Welcome to the second episode of our podcast series, “Allergy, Asthma & Immunology Innovations Podcast.” This podcast episode is “What is Controlled Asthma: Everything You Need to Know” It examines the difference between controlled asthma and uncontrolled asthma and how patients and families can better manage asthma to keep it from becoming uncontrolled.
The podcast is a joint collaboration between Allergy & Asthma Network and The Itch Podcast. It’s hosted by The Itch Podcast’s Kortney Kwong Hing and allergist/immunologist Payel Gupta, MD. Allergy & Asthma Network thanks AstraZeneca for their funding support to make “What is Controlled Asthma: Everything You Need to Know” possible.
You can also listen to or download the podcast on ItchPodcast.com for listening anytime, anywhere. The podcast can be downloaded at:
1:30 – What is asthma? A quick overview by Dr. Gupta
2:35 – A closer look at mild, moderate and severe asthma
4:25 – Medications and treatments to help control asthma
7:06 – The Rules of 2 for asthma
9:18 – Keeping asthma under control and using your inhaler correctly
13:48 – Long-term effects of asthma: airway remodeling
15:50 – Asthma triggers and the September Asthma Peak
18:00 – What is an Asthma Action Plan?
20:12 – What your Asthma Action Plan tells you about what it’s time to see a doctor
22:20 – Type 2 inflammation and asthma
28:08 – Free virtual asthma coach – how they can help people with asthma
In the second episode of the Allergy, Asthma & Immunology Innovations podcast series, Kortney Kwong Hing and Payel Gupta, MD dive into the topic of controlled vs. uncontrolled asthma. How do you know if you have uncontrolled asthma? Dr. Gupta cites the Rules of 2 as one way to find out.
What are the Rules of Two?
Rules of TWO®
When is quick relief for asthma NOT ENOUGH?
- Take your quick relief inhaler more than TWO TIMES A WEEK?
- Awaken at night with asthma more than TWO TIMES A MONTH?
- Do you refill your quick relief inhaler more than TWO TIMES A YEAR?
- Use prednisone TWO or more times a year for flares of asthma?
- Measure changes in peak flow with asthma symptoms of more than TWO TIMES 10 (20%)?
If you answer yes to any of the questions talk with your doctor.
Some people mistakenly call quick relief medications “rescue” medications but this is a life-threatening misunderstanding.
Quick-relief bronchodilators should be used to relieve breathing at the first sign of symptoms – the earlier you use the medication, the less you are likely to need.
Kortney and Dr. Gupta shed light on various aspects of asthma, including its types, severity levels, medications, and the importance of an Asthma Action Plan. They focus on how Type 2 inflammation can cause or worsen asthma.
Avoidance of triggers – ragweed pollen, mold and respiratory viruses are primary culprits – is the key to managing asthma during the September Asthma Peak, Dr. Gupta says. This is a time of year when cases of asthma flares that require hospitalization tend to spike. Asthma management strategies are essential at this time of year.
Finally, Kortney and Dr. Gupta also discuss how an Asthma Coach can help people better manage their asthma. They mention Allergy & Asthma Network’s free virtual asthma coaching program.
Kortney Kwong Hing: You’re listening to The Itch, a podcast exploring all things allergy, asthma and immunology. I’m your co-host Kortney, a real-life allergy, asthma and eczema girl.
Payel Gupta, MD: And I’m your second host, Dr. Payel Gupta, a board-certified allergy, asthma and immunology doctor. Kortney and I hope to balance each other out so that we get you all the information that you want and need about allergies, asthma and immunology.
Kortney: Today we’re exploring what it means to have controlled asthma. I thought my asthma was well handled, but it most definitely was not, which is actually one of the reasons why I felt so strongly about starting this podcast with Dr. G. This is why, for our second episode in our Allergy, Asthma, and Immunology Innovations podcast series, in collaboration with Allergy & Asthma Network, we’re taking on the topic of what controlled and uncontrolled asthma looks like.
Before we jump in, we want to thank Amgen for their funding support to make this podcast possible. Just so you guys know, we aren’t going to get into the nitty gritty of asthma today because we’ve actually covered this in depth in episode 7, so check that out if you’re really looking for some more details.
Today we’ll start out with a quick rundown on asthma, and then we’ll get right into the whole idea of what is controlled asthma. So welcome Doctor G, and can you give us a rundown on what is asthma?
