TRUMP’S MEDICAL “CHECKUP”: IS HE REALLY IN EXCELLENT HEALTH?

We physicians are often asked to conclude two things from a regular “checkup” of someone who has no symptoms to suggest present disease: 1) What is the likelihood that one is harboring an unrecognized but hidden disease? 2) What is the likelihood that disease will develop in the future?

In the absence of complaints, information from a physical exam seldom discloses unrecognized diseases, and routine laboratory screening tests seldom add much of additional value. Thus the results of Trump’s exam tell us very little about any present physical diseases, especially in the absence of psychological testing. But can his findings tell us anything about his chances of impending future health disasters? Based upon his lifestyle choices and family history, his greatest chances of future diseases are cardiovascular events (heart attacks, stroke, etc.) and dementia (Alzheimer’s disease).

With regard to cardiovascular risk (our largest killer by far), using the various charts supplied by the American Heart Association and others, which include age, sex, blood pressure, and certain blood tests, Trump’s chances of developing serious cardiovascular events within the next ten years are approximately 15%. At his age, less than 10% is considered reasonably low.

But additional factors must be added that include his coronary artery calcium score of 98 (on CT scans), a number that means he already has asymptomatic cardiac vascular disease.  The calcium score directly correlates with the risk of overt future cardiac events. People with higher scores have greater plaque burden on the linings of these arteries, carrying a higher risk for cardiac events regardless of whether symptoms are present. For asymptomatic individuals, a calcium score of 0 indicates absence of detected calcium and an extremely low likelihood (<1%) of any coronary arterial disease. The odds ratio (ratio of events in an interest group vs. events in a baseline population) of developing symptomatic cardiovascular disease is 3:1 for people with scores of 1 to 80 (where the zero score group is the baseline population), 8:1 for people with scores between 80 and 400 (Trump’s group) and nearly 25:1 for people with scores above 400. In fairness, Trump is taking “statin” drug and aspirin to minimize this risk, but, nevertheless, the dangers are clearly present.

What may be more damming, however, is Trump’s widely publicized poor diet with obesity (yes, folks, despite his denials, according to the published charts, he is obese), and lack of regular exercise, factors that, while difficult to quantify, when coupled with the presence of coronary calcium, would raise his overall odds of serious cardiovascular events to at least 20-30% over the next ten years (three years obviously being a substantial portion of this number). Obesity, per se, raises his odds significantly for developing various cancers: https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/.

But what if we add his chances of present or future dementia? Based upon his family history (his father suffered from this disease), it is entirely possible that Trump himself already is manifesting its early phases or, at least, has greater chances of developing this malady soon in comparison with the general population. Such information, coupled with Trump’s erratic behavior, should mandate an immediate and comprehensive neuropsychiatric examination, which, sadly, is likely to be denied.

Does this information justify the declaration by the White House that Trump is in “excellent health”? For the present, maybe so, maybe not. But for the future, I’m taking no bets, and neither should you!

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EXERCISE: THE INFORMATION CONTINUES TO MOUNT

     For the past sixty plus years, we have known that exercise—in almost all forms—is beneficial to health. The European Guidelines on Cardiovascular Disease Prevention, the World Health Organization, and the Physical Activity Guidelines for Americans all recommend that healthy individuals engage in 150 minutes per week of moderate intensity exercise, such as brisk walking, or 75 minutes of high intensity exercise, such as jogging. But recent research has also hinted that there may be added benefit from pushing yourself intermittently, at least a little extra, bringing about changes deep within our body’s cells—those tiny building blocks that constitute all of us. Exemplifying this idea is the case of Robert Marchand, a diminutive French centenarian who took up competitive cycling as a retiree and began setting age-group records. After he was advised to add intermittent strenuous pedaling, Mr. Marchand decisively bettered his own records and, at the age of 103, set a new world mark for the most miles pedaled in an hour by a centenarian.

His efforts help to refute entrenched beliefs about older people, that physical performance and aerobic capacity inevitably decline with age and that intense exercise is inadvisable and does not apply to the elderly.

For instance, one study disclosed that frail elderly mice were capable of completing high-intensity running on little treadmills. After four months of this kind of training, the exercised animals were stronger and more aerobically fit than other mice of the same age, especially if that exercise was supplemented with high-intensity interval training.

Extending these observations to people, scientists at the Mayo Clinic compared differences in gene expression inside muscle cells after younger and older people had completed various types of workouts. The greatest differences were seen in the operations of genes after people had practiced high-intensity interval training for 12 weeks. In younger people who exercised this way, almost 275 genes were firing differently now than they had been before the exercise. But in people older than 64, more than 400 genes were working differently now and many of those genes are known to be related to the health and aging of cells. In effect, the intense exercise seemed to be changing muscle cells in ways that theoretically could affect biological aging.

At this point, I should probably pause and explain that intensity in exercise is a relative concept. The word intense can seem daunting, but in practice, it simply means physical activity that is not a cinch for you.

For medical purposes, intensity is based on percentages of someone’s heart rate maximum. But you can ignore these technicalities and pay attention to how you feel. Exercise is easy if you can talk and sing while participating in it.

During relatively moderate exercise, singing becomes difficult.

And during intense exercise, you will find it difficult to speak without gasping.

We all should get regular exercise, but no matter what your routine, you might consider increasing its pace for a few minutes at a time, until you no longer can easily converse. The latest science suggests that your cells will thank you.

But as always, the most compelling exercise-related research this year reminds us that activity of any kind is essential for human well-being. One study of 2017 found that people reported feeling happiest during the day when they had been up and moving compared to when they had remained seated and still. The benefits of exercise extend even to those suffering from various degrees of depression, providing with another means to combat this malady.

Another memorable study concluded that, statistically, an hour spent running could add about seven hours to our life spans. These gains are not infinite. They seem to be capped at about three years of added life for people who run regularly.

But these results should inspire all of us. If Mr. Marchand can gain fitness and speed after turning 100, that should be incentive to all of us with still a half-century or more to spare.

And even if we don’t succeed in adding years to our lives, we can at least add life to our years!

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Assessing Presidential Fitness: Thoughts that have come 230 years too late—but better than never!

Several weeks after former President Ronald Reagan announced his Alzheimer disease diagnosis in 1994, his predecessor, Jimmy Carter, appealed to the medical community. But Carter, the 39th president of the United States, didn’t urge physicians to take up a fight against this neurodegenerative disease. Instead, Carter attempted to tackle presidential disability and the 25th Amendment of the US Constitution.

