Dr. Oz on L-Arginine!

 

Dr. Oz on L-Arginine

Recently Dr. Oz has emphasize the need for L-Arginine supplementation for improved cardiovascular health and overall wellness. Here is a recent video of both Dr. Oz and Dr. Mercola talking about how important L-Arginine is in maintaining the flexibility and integrity of the vascular system. Most of Dr. Oz and his discussion on L-Arginine is in the second half of this video:

http://www.doctoroz.com/videos/alternative-health-controversy-pt-3 

If you watched and listened to Dr. Oz and Dr. Mercola, they only talk about the essential amino acid L-Arginine. Technically they are correct from the standpoint of your endothelial cells using L-Arginine to create nitric oxide. Because nitric oxide relaxes the smooth muscle of the vascular wall to help maintain proper blood pressure, keeps blood platelet cells from sticking together to prevent heart attacks and stroke, and repairs the damage done to the endothelium to prevent atherosclerosis and arteriosclerosis, what Dr. Oz tells us about L-Arginine is critically important. But there are some other ingredients that need to be part of the equation, especially if you want to create nitric oxide in sufficient amounts to be therapeutic to your cardiovascular system. 

Dr. Oz, L-Arginine, and an Additional Key Ingredient! 

One of those ingredients needs to be the amino acid L-Citrulline. L-Citrulline recycles L-Arginine to have a synergistic effect on extending the endothelium’s ability to properly produce nitric oxide. Here’s what I mean. 

If you consume a therapeutic level of L-Arginine you will typically get a 30 minute to 2 hour window of improved nitric oxide production resulting in a small window of improved circulation. 

What Dr. Oz doesn’t tell you is critically important. If you combine your L-Arginine with a therapeutic level of L-Citrulline then you will increase this window of improved nitric oxide production to a 24 to 36 hour window. That’s huge especially in helping to repair your endothelium so that you can heal your vascular wall for long term improvements in your circulation. 

This means that you need both of these amino acids in sufficient quantities to truly obtain a benefit. To help you better understand this I’d like to provide two quotes from Dr. Louis J. Ignarro. Dr. Ignarro won the 1998 Nobel Prize in Medicine, along with two other American researchers, for discovering how your endothelium converts the essential amino acid L-Arginine into nitric oxide – the most powerful signaling molecule of your entire cardiovascular system. These quotes are taking from his 2005 bestseller NO More Heart Disease. 

My research shows that L-arginine in doses smaller than 4 to 6 grams produces almost zero increase in NO, so it is in essence an ‘all or nothing’ proposition – you must receive the full dose of L-arginine.” 

It is the synergy between the L-arginine (in a large enough dose), the L-citrulline, and the key antioxidants that creates dramatic increases in your body’s nitric oxide production. Without the proper combination of these nutrients, which so many other programs lack, you will receive little to no benefit from NO therapy.” 

Dr. Oz Doesn’t Tell You How Much L-Arginine to Use! 

While there is more I could say about additional ingredients, here are the two most important factors you need to consider in evaluating an L-Arginine product: 

  1. Does it include L-Citrulline? If it doesn’t, then you are wasting your time and money.
  2. Does it include sufficient amounts of both L-Arginine and L-Citrulline to create a synergistic and therapeutic benefit? According to Dr. Ignarro you need 4-6 grams of L-Arginine and 200 to 1000 mg of L-Citrulline to have a therapeutic effect. Anything less and you’re not going to get improved nitric oxide production. 

According to Dr. Ignarro, “Nitric oxide is the body’s natural cardiovascular wonder drug.” But for you to get a therapeutic effect to aid you in improving the health of your cardiovascular system, then you need to be taking both L-Arginine and L-Citrulline in sufficient quantities.  

There’s much more that could be said about the creation of nitric oxide; such as the need for Folic Acid and other antioxidants to enhance nitric oxide production over a long period leading to therapeutic benefits. I’ve prepared two videos to help you better understand this. My next post will highlight these two videos. The first video covers which foods will help you obtain L-Arginine, L-Citrulline, and Folic Acid since these three are critically important in helping your endothelium properly produce nitric oxide. The second video will cover whether it is better to get your L-Arginine, L-Citrulline, and Folic Acid through food or supplementation.

If you would like to order Dr. Ignarro’s book NO More Heart Disease then please click here!  