Dr. Gupta: Asthma is a chronic lung condition. When people have asthma, they cannot get enough air into their lungs because of two things. One, there is swelling that occurs in the breathing tubes. Which we call inflammation that leads to a closure of the tubes that normally allow air to go in. And then the second thing is that the muscles around the airways also tighten up because of different triggers that the person is exposed to. So those two things put together lead to a closed-off airway where someone can’t get enough air into their lungs.
Kortney: Super, thank you. That’s a really good Cliff’s Notes for asthma. That’s all we’re giving you guys today for what is asthma, but we’re going to get into some more details. So I know that there are a lot of different types of asthma, and I’ve also heard three different terms used to describe asthma: mild, moderate and severe. Dr. G, can you tell us a little bit about the different types of asthma and then what that means if your asthma is mild, moderate or severe?
Dr. Gupta: Yes, so there are various types of asthma based on different factors, triggers and clinical characteristics. When we look at these different types of asthma, we’re focused on what are the different triggers that cause a person’s asthma. And then also what is that underlying mechanism that might be causing them to have asthma or that inflammation in their body.
When we look at someone’s asthma, we also look to see, ‘Do they have mild asthma, moderate asthma or severe asthma?’ This is important because it really allows us to treat the person’s asthma in different ways.
So when someone has mild asthma, they will have occasional symptoms only when they’re exposed to certain triggers. For example, this person might only have asthma when they’re doing a lot of exercise, or when they’re sick with a cold or a virus. But in between these episodes, they’re completely fine. They’re not having symptoms at night or in the daytime when they’re doing normal activities.
People with moderate asthma will have more frequent symptoms than someone with mild asthma, and may experience symptoms on a weekly basis. And they may have nighttime symptoms several times a month. With moderate asthma, your lung function will be compromised.
People with severe asthma have more frequent symptoms and will likely have symptoms almost daily. They require medication to resolve these symptoms. And their lung function testing will definitely be lower than that with a person with moderate asthma.
Kortney: So I take it that depending on whether you have mild, moderate or severe asthma, that’s kind of how you gauge where you’re going to go with treating that asthma. In that regard, can you talk a little bit about what you do to treat asthma?
Dr. Gupta: There are two different categories of medication and asthma treatment. We label them as rescue medication and controller medications. So the rescue medication is what you would reach for if you’re having an asthma exacerbation and your lungs feel like they’re tightening up. That’s the medication that you would go to for help opening up those airways quickly. That’s the medication that really works on those airway muscles and helps open those muscles up.
Now we’re also starting to add in a little bit of some antiinflammatory medication with our rescue medications. But in general, the rescue medications open up the muscles and then control our medications. They help really with that inflammation or that swelling in the airways and that’s what we’re targeting when we’re looking at controller medications.
So if you have mild asthma, you generally only need rescue medication or the emergency medication when you have moderate or severe asthma. Then we’ll put you more on that controller medication to control that underlying inflammation in your airways. So again, I’ve talked about inflammation when someone has moderate or severe asthma, they have more of that inflammation in their airways and we need to treat them with an antiinflammatory medication to keep that inflammation down.
The medications that can be used as controller medications include inhalers that have steroids in them and other medications. They also reduce inflammation like leukotriene inhibitors and then biologic medications for people with more severe asthma. So we have an entire episode on biologics if you want to learn more about these medications. And that episode number is 56.
Kortney: Okay, you’ve got these medications, so how do you know if they’re actually working?
Dr. Gupta: So once your doctor puts you on these medications and creates a plan for your asthma, or what we call an Asthma Action Plan, we give your body two to four weeks to see how you’re doing. So you should start feeling better slowly as the inflammation in the airways starts to go away. Really we want you to check in with your asthma doctor more frequently during this time, as we’re trying to get your asthma under control so that we can really get you on the right medications to help keep that inflammation down, if you do have signs of inflammation.
Kortney: So now you’ve got your medication and you’ve got a routine. What constitutes good asthma control?
Dr. Gupta: Good asthma control means that you really have minimal asthma symptoms with no daily activity limitation. Essentially, our goal is to take someone with moderate or severe asthma and have them look more like a mild asthmatic.
We really use the Rule of Twos for asthma control. There are some simple questions that we can ask you quickly to see if your asthma is under control or not.