In a published commentary, Carter contended that Section 4 of the amendment—a mechanism that allows the vice president and a majority of Cabinet members to pronounce a president “unable to discharge the powers and duties of his office”—is inadequate. They would need accurate, unbiased medical advice from qualified physicians, Carter wrote. It would require those physicians to delicately balance patient confidentiality, personal interest, and the country’s well-being.

“We must find a better way,” he stated.

His suggestion: create a nonpartisan group of medical experts not directly involved in the president’s care to determine presidential disability. Twenty-three years later, Carter’s proposal hasn’t come to fruition. But it’s no longer lying dormant.

Rep Jamie Raskin (D, Maryland) introduced a House bill in April to create an 11-member “presidential capacity” commission composed of psychiatrists, other physicians, and retired government officials selected by leaders in Congress. “Now is the time to do it,” Raskin said in a statement.

In a recent bestselling book, 2 practicing psychiatrists offered an alternative proposal, recommending that a 7-member expert panel be established to evaluate presidential fitness.

During an interview with JAMA, a leading medical journal, one of these psychiatrists discussed the issue of presidents’—past and present—fitness to serve. An edited version of that conversation follows.

Question: Why did you decide to wade into the territory of presidential fitness?

Answer:  President Trump’s mental status engendered controversy among our colleagues because of the Goldwater rule. During Barry Goldwater’s run for president in 1964, a magazine polled about 1100 psychiatrists who rendered opinions about his mental fitness without seeing him for an evaluation. Afterward, Goldwater sued the magazine for libel and won. As a result, the American Psychiatric Association instituted the Goldwater Rule, which prohibits psychiatrists from diagnosing an individual without a face-to-face evaluation. When mental health professionals began to raise concerns about President Trump’s mental stability, the APA added a further proscription against offering any opinion about his mental health. In April, Dr Bandy Lee (assistant clinical professor in the Law and Psychiatry Division, Yale School of Medicine) chaired a conference at Yale to discuss psychiatrists’ “duty to warn.”

Question: What is duty to warn, and could you explain how the concept came about?

Psychiatrist’s answer: This obligation is derived from the landmark [Tarasoff v Regents of the University of California] decision by the California Supreme Court in 1976. It states that if patients disclose to their therapist that they intend to injure specific individuals, the therapist has a duty to warn those individuals. The Tarasoff decision ultimately created a legal duty to protect that overrode the confidentiality of the patient-therapist relationship. This duty was subsequently adopted in other states in various forms and has become a standard of mental health practice.

Question: To what other US presidents would a presidential fitness commission have been applicable?

Answer: A review of US Presidents from 1776 to 1974 found that 49% of those 37 presidents met criteria that suggest neuropsychiatric disorders. For example, Presidents Franklin Pierce and Abraham Lincoln had symptoms of depression; Nixon and Johnson, paranoia; and Reagan, dementia. President Woodrow Wilson suffered a massive stroke in office that resulted in severe cognitive impairments. Although military personnel who are charged with relaying and executing nuclear orders from the president must undergo rigorous medical, psychological, and financial evaluations to determine their fitness for duty, no such evaluation is necessary for their commander-in-chief. We feel that this glaring omission can be remedied.

Question: What is the remedy?

Answer: The 25th Amendment to the Constitution addresses presidential disability and succession. Section Four of this amendment has never been invoked to evaluate whether a president is fit to serve. We exhort Congress to use this section of the 25th Amendment to impanel an independent, impartial group of experts to evaluate whether the current and future presidents and vice presidents are mentally fit to fulfill the duties of office.

Question: Who would serve on such a panel and how would the members be chosen?

Answer: The panel should consist of 3 psychiatrists—1 clinical, 1 academic, and 1 military; 1 clinical psychologist; 1 neurologist; and 2 internists. Panel members should be nominated by the nonpartisan, nongovernmental National Academy of Medicine. The experts should serve 6-year terms with the provision that 1 member per year be rotated off and replaced. Congress should enact legislation to authorize this panel to perform comprehensive mental health and medical evaluations of the president and vice president on an annual basis. The legislation should require the panel to evaluate all future presidential and vice presidential candidates. The panel should also be empowered to conduct emergency evaluations should there be an acute change in the mental or physical health of the president or vice president. The evaluation should be strictly confidential unless the panel determines that the mental health or medical condition of the president or vice president renders him or her incapable of fulfilling the duties of office. We feel that this process should be initiated immediately.

Question: How did you decide on the types of experts that should be on the panel?

Answer: Psychiatrists would be able to evaluate someone’s mental status and diagnose any significant mental disorders and also to evaluate for potential dangerousness. The clinical psychologist is usually a specialist in psychological testing, and a neurologist could help evaluate cognitive and brain functioning. Of course, internists would look at the general medical status of the person. We figured that would cover all the bases that we would need to be concerned about.

Question: Why did you want to have a military panel member?

Answer: We thought it would be fair to have someone who may have a better sense of the kinds of situations that a president would face in terms of handling the nuclear arsenal.

Question: Would nominations to the panel require approval by Congress or some other body?

Answer: Since this is brand new territory, I suspect that it would be incumbent upon the Congress to impanel this group of professionals. But I think it could be difficult, so in my opinion, it would be better if Congress would rely on the National Academy of Medicine to come up with these experts. You want it as nonpartisan as possible.

Question: You’ve shared your ideas with President Obama and some members of Congress. Did you consider that part of your duty to warn?

Answer: Yes. We believe that we have a higher duty to warn if we feel that the US president presents a danger to others—others being this country and the world.

CONCLUSION

From a medical perspective, I believe these suggestions are quite reasonable and should be implemented quickly. In today’s toxic political environment, however, this may be a pipe dream. But, nevertheless, it could at least serve to identify those voting against such a plan as certifiably insane and legitimate candidates for the loony house! Now which party do you suppose could comprise the lion’s share of those “no” votes?

 

 

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DON’T FORGET YOUR FLU SHOT!

        

 Since 2010, the flu has resulted in about 500,000 hospitalizations yearly and contributed to about 25,000 deaths. That’s why the CDC (Centers for Disease Control) urges everyone 6 months and older to get vaccinated. But a recent survey disclosed that only 48% of adults said they had received a flu shot in the previous 12 months.

