running from the jaw to the hyoid bone: if the supra-hyoid muscles is tight this line become more straight, indicating TMJ problems

Look at the position of the legs, particularly knees (genu recurvatum)

Look at the greater trochanter- MTFL: if groove is present-MTFL is tight


Structure and synthesis of collagen in the human body

Collagen is the most abundant protein found in mammals, making up about 25 percent of the total proteins in the human body. There are at least 16 types of collagen, but 80 – 90 percent of the collagen in the body consists of types I, II, III and IV. Type I: Makes up the fibers found in connective tissues of the skin, bone, teeth, tendons and ligaments.
Type II: Round fibers found in cartilage.
Type III: Forms connective tissues that give shape and strength to organs, such as the liver, heart, kidneys, etc.
Type IV: Forms sheets that lie between layers of cells in the blood vessels, muscles, and eye.

These collagen molecules pack together to form long thin fibrils of similar structure.  At one time it was thought that all collagens were secreted by fibroblasts in connective tissue, but we now know that numerous epithelial cells make certain types of collagens. The various collagens and the structures they form all serve the same purpose, to help tissues withstand stretching.

The triple-helical structure of collagen arises from an unusual abundance of three amino acids: glycine, proline, and hydroxyproline. These amino acids make up the characteristic, repeating motif Gly-Pro-X, where X can be any amino acid. Each amino acid has a precise function.  Collagen biosynthesis and assembly follows the normal pathway for a secreted protein. The collagen chains are synthesized as longer precursors called procollagens; the growing peptide chains are co-translationally transported into the lumen of the rough endoplasmic reticulum (ER). In the ER, the procollagen chain undergoes a series of processing reactions.

Post-translational modification of procollagen is crucial for the formation of mature collagen molecules and their assembly into fibrils. Defects in this process have serious consequences, as ancient mariners frequently experienced. For example, the activity of hydroxylases requires an essential cofactor, ascorbic acid (vitamin C). In cells deprived of ascorbate, as in the disease scurvy, the procollagen chains are not hydroxylated sufficiently to form stable triple helices at normal body temperature, nor can they form normal fibrils. Consequently, nonhydroxylated procollagen chains are degraded within the cell. Without the structural support of collagen, blood vessels, tendons, and skin become fragile. A supply of fresh fruit provides sufficient vitamin C to process procollagen properly.

The biosynthetic pathway responsible for collagen production is a very complex one. In addition to Vitamin C, collagen crosslinking requires Copper, Iron and Manganese.

Prolyl hydroxylase and lysyl hydroxylase require vitamin C and iron as cofactors. Lysyl oxidase deaminates lysine and hydroxylysine in the first step for collagen crosslinking, and this requires copper (hence the hair and skin signs in Menkes disease).

Linus Pauling

In 1989, the eminent American scientist and two-time Nobel Prize winner, Linus Pauling, announced a breakthrough “A Unified Theory of Human Cardiovascular Disease,” Linus Pauling thought that the deposits of plaque seen in atherosclerosis were not the cause of heart disease, but were actually the result of our bodies trying to repair the damage caused by long-term vitamin C deficiency. In essence, Pauling believed that heart disease is a form of scurvy, and plaque is the body’s attempt to reinforce and patch weakened blood vessels and arteries that would otherwise rupture. Pauling also showed that heart disease can be prevented or treated by taking vitamin C and other supplements.

Plaque Deposits

Pauling based his revolutionary theory on a number of important scientific findings. First was the discovery that plaque deposits found in human aortas are made up of a special form of cholesterol called lipoprotein (a) or Lp(a), not from ordinary LDL cholesterol. Lp(a) is a special form of LDL cholesterol that forms the thick sheets of plaque that obstruct arteries.

Another finding central to Pauling’s theory was the observation that plaque deposits are not formed randomly throughout the circulatory system. This was first reported in the early 1950s when a Canadian doctor, G. C. Willis, MD, observed that plaque always forms nearest the heart, where blood vessels and arteries are constantly being stretched and bent, rather than being spread evenly throughout the entire cardiovascular system. Willis also noted that plaque deposits always occur in regions that are exposed to the highest blood pressures, such as the aorta, where blood is forcefully ejected from the heart.