Do you have symptoms more than two days a week? If a person’s asthma is not doing well, then they’ll be wheezing, coughing, having shortness of breath or chest tightness more than two days a week. It suggests that their asthma is not well controlled.
Do you use your quick-relief medication more than two times a week, or that rescue medication more than two times a week? If a person needs to use their quick-relief medication often, then that also means that their asthma is not controlled.
For nighttime symptoms – so we’ve talked about this before with asthma. But there is a circadian rhythm to asthma, and nighttime awakenings are common for people with uncontrolled asthma. So if someone’s waking up more than two times a month, that can mean that someone’s asthma is not well controlled.
And lastly, if someone’s asthma is causing them to go to the doctor and get what we call oral corticosteroid medications, that’s also a sign that their asthma is not well controlled. Some say it’s if you’re using oral corticosteroids twice a year, but for me, even once a year means that we really need to look at what’s going on with that person’s asthma. And we need to make sure that we have them on the right treatment plan.
Kortney: I know that when we first met, I actually had three of the four things to look out for that say that you have uncontrolled asthma. Honestly, I thought everything was normal, but after spending a whole day with you, I found out very fast that I had uncontrolled asthma.
So those are just small things that happen in your everyday life that you might not realize are asthma-related but if you are getting any of those Rules of Two, then definitely go talk to your doctor about your asthma.
That being said, how does asthma even get out of control?
Dr. Gupta: So asthma can get out of control for a lot of reasons. The number one thing is we have to make sure as a team, as your doctor and as the patient, that we have you on the right medications. And once we’ve developed that asthma treatment plan or Asthma Action Plan, then we have to make sure that you’re following that Asthma Action Plan – and that you’re able to take the medications that we’ve determined are important for your asthma to stay under control.
We always want to work together as a team to say, ‘You know what, this medication doesn’t feel like it’s going to work for me because I don’t think I can take it this many times a day or I don’t think that I want to use an injectable medication for my asthma it just doesn’t make me feel comfortable.’ Those are the kind of conversations that you really need to be able to have with your doctors so that you can really follow your Asthma Action Plan.
I just wanted to emphasize that a lot of the time people don’t realize that it is important to use Shared Decision-Making, which is a term that we use in medicine to say that it should be shared decisions. You really should be asking your doctor, ‘Are there other options because I don’t feel comfortable doing XYZ .’ And so there are a lot of different ways that you can treat asthma and so talking to your doctor and making sure you’re both on the same page is important.
You might not be using the medications properly because you haven’t been taught how to use them properly. And so really good inhaler technique is very important. Using a spacer for your inhaler is important. If you don’t know what that is, then you should talk to your doctor about that.
You might be in a situation where you’re exposed to a lot of your asthma triggers, and that might be causing your asthma to be out of control. You might be sick with a cold or an infection of some sort that can lead to inflammation in your airways, and that can also lead your asthma to be out of control. So there’s a lot of different reasons that asthma can be considered out of control.
Kortney: That’s a lot to think about and a lot to look out for. And I’m curious because, you know, I was fine. I thought I was fine living with my uncontrolled asthma until it was controlled and I realized, ‘Oh my goodness, I was definitely not fine.’
But for those who are, you know, just going about their daily life with their uncontrolled asthma, why is it so important for them to get their asthma under control? Not only is it just because it makes you feel way better, but there’s probably a lot of other reasons why you need to get your asthma under control.Dr. Gupta: So good asthma control – the reason that we’re so focused on it is because, again, it’s caused by those two different components: the inflammation and the tightening of the muscles around the airways. What we’ve emphasized today is that inflammation in the airways and inflammation or swelling of any sort is actually very difficult to get rid of quickly.
If you think about it, if you’ve ever had a cut on your hand or anywhere, right, and you have swelling in that area, it takes time for that swelling to go away. That’s the same thing that’s going on in your airways, you just can’t see it. That inflammation is what we’re really most worried about if you are exposed. Something that causes your asthma to get worse, like a cat that you’re allergic to or someone smoking, and all of a sudden the muscles around your airways tighten up. Then you have release of chemicals that cause even more inflammation and that tube that you’re trying to breathe out of gets even smaller and if you have a lot of inflammation or swelling that’s blocking that tube already, then we can get into a really scary situation where the doctors can’t do anything to open up those airways quickly enough. We can lose the airway, which means that we can’t put oxygen into your body, which can create a very dangerous situation. So the more that we can reduce that inflammation, the better it is.