One reason for not receiving this valuable protection is based on the premise that the shot “doesn’t work,” but actual research indicates that the shot cuts your risk by about 50% or more. And even if you contract the flu, the symptoms will be mitigated with a reduced likelihood of serious complications—including death!

Another reason frequently given is that the shot may actually cause the flu. However, all the flu vaccines in use today contain an inactivated virus that can’t trigger the flu. But since the vaccine doesn’t eliminate entirely your chance of getting the flu, some people who develop flu-like symptoms after getting the shot wrongly blame the vaccine, or might be suffering from a condition that only mimics the flu.

Another excuse I hear for not getting the shot is that is contains a harmful amount of mercury. But this is a mercury-containing preservative called thimerosal found in some vaccines, but if present, only in trace amounts. This kind of mercury—ethylmercury—is eliminated by the body more quickly than is methylmercury, the form in some seafood. Moreover, no research has ever linked this substance to any complications, including autism.

WHICH VACCINE SHOULD YOU RECEIVE?

    For teens and adults: a quadrivalent vaccine is recommended, which protects against four flu strains.

For people 50 and older: Flublok Quadrivalent, which has triple the dose of other quadrivalents.

For people 65 and older: They have two choices—Fluzone High-Dose and Fluad. Both protect against three strains, but Fluzone has four times the dose and Fluad adds an ingredient to boost the immune system’s response, a property that leads me to recommend this latter choice.

Under all circumstances, do not fail to consider this protection, which can be obtained from you doctor, but also quickly and easily in many pharmacies such as Walgreen’s and CVS.

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BEWARE OF CELEBRITIES SHARING THEIR MEDICAL EXPERIENCES!

Soon after her husband died of colon cancer in 1998, Katie Couric, the journalist and television personality had a televised colonoscopy to promote the test. Rates of screening colonoscopies soared for at least a year. Or, call it the “Angelina Jolie effect”. In 2013, the actress wrote an editorial in the New York Times about the tests she had for genes (called BRCA) linked with breast and ovarian cancer, and how the positive result led her to have a double mastectomy. Soon after, rates of BRCA testing jumped.

Whatever you call it, the effect is real. When it comes to matters of health, celebrities can have an enormous impact.

It’s good when celebrities do good

The impulse to take a challenging or tragic medical experience and turn it into something that helps others is commendable. It may be easier to keep such matters private or avoid talking about them in public. But time and again, we see celebrities joining forces with health-promoting organizations, speaking out, and sharing their stories to help others in making decisions. Many have credited Katie Couric with removing the embarrassment associated with colonoscopy and showing how apparently easy it is.

But there is a downside

There are a number of ways celebrity pronouncements on matters of health can go wrong. For example, the information can be faulty or confusing. The forays of Jenny McCarthy (who claimed vaccines cause autism) and Gwyneth Paltrow (who recommended vaginal steams to “cleanse the uterus”) into matters of health and illness are examples of influence most doctors would consider unhelpful or even dangerous.

Although Katie Couric’s colonoscopy experience seemed like a brave and unique way to get her message across, she was 43 years old at the time. Since guidelines suggest people begin routine screening at age 50, she was actually not a good candidate for the test. Unless she had symptoms (such as intestinal bleeding), a strong family history of early colon cancer, or some other special circumstance that put her at higher than average risk for colon cancer, her colonoscopy could be considered unnecessary testing. And that could have led others to have unnecessary testing as well.

A recent study raises a similar concern about Angelina Jolie’s BRCA testing. It found that in the weeks after her editorial was published, testing increased by more than 60% (at an estimated cost of $13.5 million). However, mastectomy rates actually fell over the next two to six months, leading the authors to suggest that most of the additional women who had testing had negative results and therefore may have been poor candidates for testing in the first place. Of note, the study did not confirm whether those having the BRCA test had risk factors (especially a family history of early breast or ovarian cancer) that would make the test appropriate. Critics of the study have suggested that mastectomy rates within six months of testing is not an adequate measure of whether the tests were appropriate. Still, the point is worth considering. When a celebrity recommends a medical test or treatment, the audience is not limited to those who are most likely to benefit.

But this is only a small sample of so much mischief reverberating in our media. Both Dr. Mehmet Oz and Dr. Travis Stork and his co-hosts (The Doctors) are licensed physicians (celebrities?), but despite their credentials, seem to be willing to dispense unproven, false or misleading information. Many other so-called “authorities” lack even these credentials and, as you might anticipate, they dole out copious misinformation to an unsuspecting—and often uncritical—public. One example (of many) concerning Ozy was a charge brought by the U.S.  Federal Trade Commission (FTC) that he was involved in a scam to deceive consumers through fake news sites and bogus weight loss claims: Oz had touted the use of the dietary supplement Pure Green Coffee as a potent weight loss treatment that supposedly burns fat. He claimed falsely that users of this product could lose 20 pounds in four weeks, 16% of body fat in 12 weeks, and 30 pounds and four-to-six inches of belly fat in 3 to 5 months. Sounds too good to be true—yes it was! According to representatives of the FTC, “Not only did these defendants trick consumers with their phony weight loss claims, they also compounded the deception by advertising on pretended news sites.”

The bottom line

For any medical test or treatment, ask whether it’s likely to be helpful. The answer may be straightforward. For example, a well-studied and well-accepted screening test may be recommended based only on your age and gender. But in many cases, the answer may rely on a considerable amount of judgment based on how likely it is that you have—or may develop—a particular condition, the ability of the test to detect it, and the impact of the test result on treatment decisions. For example, if a person has knee pain that’s mild and well-controlled with exercises, it may make little sense to have an MRI, as the results are highly unlikely to affect treatment.

If your doctor recommends a test or treatment, make sure you understand why. And if it’s a celebrity making the recommendation, do yourself a favor: run it by your own doctor—and not the TV variety!

 

 

y http://www.mortontavel.com/2014/05/28/

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EATING RAPIDLY: CAUSE OF OBESITY?

      Skipping breakfast, unhealthy diets, and overeating are known to contribute to weight gain, but new research suggests the simple act of eating too fast may also promote obesity.

After 5 years of follow-up of 1083 Japanese men and women who rated their eating speed during a yearly health exam, new-onset obesity was diagnosed in 11.6% of fast eaters, 6.5% of normal eaters, and 2.3% of slow eaters. Fast eaters also saw greater gains in waist circumference as well as overall body weight, according to data reported at the American Heart Association 2017 Scientific Sessions.