Together we can work to save a million lives by help to education others about what was said by Dr. Oz on L-Arginine but also including the other key nutrients for improved nitric oxide production! 

Dan Hammer 

Dan Hammer has a background in biology, chemistry, and exercise physiology. He used to run one of the largest health club operations in the Chicagoland area and has been helping people with their wellness issues for more than 25 years.  

The information contained in this article is for general information purposes only and never as a substitute for professional medical advice or medical exam. The information about Dr. Oz on L-Arginine has not been evaluated by the Food and Drug Administration and should not be used to diagnose, treat, cure or prevent any disease without the supervision of a qualified medical doctor.

Atherosclerosis and Osteoporosis Link!

atherosclerosisAtherosclerosis involves the calcification of your vascular tissue. Osteoporosis involves the decalcification of bone tissue. Could there be a link between the two?

Here is a medical fact that few physicians know and even fewer in the general population have ever heard about. As you age your endothelial cells, which line all of your cardiovascular system, can turn into bone cells. They are known as osteoblasts and they normally regulate bone formation.

This discovery was originally made in 1993. Since this discovery research has shown a link between atherosclerosis and osteoporosis. Those with atherosclerosis typically also have weaker, more brittle bone with an increased risk for fracture. Those with osteoporosis typically exhibit hardening of the arteries or atherosclerotic calcification leading to atherosclerosis.

To date the precise biological mechanisms behind the transformation of endothelial cells into osteoblasts, or bone-forming cells, is not fully understood. What is understood is the key role Vitamins D and K play in ensuring that calcium is properly used in bone formation while at the same time preventing the pathological calcification of your arteries.

These two nutrients operate synergistically to combat osteoporosis and atherosclerosis.

Vitamin D and Its Role in Atherosclerosis!

Most people know about the role Vitamin D plays in healthy bone structure and function. What most people do not know is how important Vitamin D is to cardiovascular health. Here is a short list:

  • Vitamin D inhibits vascular calcification, which can lead to atherosclerosis.
  • Vitamin D deficiencies are associated with hypertension, diabetes, increased thickness of the carotid artery, heart attack, and stroke.
  • Below normal levels of vitamin D is also implicated in congestive heart failure.

We’ll examine the function of Vitamin D and cardiovascular health in a future article.

Vitamin K and Its Role in Atherosclerosis!

Most people have never heard of Vitamin K yet it plays a critical role in stimulating new bone formation. Without the proper amount of Vitamin K in your system, your body cannot properly bind calcium and phosphorus to form the matrix necessary to produce and maintain solid, well-mineralized bone.

While the presence of Vitamin K is critical for bone formation, it is also necessary to protect against the calcification of the vascular system.

We’ll examine this function of Vitamin K and cardiovascular health in a future article.

Atherosclerosis and Osteoporosis!

Two age-related diseases are atherosclerosis and osteoporosis. While there are many contributing factors to the progression of each of these two diseases, medical science has now been able to establish a direct link between them. That direct link points to deficiencies of both Vitamin D and Vitamin K. Research has clearly shown that these two vitamins work synergistically to facilitate bone mineralization leading to strong and healthy bones. At the same time they work synergistically to prevent calcium deposits from accumulating in your vascular system leading to atherosclerosis.

Together we can work to save a million lives!

Dan Hammer

Dan Hammer has a background in biology, chemistry, and exercise physiology. He used to run one of the largest health club operations in the Chicagoland area and has been helping people with their wellness issues for more than 25 years.

The information contained in this article is for general information purposes only and never as a substitute for professional medical advice or medical exam. The information about atherosclerosis and osteoporosis has not been evaluated by the Food and Drug Administration and should not be used to diagnose, treat, cure or prevent any disease without the supervision of a qualified medical doctor.

Arteriosclerosis and Atherosclerosis – Treatment Programs!

ArteriosclerosisAccording to the American Heart Association, arteriosclerosis and atherosclerosis account for nearly 75% of all deaths from heart disease! To have a significant impact on reducing the number one killer of people worldwide, it would make sense to focus on treatment programs that address these cardiovascular diseases.

As I gathered data for this article many of the websites made the following comment – “The exact cause of arteriosclerosis is not known.”

This author would like to disagree with that statement.


The exact cause of arteriosclerosis and atherosclerosis is known!