Kortney: It’s interesting that you say that this is inflammation we can’t see and I’m just thinking about my eczema. I can see when my eczema is inflamed, and I know that prolonged inflammation for my eczema can lead to scarring, and that makes me wonder, is it the same thing for asthma? Are there long-term effects of having prolonged, uncontrolled inflammation in your airways?
Dr. Gupta: That is a great question. When we have inflammation in the airways and that process is not controlled, the inflammation is not controlled. It can cause something called airway remodeling. If you think about the word remodeling, that basically means that there are structural changes that are occurring within the airways.
Essentially we don’t want to remodel any part of our body, we want it to stay natural and so when airway remodeling occurs, it just causes changes and restrictions in the way that air flows into the airways and that’s not something that we want. So yes, chronic inflammation can do that.
Kortney: All right. If anyone seriously needed a reason why they need to control their asthma, I think this is one of the biggies. Just to reemphasize it and to make sure that I understood it correctly, basically your airway becomes thicker because you’ve had all of this uncontrolled inflammation, which then essentially thickens your airway and there’s less space for air to enter. And when there’s less space for air to enter, it’s harder to breathe. And I can also imagine that if there’s less space for air to enter, the more inflamed you are, the less space you’re going to have for air to enter. So is this something that’s very common in asthma patients?
Dr. Gupta: It’s something that we’re trying to prevent by using medications early and consistently, especially in those patients with moderate or severe asthma. Because once the airway remodeling starts, then it’s difficult to bring the airways and the lungs back to where they originally were, and essentially we kind of consider them to be permanently damaged, for lack of a better term.
Kortney: One thing you’ve mentioned a couple of times already are triggers, and I was wondering if we could just dive into those for a quick second. What are triggers and why are they important for controlled asthma?
Dr. Gupta: An asthma trigger is essentially a term that we use for different substances, conditions or activities that can lead to someone’s asthma essentially being triggered or being exacerbated so it’s something that causes the asthma to worsen. And so these triggers can really vary from person to person and not everyone will be sensitive to the same triggers.
We want to highlight one particular time of the year called the September Asthma Peak week, which is at the beginning of the school year. And it’s a time in the U.S, when we see a lot of complications and people coming in with their asthma being worse than it normally is. And the reason for that is this is when kids go back to school, or even adults that are in school go back to school, there’s a lot of people gathering, which causes the exchange of germs and bacteria and viruses. And so people will bring those back to their homes and it causes everyone around them to get sick.
The weather also changes and starts getting colder and that can be a risk factor for people. And then thirdly, an increase in the allergens in the air, particularly ragweed pollen is higher, and then also people are staying indoors more and maybe exposed to dust mite allergens.
So really, knowing what your asthma triggers are is important. Because as you can see, there’s so many different things that can trigger someone’s asthma and knowing what your body gets triggered by is important so that you know, if you’re going to be in someone’s house with a cat, you definitely need to take inhalers with you.
Kortney: How do we maintain controlled asthma? And I know that a buzzword that I’ve heard is Asthma Action Plan. So, Dr. G, what the heck is an Asthma Action Plan?
Dr. Gupta: An asthma action plan is really what it sounds like. It’s a plan for you and your asthma. It’s a personalized document that you can create with your healthcare provider that really outlines the specific instructions that you need to follow for your asthma.
There’s going to be what we call the Green Zone and that Green Zone is really a green light for when you’re doing really well. These are the medications that you need to take on a daily basis. For somebody with mild asthma, they might not have anything in that category, But for somebody with moderate to severe asthma, they will have something that they’re taking on a daily or weekly basis. And so we write that down in that Green Zone.
And then there’s the yellow and red zone. So the yellow zone will be where you’re having some mild symptoms. It explains what you can change or what you’re taking so that we can prevent those mild symptoms from getting worse. And then the red zone is when you’re really having a lot of symptoms and those are all outlined in your Asthma Action Plan. And if you’re having those particular symptoms, then what are the steps that you can take to get your asthma back under control? It’s just important that we have the action steps on what you can do to get your asthma back to where it needs to be so that you don’t run into problems, where then you’re needing to get a higher level of care.