“If you feel your own eating speed is faster than other people in daily life, you may have a risk factor for obesity, a risk factor for diabetes”, according to author Dr Takayuki Yamaji (Miyoshi Central Hospital, Hiroshima, Japan)..

This is not the first time the association has been observed, with another study, among 8941 Japanese adults reporting that fast eating correlated with a 30% risk-adjusted increase in obesity compared with slower eating. Several studies have also shown that fast eating contributes to the new onset of obesity, in part because it prompts overeating.

“If you chew your food many times, you spend more time at meals, you’re more likely to feel full,” Yamaji said. “It takes about 20 minutes for signals from your stomach indicating that you are full to reach your brain.”  Eating fast also causes acute glucose fluctuations, he said. As a result, oxidative stress is increased which leads to increased insulin resistance, decreased insulin secretion, and can further lead to hyperglycemia (elevated blood sugar levels). Fast eaters were also significantly more likely than slow eaters to have higher levels of fasting blood glucose (sugar) and lower levels of HDL (good) cholesterol, though triglycerides and blood pressure were similar.

Fast eaters were less likely than normal or slow eaters to report drinking alcohol everyday but also significantly more likely to eat dinner 2 hours before sleeping at least three times a week, snack after dinner three or more times a week, and to have gained weight in the past year.

Even after adjustment for multiple potential confounders, however, risk of new-onset obesity remained significantly higher among fast eaters than normal eaters or slow eaters.

Dr Scott Grundy (University of Texas Southwestern, Dallas), who was not involved with the study, said “This is not a subject that I’ve seen in the literature, but it’s worth consideration and future research. It’s an interesting idea.” He also noted that it seems reasonable that people who eat too fast may also eat too much.

Yamaji suggests this can be particularly perilous as Americans consume holiday meals, where the sentiment is often whoever eats the fastest gets the most. “Festive meals tend to have more calories. Please eat slowly and be careful not to eat too much,” he cautioned.

CONCLUSION

This information raises the age-old question: Does correlation mean causation? That is, does fast eating cause obesity, or do people who eat rapidly possess other (maybe unknown) characteristics that destine them to become obese even if they were to slow their eating pace? Moreover, do Japanese differ in other ways that may invalidate these conclusions? Such questions extend to all sorts of scientific investigation—even political—as exemplified our rising stock market since the election of Trump. Did Trump cause the market to rise, or would it have risen anyway of its own volition. You can supply lots of other examples by observing a plethora of current and historical events. Unfortunately, in these historical or societal situations, there is almost no way to gain definitive answers.

In the case of rapid eating, however, we could design an intervention in which we enlist two normal groups—one instructed to eat slowly, and the other, to eat rapidly. After several months of careful follow-up, weight differences between the groups are tabulated. If, after such study, excessive weight accumulation is found in the rapid-eaters, then we are positioned to form a more accurate conclusion that eating fast truly causes more weight gain.

In the meantime, it certainly doesn’t hurt to eat slowly and chew your food well!

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MASS MURDERS AND INSANITY

The NRA party line is that people who commit mass firearm homicides are simply insane. Therefore, the problem of firearm homicide is basically a public health issue; if we were sufficiently adept at identifying and treating mental illness, the problem of mass firearm homicide would go away. Not so, say experts in mental illness. Most mass murderers are not insane, and Americans are not more prone to mental illness than citizens of other countries in which mass firearm homicide is almost nonexistent. The explanation for the daily occurrence of mass firearm homicides in the United States is simply this: the easy availability of military grade weapons with high capacity magazines.

If what people do is any reflection of who they are, then Devin P. Kelley, who slaughtered 26 churchgoers recently in Texas, surely was a madman.

Before the atrocity, he had attempted to sneak weapons onto an Air Force base after making death threats to his superiors, according to a local police report. In 2012, he had escaped from a mental hospital in New Mexico to which he had been sent after assaulting his wife and fracturing his stepson’s skull. A video of the church killing reportedly shows Mr. Kelley working his way methodically through the aisles, shooting some parishioners, even children, at point-blank range.

“I think that mental health is your problem here,” President Trump told reporters after that particular killing spree.

It is true that severe mental illnesses are found more often among mass murderers. About one in five are likely psychotic or delusional, according to Dr. Michael Stone, a forensic psychiatrist at Columbia University who maintains a database of 350 mass killers going back more than a century. Although the figure for the general public is probably closer to 1 percent, many experts place that at a higher number.

Most of these murderers do not have any severe, diagnosable disorder. Though he was abusive to his wife, Omar Mateen, who killed 49 people in an Orlando nightclub, had no apparent serious mental illness. Neither did Stephen Paddock, who mowed down 58 concertgoers from a hotel window in Las Vegas.

Ditto for Dylan Roof, the racist who murdered nine African-American churchgoers in South Carolina in 2015, and Christopher Harper-Mercer, the angry young man who killed nine people at a community college in Oregon the same year.

Nor does anything in these criminals’ history — including domestic violence, like Mr. Kelley’s — serve to reliably predict their spectacularly cruel acts. Even if spree killers have committed domestic violence disproportionately more often — and this assertion is in dispute — the vast majority of men who are guilty of that crime never proceed to mass murder.

Most mass murderers instead belong to a rogue’s gallery of the disgruntled and aggrieved, whose anger and intentions wax and wane over time, eventually culminating in violence in the wake of some perceived humiliation.

“In almost all high-end mass killings, the perpetrator’s thinking evolves,” said Kevin Cameron, executive director of the Canadian Center for Threat Assessment and Trauma Response. “They have a passing thought. They think about it more, they fantasize, they slowly build a justification. They prepare, and then when the right set of circumstances comes along, it unleashes the rage.”

This evolution proceeds rationally and logically, at least in the murderer’s mind. The unthinkable becomes thinkable, then inevitable.

Researchers define mass killings as an event leaving four or more dead at the same place and time. These incidents occur at an average of about one a day across the United States; few make national headlines.

At least half of the perpetrators die in the act, either by committing suicide (Mr. Kelley is said to have shot himself in the head) or being felled by police.

Analyzing his database, Dr. Stone has concluded that about 65 percent of mass killers exhibited no evidence of a severe mental disorder; 22 percent likely had psychosis, the delusional thinking and hallucinations that characterize schizophrenia, or sometimes accompany mania and severe depression. (The remainder likely had depressive or antisocial traits.)