It is damage to the endothelial cells that line all of your cardiovascular system, which reduces their ability to properly produce nitric oxide, the master signaling molecule of the cardiovascular system. Nitric oxide is key to cardiovascular health. According to Dr. Louis J. Ignarro, the 1998 Nobel Laureate in Medicine,

NO – as it is known by chemists – is produced by the body specifically to help keep arteries and veins free of the plaque that causes stroke and to maintain normal blood pressure by relaxing the arteries, thereby regulating the rate of blood flow and preventing coronaries. Nitric oxide is the body’s natural cardiovascular wonder drug.”

If you look closely at Dr. Ignarro’s statement you will notice the following significant phrase: “. . . specifically to help keep arteries and veins free of the plaque that causes stroke. . .” Plaque formation is at the heart of atherosclerosis. Calcification of these plaque formations lead to arteriosclerosis.

The “natural cardiovascular wonder drug” Dr. Ignarro was referring to is nitric oxide, which is produced by the endothelial cells from two important amino acids: L-arginine and L-citrulline. Nitric oxide can specifically prevent both arteriosclerosis and atherosclerosis. Many researchers would also suggest that the proper production of nitric oxide, by your endothelial cells, can reverse both of these cardiovascular diseases.

The following is a review of many of the treatment programs for arteriosclerosis and atherosclerosis. These treatment programs can be broken down into two major categories: self-care at home and medical treatment. The overall goals of these treatment programs are to reduce symptoms and prevent the progression of the disease so that potential blockages can be prevented. But, the question remains:

Is there a better treatment program and can it actually reverse arteriosclerosis and atherosclerosis?”

We’ll examine this after we look at the standard treatment programs usually recommended to patients diagnosed with arteriosclerosis and atherosclerosis.

Self-Care at Home Treatment Programs!

Self-care treatment programs typically mean lifestyle changes. Let’s look at each of these lifestyle changes in relationship to their effects on the endothelial cells and the production of nitric oxide:

  1. Eat food that is low in saturated fats and low in cholesterol. This is a big topic but in its simplest terms LDL cholesterol (Bad Cholesterol) can damage your endothelial cells leading to plaque formations.

  2. Restrict salt intake especially if you have high blood pressure. Again this is a big topic because it only focuses on one mineral: sodium. Also important to this equation is potassium, magnesium, and calcium for proper cardiovascular metabolism.

  3. Increase the consumption of high fiber foods especially vegetables and fruits. High fiber foods help to absorb bile salts that your body uses in digestion. Your liver manufactures bile from cholesterol. Thus, high fiber foods are a natural way to reduce LDL cholesterol, which reduces the potential damage they can cause to your endothelial cells. Also, vegetables and fruits have little sodium but are high in potassium, magnesium, and calcium, which helps maintain proper cardiovascular metabolism.

  4. Quit smoking. This habit has major effects on your cardiovascular system, especially your endothelial cells. Nicotine damages endothelial cells. Cigarette smoking decreases “Good” cholesterol that helps to protect your endothelial cells and increases the “Bad” cholesterol that damages your endothelial cells. The carbon monoxide produced from cigarette smoking also damages endothelial cells and can facilitate plaque formation. Plus, smoking constricts arteries leading to an increased risk of blockages.

  5. Lose weight if overweight or obese. Fat cells absorb and store Vitamin D. Vitamin D inhibits vascular calcification. Vascular calcification is at the heart of arteriosclerosis. Thus, losing weight releases needed Vitamin D back into your system and improves your body’s ability to utilize Vitamin D to reduce multiple risk factors for cardiovascular disease.

  6. Mild to moderate exercise under the supervision of a health care provider. Exercise increases blood flow. Increased blood flow stimulates the endothelial cells to produce nitric oxide.

  7. Maintain normal blood glucose (sugar) levels. When blood glucose is above the normal range it causes oxidative stress to the endothelial cells resulting in damage and a reduction in nitric oxide production.

Medical Treatment Programs

Medical treatment programs usually center on prescription drugs, surgical procedures, or a combination of both to either reduce the risk or repair existing damage to the vascular system. While this list is not exhaustive it does include many of the more prominent treatment programs. Let’s look at each in relationship to the endothelial cells and nitric oxide production.