An Asthma Action Plan is really important for somebody with asthma or somebody who’s taking care of somebody with asthma. It really just gives you a guide on how to take care of the asthma and how to change the plan if things aren’t going the way that you normally expect them to be going. And it’s really important to update that plan regularly with your doctor or just to make sure that there are no changes and then.
In addition, now with our phones, I also like to tell people that they can take a picture of their Asthma Action Plan and keep it in a separate healthcare folder in their album section so that you always have that Asthma Action Plan accessible.
Kortney: It sounds to me that an Asthma Action Plan is really something that keeps you accountable. So now you’ve listened to this episode and you’ve gotten to this point, you’re thinking, ‘When do I go see my doctor? How often should I see my doctor?’ When do they come into play?
Dr. Gupta: In general, you should see your doctor anytime that you feel your asthma is not under control. Anytime that you’re in the yellow or red zone on your Asthma Action Plan, you should see your doctor and touch base with them to let them know what’s going on.
One of my big things that I want to get through to people all the time is about the urgent care and emergency room. That is not who your doctor is for your asthma. That is the place that you use when you’re having difficulty with your asthma, late night, early morning, when your doctor’s office is not open, or when you’re in really big trouble and you really need emergency care to get your airways open. It’s not where we want you to feel like you’re getting your asthma care from regularly. And if that’s what’s happening, then you really need to see your doctor right away, because that means something is not going the way that we want it to go. The urgent care, really. shouldn’t even be something that you need if you have asthma.
Again, if you feel like you’re not under control with symptoms more than two days a week, waking up with your asthma, taking your quick-relief medication often, having to go again and get oral steroids for your asthma, this means that you need to go back and touch base with your doctor. We want you to touch base with your doctor at least once a year, and if you have moderate to severe asthma, that might mean three to four times a year, just to make sure that we’re following up to tell them anything that we’re experiencing.
Sometimes people with asthma, because they’ve been experiencing the symptoms for so long, they’re not as aware that waking up at night should not be happening or that they shouldn’t be feeling shortness of breath just walking down the street. So sometimes talking it through with somebody that understands asthma can really help to determine if your treatment plan needs to be changed.
Kortney: Quick question, this is a little aside, but since there are so many forms of asthma, are there some that are actually harder to control than others?
Dr. Gupta: We’ve mentioned moderate and severe asthma so a particular type of asthma inflammation that I want to mention and something that people might hear about is Type 2 inflammation. So Type 2 inflammation is present in as many as 50% to 70% of patients with asthma. In these people, inflammation is essentially caused by a response in the body that may or may not be secondary to a trigger and it causes the release of a lot of chemicals in the airways in particular that cause that swelling and inflammation that we’re worried about. So when someone has this type of inflammation or asthma, a specialist will look for it by checking for the particular type of cell called eosinophils. And these are a type of white blood cell that cause inflammation and are produced in higher quantities in some people with asthma.
Kortney: Thank you, Doctor G. I’m happy that my question was not so weird and offsided. And actually it’s quite interesting that it led to the term Type 2 inflammation because that’s a buzzword I feel like has been popping up a lot in my life as a patient. Can you maybe unpack why Type 2 inflammation is such a buzzword?
Dr. Gupta: I think we’re understanding the different types of inflammation that can happen in someone’s airway when they have asthma. This particular type of inflammation, which can be caused by the eosinophils, that particular type of white blood cells – a lot of the biologic medications actually target this type of inflammation and help reduce the number of eosinophils that are present in the airways. We can take away that aspect of inflammation that can occur in someone’s airway and so I’m just really excited about all of it, because we used to just have steroids to treat inflammation and now we have so many other types of medications that can help reduce that inflammation that don’t cause as much harm to the body.
We have a whole episode dedicated to the biologic medications, and it’s something that’s really changing the way that we’re treating moderate severe asthma. I just am so happy about it because I think that we can really save a lot of people’s lives because of these medications. We just need to make sure that we have the right people on the medications and that’s really where all the education is going towards, is making sure that not only do patients know about these medications, but that doctors also know about that because the medications are so new that sometimes a lot of doctors are not aware that they exist or how they work. And so that’s why it’s really important to see an asthma specialist who understands all of these newer medications.