Adam Lanza, who in 2012 killed 26 people at Sandy Hook Elementary in Newtown, Conn., exhibited insanity characterized by extreme paranoia in the months leading up to his crime, isolating himself in his room.

But what to make of John Robert Neumann Jr., who in June shot and killed five former co-workers at a warehouse in Orlando before turning the gun on himself? Mr. Neumann was not overtly psychotic, as far as anyone knows, and this is far more typical of the men who commit mass killings generally.

“The majority of the killers were disgruntled workers or jilted lovers who were acting on a deep sense of injustice,” and not mentally ill, Dr. Stone said of his research.

In a 2016 analysis of 71 lone-actor terrorists and 115 mass killers, researchers convened by the Department of Justice found the rate of psychotic disorders to be about what Dr. Stone had discovered: roughly 20 percent.

The overall rate of any psychiatric history among mass killers — including such probable diagnoses as depression, learning disabilities or A.D.H.D. — was 48 percent. About two-thirds of this group had faced “long-term stress,” like trouble at school or keeping a job, failure in business, or disabling physical injuries from, say, a car accident.

Substance abuse was also common: More than 40 percent had problems with alcohol, marijuana or other drugs.

Looking at prior studies, and using data from his own work, J. Reid Meloy, a forensic psychologist who consults with the F.B.I., has identified what he believes is a common thread: a “paranoid spectrum,” he calls it.

At the extreme end is patent psychosis. But the majority of people on this spectrum are not deeply ill; rather, they are injustice collectors. They are prone to perceive insults and failures as cumulative, and often to blame them on one person or one group. “If you have this paranoid streak, this vigilance, this sense that others have been persecuting you for years, there’s an accumulation of maltreatment and an intense urge to stop that persecution,” Dr. Meloy said. “That may never happen. The person may never act on the urge. But when they do, typically there’s a triggering event. It’s a loss in love or work — something that starts a clock ticking, that starts the planning.” Mental health treatment might make a difference for the one in five murders who have severe mental disorders, experts say. Prevention is also possible in a few other cases — for instance, if the perpetrators make overt threats and those threats are reported.

But other factors must be weighed. “In my large file of mass murders, if you look decade by decade, the numbers of victims are fairly small up until the 1960s,” said Dr. Stone. “That’s when the deaths start going way up. When the AK-47s and the Kalashnikovs and the Uzis — all these semiautomatic weapons, when they became so easily accessible.”

               THE BOTTOM LINE?

Attempting to discover the vast numbers of people who possess mental disorders that might be potential murderers is clearly impossible. Even if we could detect those most likely to perform such acts, society’s rules usually preclude any attempts to force them to undergo treatment prior to any acts of violence. Thus the only possible countermeasures are—prior to all firearms purchases—careful background checks for past mental disorders or violent and/or other antisocial acts. This must also be coupled with rigorous general restrictions of assault weapens capable of rapid repetitive fire into multiple targets.

Perhaps the demented leaders of the N.R.A. should be brought in for mental evaluations prior to more mass shootings!

The ultimate irony? If one believes that insanity should disqualify all persons from gun ownership, then the opinions of 27 mental health experts (http://www.mortontavel.com/2017/10/09/) should be enough to prevent Trump himself from getting his hands on any lethal weapons, especially of the nuclear variety!

 

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THE REAL CAUSE OF OUR BROKEN HEALTHCARE SYSTEM

This nation spends 3 trillion dollars yearly on healthcare, representing 17% of our total economy, which is—per capita—about double that of other western nations. Of that total, 40-50% goes to hospital charges, 20-30%, to tests and other services, 20% to doctors, 15% to drugs and devices, and 5% to nursing homes.

Conventional wisdom teaches us that prices for healthcare should come down when subjected to “free-market” forces, i.e. supply and demand, like the pricing of automobiles, household goods, etc. But nothing could be further from the truth! When did we see hospitals advertise the lowest rates in town, or healthcare purveyors state that hip replacements or cataract surgery was going on sale next month—or any month? Or, when confronted by an emergency, the cost of an ambulance would be based upon a prearranged lowest competitive price to transport a stricken patient to a nearby hospital offering competitive daily occupancy rates? And this extends to virtually all of healthcare. If we are lucky enough to possess good insurance, we may not worry about these charges, but history shows that once a procedure is covered by insurance, its sticker price generally goes up because patients (and physicians) are largely insulated from the costs, and this further prevents a “free market.”

In the face of rising healthcare costs in the early 20th century, Medicare first entered the market and covered usual charges from 1965 until the 1990s, but because of rapidly increasing charges, Medicare began limiting payouts, which served as a partial restraint on some of the rising charges: For instance it applied a system to bundle and restrain allowable hospital charges for given diseases/and or treatments. Also Relative Value Units extended to physicians’ compensation. But such limits don’t extend to private insurance or to the uninsured, unless by negotiated agreement.

Working through private insurers, the ACA (Obamacare) has provided some financial support for people needing insurance, but it also provided no effective means to control healthcare charges, which are continuing to spiral even higher. Notwithstanding Medicare, there are no real limits on most charges, meaning that most healthcare facilities can charge what they wish, free of any governmental or outside interference.

For instance, hospitals can pad their bills through the use of inscrutable charges that include all sorts of add-ons such as “facility fees,” needles, pills, laundry, multiple doctors, various tests etc. Moreover, excessive hospital charges encompass administration that often rewards CEOs with millions of dollars yearly, includes billing and collection costs, extensive gardens and physical additions, etc. Despite their being called “non profit,” most hospitals are de facto private entities, calling profits “operational excesses” and reaping the benefits of the avoidance of local taxes, while, at the same time, encouraging tax deductible contributions.

With regard to drug prices, there are no effective restraints on pharmaceutical companies’ charges. Unlike other countries, our government-run Medicare program is prohibited by federal law from negotiating lower drug prices with manufacturers. Prices for newer patent protected drugs are often excessive, and overcharges for older, generic drugs are also commonplace. In the case of certain cheaper generic drugs whose interest and availability are waning, they may become subject to a single company’s seizure of exclusive control of limited supplies, and then becoming a de facto monopoly, allowing for prices to suddenly surge to stratospheric levels. Collusion between competitors has also been alleged as another means to raise these latter prices.