  1. Taking drugs to normalize blood pressure. High blood pressure can damage the endothelial cells. Yet, learning how to naturally nourish your endothelial cells to improve their ability to produce nitric oxide can also normalize blood pressure but without the side effects of medications.

  2. Taking drugs to normalize blood sugar levels. This is especially important for those with diabetes. But, equally important is having in place a nutritional program that will help to repair the damage high blood sugar can cause the endothelial cells.

  3. Taking drugs to lower lipid levels. Statin drugs are the most commonly used lipid-lowering drugs because they effectively interfere with the production of cholesterol by your liver. Unfortunately, they also interfere with the creation of Co-Q10 which is extremely important for heart health and overall energy production. The main purpose of statin drugs is to keep LDL Cholesterol or Bad Cholesterol from damaging the endothelial cells. The proper production of nitric oxide can also repair this damage and keep the “Bad” cholesterol from creating damage in the first place.

  4. Aspirin inhibits sticky platelets cells from forming a blood clot. Nitric oxide also keeps blood platelet cells from sticking together but without the potential risk for bleeding.

  5. Balloon angioplasty. To open blocked or narrowed vascular vessels a balloon-tipped catheter is inserted into the body. When the narrowed vascular area is reached the balloon is inflated to press the plaque deposit against the vascular wall. This procedure is designed to increase the diameter of the affected area to improve blood flow. The concern is that the balloon procedure will damage the endothelial cells creating a stimulus for additional scarring and plaque formation. This procedure treats a symptom but doesn’t solve the underlying problem.

  6. Stenting. Following angioplasty a metal tube called a stent will be placed in the vascular area to help keep it open. The stent acts as a scaffold to support the vascular wall. To prevent additional complications from the endothelium and blood clotting on the metal surface, patient are asked to take specific drugs. Again, this procedure treats a symptom but doesn’t solve the underlying problem.

  7. Bypass surgery. This surgical procedure uses arteries or veins from other areas of the person’s body to bypass the blocked vascular area to improve blood flow. Again, this procedure treats the life-threatening event but doesn’t solve the underlying problem.

All of these treatment programs are important. Most of the self-care at home treatment programs help to protect and nourish the endothelial cells. Most of the medical treatment programs limit additional damage to the endothelial cells or are used to correct a problematic area of the vascular system. No one is questioning the proper use in helping to reduce risk and/or save a person’s life from the arteriosclerosis and atherosclerosis.

But, the question still remains is:

Is there a better treatment program and can it actually reverse arteriosclerosis and atherosclerosis?”

The answer is “YES!”

It all centers on nourishing and repairing the endothelial cells to improve their ability to properly product nitric oxide, the master signaling molecule of the cardiovascular system or what Dr. Ignarro refers to as “the body’s natural cardiovascular wonder drug.” We’ll explore this in future articles.

Together we can work to save a million lives!

Dan Hammer

Dan@agingnomore.com

630-936-8079

Dan Hammer has a background in biology, chemistry, and exercise physiology. He used to run one of the largest health club operations in the Chicagoland area and has been helping people with their wellness issues for more than 25 years.

The information contained in this article is for general information purposes only and never as a substitute for professional medical advice or medical exam. The information about Arteriosclerosis and Atherosclerosis contained in this article has not been evaluated by the Food and Drug Administration and should not be used to diagnose, treat, cure or prevent any disease without the supervision of a qualified medical doctor.

Dr. J. Joseph Prendergast Video!

Dr. Joseph PrendergastI came across this short but very interesting video of Dr. J. Joseph Prendergast.  For those who don’t know Dr. Joe (as he prefers to call himself), he is the product formulator of ProArgi-9 Plus.  Dr. Joe is Board Certified in Internal Medicine as well as Endocrinology and Metabolism.  He is an expert in integrative L-arginine therapy and has been using this type of therapy in his practice since 1991.

Due to family heredity Dr. Joe was diagnosed at the age of 37 with severe atherosclerosis or hardening of the arteries. It was estimated that he had the cardiovascular system of an 80 year old individual.  This led him on a quest to find a solution to his health problem.  Using cutting edge research from Dr. John Cooke and Nobel Prize winning science from Dr. Louis Ignarro and others, Dr. Joe began to work on L-arginine / L-citrulline formulations; formulations that would positively impact the health of the endothelial cells and their ability to repair themselves and produce Nitric Oxide.