Kortney: What you said, Dr. G, is super interesting and there are a few things that I’m really taking out of this. The first is that there are these new medications on the block and not every general practitioner might know about them. I’m talking from personal experience that I told my GP I’ve been considering going on a biologic and they didn’t really know what that was. And number two, this is another reason why you might consider seeing an asthma specialist if you have asthma. Number three, it’s super important to, at minimum, do a yearly check-in about your asthma because all these new medications are coming on the market and your Asthma Action Plan might change because of them.
There might be a better solution out there because of these biologics. And even if the biologic isn’t something for you, it’s just another reason why you want to go back every year to see your doctor because you don’t know what’s going to be on the market for you next year. So those are some really good points thank you, Dr. G. I’m happy that we got to discuss Type 2 inflammation, and it led us to that.
So I think that we’ve kind of hit it all, really, and I’d like to just really recap what we’ve talked about. I know that it might have felt slightly repetitive, but it’s really important to have your asthma under control. And I say that slowly, and I emphasize that because I am a poster child for that. I lived for many years with uncontrolled asthma, and I honestly didn’t realize it and didn’t realize how good I could feel once I got everything in control.
So here’s my recap for you, my friends, to have successful asthma management. First, a frequent relationship with your doctor. Make sure you check in to see if everything regarding your asthma action plan is up to date and you’re, like I said, taking the best medication for your asthma. Also consider an asthma specialist if you feel like you are unsatisfied with your current asthma action plan.
And the second thing, which we haven’t emphasized much, is that there’s a lot you have to do on your own when it comes to asthma management. So making sure you’re following your plan, you’re talking to your doctor, and you’re taking your medication as prescribed. You’re taking them properly so you’re using a spacer when you use your inhaler. You know your triggers and you know how to eliminate your triggers as much as possible. You know when your triggers are going to come, if they’re seasonal or if they’re your best friend’s cat. And you know that when things go bad, you see your doctor.
So like I said, this is stuff that you have to do on your own and I’m just curious before we end out the show, and I think I know the answer, but I’m gonna let Dr. G help us with this one. Is there a place or is there a resource for people who are looking for more support other than just their doctor for their asthma control?
Dr. Gupta: Yes, so as you mentioned, Kortney, a lot of asthma treatment or a lot of any treatment for any condition relies on you as the person with the condition to understand your condition and to take the medications and do all of these things at home, and sometimes that can be harder to do than we think. And so that’s why some clinics that have special funding can have extra resources like asthma educators that can help you understand your Asthma Action Plan better. And it can help you really evaluate your home and look at the different things that you can do within your home that may be better for your asthma control.
So what I want to mention is a really cool program that our friends at Allergy & Asthma Network have. They’ve put together a free virtual asthma coaching program that is 1 to 1 so it’s just you and an asthma coach, which is a person that really understands asthma well, that can look at your Asthma Action Plan, that can look at the medications that you’re on and explain them to you. They can help you identify what your triggers may be based on your history and the testing that you’ve done with the doctor and so really that person can sit with you 1 to 1 over a six-week period to really answer all of your questions and serve as a resource for you as you work to get your asthma under control.
I really love the idea of all of my patients with asthma doing this, but especially those with moderate or severe asthma. I think it’s a great resource and again, it’s free, so it’s really accessible, which I love, and you can look at AsthmaCoach.org to get more information and sign up. And of course, that link will be in the show notes too.
Kortney: Yeah, I think having support like that, even if you think you know what you’re doing, is amazing because these are experts you’re talking to. And they might see something that you do in your everyday life, or something in your health that you didn’t even consider being a trigger or being something that would potentially make your asthma control much more challenging. So even if you think you’re like a super asthma pro, this program is definitely something to consider.
I want to thank you, Dr. G. This was a super episode. I hope that we help a lot of people breathe freer, breathe happier, breathe bigger. I know that five years ago when I had uncontrolled asthma, I did not think I would ever get to the point that I am at right now so thank you again.
We have a ton of links in our show notes because this was a hefty episode. So if you want to know more about Type 2 inflammation, biologics or asthma coaches, check out our show notes. We would really like to thank our partners, the Allergy & Asthma Network, whose website, by the way, is also a super resource for anyone with asthma. And thank you to Amgen for supporting this episode.
Dr. Gupta: Thank you for listening to today’s episode. Remember that all information you hear today is for informational purposes only and is not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified physician or healthcare provider.
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