In contrast with all western countries save New Zealand, pharmaceutical companies in the U.S. are legally allowed to advertise prescription drugs on television, provided that they list various side effects and dangers as well. Predictably these products are regularly expensive and may or may not be superior to older generics. Advertising costs these drugs generally account for about 30% of the companies’ expenditures, whereas research in new drug development amounts to a paltry 15%.

In order to deal with our broken healthcare system, we can learn from other countries’ experiences. Although some pundits claim otherwise, our outcomes are clearly not better than those of other advanced countries, meaning that our profuse money outlay is largely wasted. Although there are several contrasting methods, they all contain governmental price controls and universal participation. The best examples are provided by Germany, Japan and Belgium, in which rates for all services are set that include upper caps. In Germany, for instance, most individuals must purchase state sponsored insurance, with premiums based upon one’s income. Private insurance is allowed and may supplant the base insurance for the few who can afford deluxe services. Canada, Australia, the United Kingdom and Denmark, use variants of a single payer system, all of which couple price limits for services together with a mandate that the entire population will be insured.

The U.S. could adopt any of these methods, but a single payer (“public option”, or Medicare for all) would seem to be the most cost-effective. Administrative costs for Medicare average about 2-3%, in comparison to about 20-30% of most private insurers.

Expanded Medicare would not preclude the addition of supplemental private insurance, as we now have in combination with its basic coverage. An overall plan directed by the single payer must be empowered to control prices for all methods and procedures, allowing us to approach costs of other western countries. A single payer system would also simplify record keeping and unify documents, reducing time required by physicians and office personnel. It could be phased in gradually by lowering age eligibility for Medicare.

Given these facts, the underlying problem becomes clear: We are overpaying for virtually all components of our health care system, and governmental restraints on charges are necessary. This must be coupled with universal participation.

 

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Price-fixing collusion: Another reason for drug price gouging

A large group of U.S. states accused key players in the generic drug industry of a broad price-fixing conspiracy, moving on Tuesday to widen an earlier lawsuit to add many more drug makers and medicines in an action that sent some company shares tumbling.

Mylan Labs CEO, Heather Bresch, was sworn in before a House Oversight and Government Reform Committee hearing on the Rising Price of EpiPens, at the Capitol in Washington September 21, 2016. The lawsuit, brought by the attorneys general of 45 states and the District of Columbia, accused 18 companies and subsidiaries and named 15 medicines. Shares of Pennsylvania-based Mylan, named as one of the defendants, closed down 6.6 percent.

The states said the drug makers and executives divided customers for their drugs among themselves, agreeing that each company would have a certain percentage of the market. The companies sometimes agreed on price increases in advance, the states added.

The states said company leaders had communicated directly to agree on their companies’ shares of the market for a delayed-release version of a common antibiotic, doxycycline.

“It is our belief that price-fixing is systematic, it is pervasive, and that a culture of collusion exists in the industry,” Connecticut Attorney General George Jepsen, who is leading the case, told a news conference in Hartford.

Mylan said in a statement it had found no evidence of price-fixing by the company or any of its employees, and vowed to defend itself vigorously. Mysteriously, the company’s second-ranking official, has received more than $50 million in compensation over the past three years, last year making more than its CEO Rajiv Malik.

“Mylan has deep faith in the integrity of its president Malik, and stands behind him fully,” the company said.

Emcure, also a defendant in the case, did not immediately respond to a request for comment.

Two former executives of Emcure’s subsidiary Heritage Pharmaceuticals pleaded guilty in January to federal charges of conspiring to fix prices and divide up the market for doxycycline and the diabetes drug glyburide. The two men, former Heritage president Jason Malek and former chairman and chief executive Jeffrey Glazer, reached a deal with 41 states and territories in which they each agreed to pay penalties of $25,000 and cooperate with the state probe.

Soaring drug prices from both branded and generic drug manufacturers have sparked outrage and investigations in the United States.

Executives like Mylan’s Bresch and former Turing Pharmaceuticals CEO Martin Shkreli have been called in front of Congress to defend the cost of their products.

MORE COMPANIES TARGETED

      The original complaint, filed in December, targeted Mylan, Heritage, Aurobindo Pharma USA Inc, Citron Pharma LLC, Mayne Pharma USA Inc and Teva Pharmaceuticals USA Inc.

The states are pressing a new complaint that would add Novartis AG’s unit Sandoz, India-based Sun Pharmaceutical Industries Ltd, Endo International PLC’s unit Par Pharmaceutical, Dr. Reddy’s Laboratories, Apotex Corp, Glenmark Generics Ltd, Lannett Company Inc, Alkem Laboratories Ltd’s unit Ascend Laboratories and Cadila Healthcare Ltd’s unit Zydus Pharmaceuticals Inc.

Jepsen said the investigation is continuing, and that claims would likely be brought against more companies, and possibly executives, in the future.

The news hurt shares of companies named in the expanded suit that are traded in the United States. In addition to Mylan’s drop, Lannett lost 13.7 percent. Shares of Endo were up 7 percent, but down from their 12 percent peak before the news of the amended lawsuit.

Teva spokeswoman Denise Bradley said the company denied the allegations. Endo spokeswoman Heather Lubeski said the company would vigorously defend itself against the claims. Other companies did not immediately respond to requests for comment.

The expansion of the suit requires the court’s permission.

The original lawsuit centered on just two medicines, delayed-release doxycycline and glyburide.

The price of doxycycline rose from $20 for 500 tablets to $1,849 between October 2013 and May 2014, according to U.S. Senator Amy Klobuchar, a Minnesota Democrat who had been pressing for action on high drug prices.

The amended complaint would expand the number of drugs to include glipizide-metformin and glyburide-metformin, which are among the most commonly used diabetes treatments.

Others include: acetazolamide, which is used to treat glaucoma and epilepsy, the blood pressure medicine fosinopril; the anti-anxiety medicine meprobamate; and the calcium channel blocking agent nimodipine.

The U.S. Justice Department is conducting a parallel criminal investigation. On Friday, the department asked the Pennsylvania court presiding over the lawsuit to put the lawsuit’s discovery process on hold, saying it could interfere with the criminal probe.

Connecticut Assistant Attorney General Joseph Nielsen said recently that states would likely oppose that request, which could slow the lawsuit.

     This should provide a sober reminder that, despite the profuse numbers of “free market,” enthusiasts, government vigilance and intervention are absolutely necessary to prevent the public from being robbed!