In 1985, a team of researchers verified that plaque only forms in areas of the artery that become damaged. These small areas of damage expose strands of the amino acid lysine (one of the primary components of collagen) to the blood stream. These strands attract Lp(a). Lp(a) is an especially “sticky” form of cholesterol that is attracted to lysine. Drawn to the break, Lp(a) begins to collect and attach to the exposed strands. As Lp(a) covers the lysine strands, free lysine in the blood is drawn to the growing deposit. Over time, this process continues as lysine and Lp(a) are both drawn from the blood to build ever-larger deposits of plaque. This process gradually reduces the inner diameter of the vessels and restricts its capacity to carry the blood.

Heart Disease as Low-Level Scurvy?

Observing the newly described process of plaque formation, Pauling recognized a similarity to underlying processes seen in scurvy. He also saw similarities between human and animal models of atherosclerosis that pointed to a connection with scurvy. First, cardiovascular disease does not occur in any of the animals that are able to manufacture their own vitamin C. Many animals produce large amounts of vitamin C that are equivalent to human doses ranging from ten to twenty grams per day. Second, the only animals that produce Lp(a) are those which, like man, have also lost the ability to produce their own vitamin C, such as apes and guinea pigs.

Pauling suggested that the ability to form plaque is really the body’s attempt to repair damage caused by a long-term deficiency of vitamin C. Pauling thought that scurvy was one of the greatest threats to humankind’s early survival, and believed that the loss of blood during times of vitamin C deficiency, particularly during the Ice Ages, likely brought humans close to the point of extinction.

Plaque as a Life Saver?

The core of Pauling’s theory is that, over time, the body developed a repair mechanism that allowed it to cope with the damage caused by chronic vitamin C deficiency. When arteries became weak and began to rupture, the body responded by “gluing” the damaged areas together with Lp(a) to prevent a slow death from internal bleeding. In essence, plaque is the body’s attempt to patch blood vessels damaged by low-level scurvy. Accordingly, Pauling believed that conventional “triggers” of plaque formation, such as homocysteine and oxidized cholesterol, are actually just additional symptoms of scurvy.

Collagen Melts Plaque, Keeps Arteries Open

In addition to taking vitamin C to prevent atherosclerosis, Pauling recommended a combination of vitamin C and the amino acids lysine and proline to help remove existing plaque while strengthening weak and damaged arteries. As mentioned previously, the body produces collagen from lysine and proline. Pauling reasoned that by increasing concentrations of lysine and proline in the blood, Lp(a) molecules would bind with the free lysine, rather than with the lysine strands exposed by the cracks in blood vessels.

Pauling Therapy for the Reversal of Heart Disease

  1. Vitamin C: to bowel tolerance – as much as you can take without diarrhea. For most people this will be in the range of five to ten grams (5,000-10,000 mg.) each day. Spread this amount into two equal doses 12 hours apart. (Vitamin C prevents further cracking of the blood vessel wall – the beginning of the disease.)
  2. L-Proline: 3 grams twice per day (acts to release lipoprotein(a) from plaque formation and prevent further deposition of same).
  3. L-Lysine: 3 grams twice each day (acts to release lipoprotein(a) from plaque formation and prevent further deposition of same).
  4. Co-enzyme Q10: 90-180 mg. twice per day (strengthens the heart muscle).
  5. L-Carnitine: 3 grams twice per day (also strengthens the heart muscle).
  6. Niacin: Decreases production of lipoprotein(a) in the liver. Inositol hexanicotinate is a form of niacin which gives less of a problem with flushing and therefore allows for larger therapeutic doses. Begin with 250 mg. at lunch, 500 mg. at dinner and 500 mg. at bedtime the first day; then increase gradually over a few days until you reach four grams per day, or the highest dose under four grams you can tolerate. Be sure to ask your doctor for liver enzyme level tests every two months or less to be sure your liver is able to handle the dose you are taking.
  7. Vitamin E: 800-2400 IU per day. (Inhibits proliferation of smooth muscle cells in the walls of arteries undergoing the atherosclerotic changes.)