The results not only benefited Dr. Joe, by reversing his atherosclerosis, but also his patient population of diabetics who had been suffering from cardiovascular issues.  Prior to his discoveries on how to effectively use L-arginine and L-citrulline, Dr. Joe use to refer many of his patients for by-pass surgery.  Since becoming an expert in integrative L-arginine therapy this has changed dramatically.  In fact, Dr. Joe makes the following statement in this video:

“. . . 80% of the people have diabetes and in 17 years we have had no problems with strokes, no problems with heart attacks, I’ve not even had any admissions in 17 years.  So this is a striking example in how we can use this product for real power for health. . . “

I would ask you to think about that.  Over the last 17 years Dr. Joe has had no admissions to the hospital for cardiovascular disease.  This is remarkable when you consider that most of his patients are diabetics.  It was so remarkable that the American Diabetes Association awarded Dr. Joe the Father of the Year award for 2008.

Please click on ProArgi-9 Plus below to view this video!

Please Note:  This link takes a couple of seconds to load.  Once it loads you have to click on the “play button” for it to start.  It then takes a couple of seconds to play.  Please be patient for what Dr. Joe has to say is well worth waiting for!

ProArgi-9 Plus Small Size

Thank you for taking the time to watch this short but powerful video.  I’d like to leave you with one important question:

How would your life change if you where one of Dr. Joe’s patients, especially if you’re a diabetic?

I’ll let you answer that question privately.  I want to thank Dr. Joet for taking his personal health challenge, combining it with cutting edge vascular research, Nobel Prize winning science, and proven clinical results to create ProArgi-9 Plus. A product that has helped both him and thousands of others improve their health.

Together we can work to save a million lives!

Dan Hammer

Dan Hammer has a background in biology, chemistry and exercise physiology.  He used to run one of the largest health club operations in the Chicagoland area and has been helping people with their wellness issues for more than 25 years.
The information contained in this article is for general information purposes only and never as a substitute for professional medical advice or medical exam.  The information contained in this article about Dr. Joseph Prendergast has not been evaluated by the Food and Drug Administration and should not be used to diagnose, treat, cure or prevent any disease without the supervision of a qualified medical doctor.

Nitric Oxide and Blood Pressure!

Blood PressureUnderstanding nitric oxide and blood pressure and the role that nitric oxide plays in helping you maintain a normal blood pressure is critical to good cardiovascular health and your overall wellness.  It is one of the reasons why most doctors and nurses will take your blood pressure every time you visit them. They are checking to make sure that your blood pressure has not increased to place you in the high blood pressure or hypertension category.  (Note: If you would like more information about the dynamics of blood pressure then please read my article “Blood Pressure Overview!”)

High Blood Pressure or Hypertension Can Be Deadly!

It’s estimated that over 50 million Americans have hypertension.  Their risk for having a stroke is seven times greater than those who have a normal blood pressure.  According to the Framingham Heart Study, 50% of all people who had their first heart attack and 66% of people who had their first stroke had blood pressure readings above 160/95 mmHg.

It’s also interesting to note that in the Framingham Heart Study two thirds of the participants who started out with normal blood pressure ended up developing hypertension.  Of the top five reasons why people visit their doctors, hypertension is either number one or number two. According to the National Institutes of Health, approximately 700,000 deaths per year have a hypertension component.

Because you cannot feel high blood pressure it is sometimes referred to as the “Silent but Deadly Disease!” Although it doesn’t typically produce outward signs, high blood pressure can cause major internal damage by injuring the endothelial cells that line the circulatory system.  This damage impairs the body’s ability to naturally produce Nitric Oxide.  It usually leads to inflammation of the arteries which is followed by atherosclerosis and plaque formations.  Hypertension can also enlarge the heart, damage the kidneys, and trigger a heart attack or stroke.

If you do not know what your blood pressure reading is or if you have not had it measured in the last 6 months, then visit your doctor’s office or your local pharmacy and have your blood pressure measured by a qualified health practitioner.  It’s that important!

Nitric Oxide and Blood Pressure – Effective Treatment thru Nitric Oxide!

The typical treatment program for most people with high blood pressure can be a combination of diet, exercise, stress management techniques, and medication.  For many who opt for the medication route, it’s estimated that 26% still do not have their hypertension under control. Since many medications also have some form of side effect it can be a frustrating journey trying to get your blood pressure under control.