 

 

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WHAT CONSTITUTES A HEALTHY BREAKFAST?

Although there are sound medical reasons for eating breakfast every day, when I look at the typical breakfast food offerings at many restaurants, supermarkets, and food trucks, and I think about the health of our nation, it’s sad! Muffins, bagels, donuts, pancakes, waffles, French toast sticks… Want some bacon, sausage, or fried potatoes with that, sir?

We are traditionally led to believe that a “well-balanced breakfast” consists of a big bowl of cereal and a few decorative strawberries on top, with a tall glass of orange juice. We believe that you need the calcium in that milk, that vitamin C in that orange juice, and the carbs in that cereal for energy. But do you?

Eating like this may be okay once in a while, but if you do so often, I guarantee these foods will make you both fat and sick, sooner or later!

Why are familiar breakfast foods not great for you?

Simply put, to the cells in your body, a bowl of cereal, or a bagel, or a piece of toast, or a muffin are all no different than a dessert. Processed carbohydrates and sugars cause blood sugar and insulin levels to rise. The insulin easily ushers all that sugar into your fat cells, where it becomes stored energy, also known as body fat.

The animal fats in bacon, sausage, and butter can clog up arteries and lead to heart attacks and strokes. Cured meats and other processed foods a cause trouble for several reasons, especially because the high salt content causes us to retain water and pushes the blood pressure up. This is all a recipe for weight gain, obesity, high blood pressure and cholesterol… and eventually, heart disease.

So… what should we eat for breakfast?

The answer is basic healthy eating advice: fruits and vegetables, whole (unprocessed) grains, and healthy proteins and fats. This is not a trend, this is not a hippie opinion. The evidence is overwhelming. And I love bacon. But, I treat it with respect because it can (and does) cause great harm to the human body if eaten often.

But many people need more guidance than just a list of food groups, including how to do so when you have a busy life.

So here’s what I suggest:

If you’re often on the go, your may need something quick, easy, transportable, and budget-friendly. So, try putting together an easy fruit/yogurt/grain/nut bowl every single day. Here’s a possible three-ingredient recipe:

  • Frozen fruit: berries, mixed fruit, fruit with kale bits, whatever. Fruit is frozen at the peak of freshness, so the quality and vitamin content can be better than what’s in the produce aisle. Try buying large bags of frozen mixed berries at the wholesale club or discount grocery, as they are much more economical than fresh and don’t go bad.
  • Nuts and/or seeds and/or grains of your preference: for example, unsalted nuts, toasted seeds or grains, or a combination such as a low-sugar granola.
  • Your favorite yogurt, ideally plain or low-sugar.
  • Eggs are no longer considered anathema, so an occasional one or two are OK, and consider hard-boiled, especially if you’re on the go.
  • More leisurely breakfast at home: You might add whole-grain toast, but make sure it contains whole grain on the label, contains less than 180 mg. of sodium and fewer than 110 calories per slice, with no saturated or trans-fats. But be careful what spread you place on top: Instead of butter, consider cholesterol-lowering sterols/stanols such as Benecol, but others containing olive oil are also acceptable.

Why is this a healthy breakfast?

The fruit is not a token sprinkle, nor a decorative touch. The fruit makes up the bulk of this meal. There’s fiber in the fruit (but little in most juices), and plant sugars in their natural form, not to mention healthy fat in the nuts, and protein in the yogurt. A low-sugar yogurt will leave us feeling more satisfied, for longer. We won’t get the insulin spike that triggers hunger pangs (unlike when we eat processed carbs).

If you want to step it up a notch, ditch the dairy. We can get plenty of calcium and other vitamins from leafy greens and other veggies, so take your choice. At any rate, consider yogurt, for it contains not only creamy protein and probiotics, which can be weighed against the recognized risks of regular consumption of animal products that should be limited as much as possible. The rest is up to you.

Enjoy!

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A Little Known Toxin, Acrylamide, and Reasons to be Concerned

Acrylamide is a neurotoxin and probable carcinogen (cancer causing agent) formed when certain starchy foods, such as wheat and potatoes, are cooked at high temperatures (>248 degrees Fahrenheit). It can also be produced when coffee and cocoa beans are roasted. It is also found in surprisingly high amounts in prune juice and some types of canned olives. Although no level of exposure is absolutely safe, amounts of acrylamide consumed by most adults are believed to represent a very low level of risk. Nevertheless, there are steps you should be aware of in order to reduce your exposure.

What levels are considered “safe”

Exposure to even extremely small amounts of acrylamide may very slightly increase cancer risk, which has led the State of California to require a cancer warning on foods providing more than 0.2 mcg of acrylamide per daily serving (below which there is no known significant risk of cancer), although up to 140 mcg is permitted before a warning regarding reproductive toxicity is required. The U.S. EPA also uses this higher 140 mcg amount as its reference dose for risk to the nervous system.

How much is in what we eat?
An adult weighing 150 lb consumes about 35 mcg of acrylamide per day (0.5 mcg/kg of bodyweight). This is well below the 140 mcg EPA limit, although exceeds California’s very stringent limit of 0.2 mcg, noted above.

In the U.S., fried potato products (i.e., French fries, potato chips, roasted potatoes) account for the greatest source of acrylamide in the diet, accounting for up to 38% of average exposure for adults, followed by crackers, cookies and cakes (17%), bread (14%), snacks such as roasted nuts, and popcorn (14%), cereal products (9%), and lastly, coffee (8%).  High amounts of acrylamide are also found in products that you might not expect, such as in prune juice and canned olives.

A study of prune products purchased in Canada, for example, disclosed that regular pitted prunes contained about 10 mcg of acrylamide per 7 prunes but organic pitted prunes contained only about one-third of that amount.; however, organic prune juice contained even higher amounts of acrylamide — about 100 mcg per 5 oz serving (a small glass), while regular prune juice contained about half that amount.

Canned black olives can contain as much as 8 mcg of acrylamide per 5 olives, while California-style green ripe olives contain much lower amounts — about 1 mcg per 5 olives.

To get a better sense of how much acrylamide this may be (and how this compares to the EPA’s limit of 140 mcg of acrylamide per day) see the table below:

Estimated amounts of acrylamide in common foods

Food Serving size Acrylamide per serving (mcg)
French fries, oven-baked 2.5 ounces (about 12 fries, depending on size) 48.8 mcg
Prune juice 5 ounces 30 mcg to 100 mcg
French fries, restaurants 2.5 ounces (about 12 fries, depending on size) 28.3 mcg
Potato chips 1 ounce (about 15 chips) 17.9 mcg
Canned black olives 5 olives 3.2 to 8 mcg
Breakfast cereal 2 ounces (1/4 cup) 6.6 mcg
Brewed coffee 8 ounces 1.9 mcg
California-style green ripe olives 5 olives 1 mcg

Coffee
Green coffee beans contain asparagine (it is the second-highest concentration amino acid in coffee beans) as well as sucrose (sugar). When roasted, significant amounts of acrylamide can be produced; however, brewed coffee (most of which is water) contains only about 2 mcg per 8-ounce cup, as shown above.

Cocoa and chocolate
As with coffee beans, cocoa beans are typically roasted during processing, resulting in the production of acrylamide. FDA tests of various cocoa powders and dark chocolate baking bars in 2002 showed amounts of acrylamide ranging from 0.29 mcg to 4.5 mcg per serving; however, there was no detectable acrylamide found in a popular milk chocolate bar.

It is likely that raw cacao contains much lower concentrations of acrylamide than cocoa and dark chocolate, as it is not roasted at high temperatures: For example, Viva Naturals claims that it’s raw cacao is lightly roasted at a maximum temperature of 114 degrees Fahrenheit, and Navitas Organics claims it is fermented only with the heat of sunlight for 24 to 48 hours. There is no regulatory definition of the term “raw” on foods, but it tends to mean minimally processed without high heat.

What can you do to reduce your acrylamide intake?

Potatoes
Limit your intake of roasted, baked and fried potatoes, chips, etc. Store raw potatoes in a cool dry place, such as a pantry or cupboard — not in the refrigerator, as the cold temperature increases the amount of sugars in potatoes, increasing acrylamide generation during high-heat cooking. Fry at the lowest possible temperature for the shortest possible amount of time (aim for a golden yellow color rather than golden brown). Soaking sliced potatoes in water for 15 to 30 minutes (or for 5 minutes in warm, slightly salted water) before frying or roasting may also reduce acrylamide formation.

Prunes and Olives
Limit your intake of prune juice. Choose green olives over black.

Coffee
Several factors can modestly reduce the amount of acrylamide in your coffee when prepared at home:

  • Choose coffee made from Arabica beans, which contain lower amounts of asparagine than Robusta beans. However, be aware that this won’t guarantee lower acrylamide, since amounts are also affected by roasting time, temperature, etc.
  • Store coffee before using for longer periods of time. Acrylamide levels in commercial ground coffee and beans decrease over time when stored in their original container. Reductions of 40—60% have been reported in coffees stored at room temperature over a period of 6—12 months.
  • Plunger pot and filtered, drip brew coffee preparation typically results in less acrylamide than coffee prepared by decoction (such as Turkish coffee) and pressure preparation (French press, expresso).

Cocoa and chocolate
Milk chocolate and alkalized cocoa products may contain less acrylamide than non-alkalized dark chocolate, but, unfortunately, will also contain lower amounts of healthy flavanols. As noted earlier, “raw” is likely to be low in acrylamide while, as shown in most tests, relatively high in beneficial flavanols.

The bottom line:
Acrylamide is a neurotoxin and probable carcinogen formed when cooking certain foods at high temperatures. Fried and roasted potato products are the greatest source of dietary acrylamide exposure in the U.S. Prune juice has particularly high amounts. Brewed coffee and cocoa contain small amounts of acrylamide. It is possible to reduce exposure to acrylamide by avoiding certain foods and modifying the way you prepare potatoes and coffee, as discussed above.

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ANALYSIS OF TRUMP: THE PSYCHIATRISTS FINALLY STEP FORWARD

The Goldwater rule: Section 7.3 of the American Psychiatric Association, code 2013, states “It is unethical for a psychiatrist to offer a professional opinion on a public figure unless he or she has conducted an examination and has been granted proper authorization for such a statement”. But this doctrine does not extend to information derived from the professional analysis of public behavior that could endanger the security of an entire nation, or even the world!

Thus a large body of professionals has broken this self-imposed silence and recently released a book entitled “The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President”, Edited by Bandy X Lee, M.D.

When assessing Trump’s behavior, the layman often states that he is “crazy like a fox,” implying that, as a presumably rational human being, Trump is merely cleverly twisting and manipulating information as a ploy to gain some advantage for the benefit of his political followers and/or society at large. But, as made amply clear by this large group of well-qualified mental health professionals, this is clearly not the case! Accuracy requires the removal of the word “fox” from this statement above, simply yielding “crazy like a crazy.” Moreover, the frequently expressed sentiment that Trump, once reaching the White House, will pivot to a rational demeanor, is clearly refuted by these experts, which, as they presciently state, will only worsen. These professional opinions also transcend all political affiliations.

Through the opinions written by this large number of mental health professionals, an overwhelming unanimity is expressed: We are dealing with a dangerously and psychopathically ill individual. The eccentricities of Trump’s behavior are known by almost everyone, but they are often misinterpreted: Examples include distorting facts and outright lying (he had the largest inaugural crowd ever), megalomania (he knows more than the generals), bullying and denigration of rivals (crooked Hillary, low energy Bush, little Marco, etc), excessive need for adulation (as demonstrated by the sycophantic and apparently forced statements made by his cabinet members), lack of empathy (let’s injure family members of terrorists), paranoid delusions (Obama has wiretapped the Trump Tower), intolerance of criticism, failure to admit errors, revering foreign despots whom he wishes to emulate, and many others.

As one pages through the psychiatric opinions of the book noted above, it is apparent that Trump’s many bizarre characteristics stem from serious mental aberrations that many would consider “psychotic.”  The disease name that most often crops up is that of “malignant narcissism,” a serious disorder that underlies his many delusions, distortions and lies, which actually represent extreme overreactions from deep-seated feelings of shame and inferiority. Making matters even more dangerous, he actually believes them to be true!

These professionals are especially fearful of the proximity of this individual to the nuclear trigger. They believe that he is capable of—through an episode of rage or irrationality—triggering a major war. The consensus of these professionals is that such a dangerously ill individual should be removed from office by any legal means as soon as possible. Thus it is important for all responsible citizens to understand what is at stake and to act accordingly.

Above all, read this book, and if you agree with me that it is important, spread the word far and wide!

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