Enhancing the body’s ability to produce Nitric Oxide is seldom considered yet Nobel Prize Laureate in Medicine Dr. Louis Ignarro makes the following statement regarding nitric oxide and blood pressure:

“More effective than any other factor in the body, nitric oxide can dilate the smooth muscle of the blood vessels.  With this dilation, the vessels can relax and allow blood to flow easily through them – and quite possibly lower the blood pressure.”

Nitric Oxide is produced by many cells in the body for various functions.  Its production by the endothelial cells is critical for proper blood flow.  The endothelial cells produce Nitric Oxide from the amino acid L-arginine by the enzymatic action of Nitric Oxide Synthase or NOS. The human genome contains 3 different genes for the encoding of NOS:

  • nNOS (Type 1) – found in neurons
  • iNOS (Type 2) – found in macrophages
  • eNOS (Type 3) – found in the endothelial cells

In healthy blood vessels, Nitric Oxide is continually being produced by eNOS.  The activity of eNOS is calcium and calmodulin dependent.  Plus, there are two fundamental pathways for the stimulation of eNOS:

  1. Shearing forces of the blood flow on the endothelial cells causes a release of calcium to activate eNOS.  Thus, with each heart beat (systole) the endothelial cells of the blood vessels release a puff of Nitric Oxide.
  2. Endothelial receptors are stimulated by a variety of molecules (acetylcholine, bradykinin, adenosine, etc.) to stimulate calcium release to activate eNOS for the production of Nitric Oxide.

Once produced Nitric Oxide diffuses freely across cell membranes to relax the smooth muscles in the wall of the arterioles.  This causes the arterioles to relax to permit the surge of blood to easily pass through it.

It is interesting to note that in mice studies, where the genes for NOS have been disabled hypertension results.

Nitric Oxide and Blood Pressure – 4 Important Keys to Consider!

I’ve given you a lot of information in this blog post about nitric oxide and blood pressure.  The following 4 keys will help you understand how to produce more Nitric Oxide naturally to aid in blood pressure control.

Key 1 – Exercise! You will note from above that increases in blood flow will stimulate Nitric Oxide formation.  Exercise increases blood flow.  It is usually one of the recommendations given to people with hypertension to help them lower their blood pressure.  A simple walking program can be very effective.  As a precaution, if you are not currently exercising then talk with a qualified health professional before starting an exercise program.

Key 2 – Vitamin D3! Calcium is needed for the NOS enzymes to work properly to product Nitric Oxide.  Vitamin D3 has long been known to aid in calcium absorption.  New research shows that D3 also plays a role in healthy cardiovascular function and supports healthy inflammatory response.

Key 3 – Diet! I’m not talking about going on a diet although this can help overweight people who have hypertension.  Instead I’m referring to the type of diet most Americans consume which is refined flour, animal protein and high intake of dark colas.  This is an acidic diet which leaches calcium from your system to affect the efficiency of the eNOS enzymes to produce Nitric Oxide.  To help you understand this process, please see my article “The Acid Alkaline Balance: Does Your Body’s pH Cause Cancer and Other Diseases? Part 1”

Key 4 – L-Arginine! You body uses this amino acid to produce Nitric Oxide.  Most people’s diets are insufficient in the amount of L-arginine needed to properly support Nitric Oxide production.  Supplementation with a good L-arginine product can be beneficial.  I recommend ProArgi-9 Plus. It contains 5 grams of pharmaceutical grade L-arginine with other ingredients to aid in Nitric Oxide production while helping to repair the endothelial cells.  Additionally, this product has a large number of clinical studies (like the High Desert Heart Institute Study) to support its effectiveness.

There are multiple ways to help your body naturally produce more Nitric Oxide.  If you are currently on hypertension medication and decide to use a Nitric Oxide protocol to help you get your blood pressure under control, then work with your health care professional so that adjustments can be properly made.

Together we can work to save a million lives by helping people understand the important relationship between nitric oxide and blood pressure!

Dan Hammer

The information contained in this blog is for general information purposes only and never as a substitute for professional medical advice or medical exam.  The information about nitric oxide and blood pressure has not been evaluated by the Food and Drug Administration and should not be used to diagnose, treat, cure or prevent any disease without the supervision of a qualified medical doctor.