Managing Menopause Matters

Menopause is a natural part of aging in women. It affects each woman differently, and the symptoms associated with menopause can be difficult for some.

Learn from Wen Shen, M.D., director of the Menopause Consultation Clinic, about menopause symptoms and the latest treatment options. Knowing what to expect can help you stay as healthy as possible during this phase of your life.

Thursday, April 20, 2017

7–8 p.m. EST

REGISTER:

US Residents

International Residents

Giving Thanks, Day 3

Adapted from http://www.maryo.co/giving-thanks-day-3/

Today I am hugely thankful that the last major issue we had here was in 2013 when Tom had his heart attack.  That event caused me to start a whole new blog to post about our experiences.

screenshot-2016-11-05-06-30-59

Adapted from https://maryomedical.com/2013/02/08/the-beginning/

January 27, 2013 was our 40th anniversary.  DH called me and said he was leaving a conference in Washington, DC and we’d go out to brunch when he got home.

The next thing I had heard was that he was in the ER with a suspected heart attack.  I rushed to the ER and found him in his cubicle.  He’d had 3 nitroglycerine pills by then and figured he could go home.

Wrong!  They had him stay overnight at the hospital.  January 28th, they decided to send him by ambulance to Fairfax Hospital for a cardiac catheterization and possible stent.

At the end of that, the surgeon came into my waiting room and said that he needed triple bypass NOW.  Three of the arteries were 100% blocked.  They got me calmed down to see him in the OR.

He was trying to get odds of not doing this surgery and just leaving then.  Finally, I said that he would do this surgery, we weren’t going to fool with this.

I really lost it when they asked me if we had any children and I said 1 son in NYC.  They called him at work in New York and had him get there as soon as possible.  I’m sure he could hear the fear in my voice.

They wheeled DH off for surgery and I waited again.  Luckily, 2 church friends came and sat with me and our pastor arrived about 8:00PM.  Our son arrived about 8:30PM after taking the Acela and a taxi directly to the hospital.

The surgery was over about 9:00PM but when we saw Tom, he was still under anesthesia.  They kept him that way until the next morning since he was too confused when they woke him up.

Long story short (too late!) – he got out of the hospital on the 31st and I played nurse 24/7.   He couldn’t drive/go anywhere for 6 weeks, and then there were 12 weeks of cardiac rehab.

One of the things that came out or cardiac rehab was becoming friendly with 2 other couples (although one of them has since split up).  We go out to dinner every couple months…and none of the surgeons would be happy about our choices.

heart-line

A slightly different take on the events, written 3 weeks later on the same blog.

Icy Days and Mondays…*

* With apologies to Karen Carpenter!

I know I’m not supposed to “relive” events.  I have done that too often with my Cushing’s and cancer adventures and I’m told that reliving causes nearly as much stress as the original event.

So, I plan to write down my memories here and try to let them go…

It all started on Sunday, January 27, 2013 – our 40th wedding anniversary.  I picked up my mom and went to church so I could sing in the choir.  DH went to a meeting of some sort on Benghazi.

After church, I stopped off in the church office for a goodie bag that the Staff Parish Committee had left.

Dropped my mom off at her house and went home.  I put the goodie bag on the dining room table and logged onto the computer to do some work.

I got a couple text messages from DH:

Text message

I figured I’d take a nap until DH came home for that late brunch.

The next thing I hear was my phone ringing, a call from DH.  He was in the ER at Fair Oaks with a heart attack.  OMG!

I immediately leaped up and rushed out the door.  I called one of my pastors and got to the ER in record time.   When I arrived, he was in a bed, all hooked up to monitors, fluids and such.  He was awake and feeling pretty well thanks to the nitroglycerine they had given him immediately after arrival.

When we had a chance to talk, it turned out that he had been in his conference and realized his chest was getting tight.  He found the hotel’s store and bought aspirin – 3 for $11.00 which he thought was extravagant.  He bought them and took them anyway – and probably saved his life.

On the way home, he was feeling pretty good so he stopped at the mall to buy an anniversary gift.  The salesgirl in Zales didn’t know that ruby was the stone for the 40th anniversary and was kind of ribbing DH for waiting until the last minute to buy a gift.  He walked out of there, felt more tightness and headed to the ER…where he called me.

DH was feeling pretty well thanks to the nitroglycerin and aspirin plus whatever else they had in the IV and wanted to go home.  The staff said no way – he had to stay overnight so he could be monitored.

The “automatic clock” on the wall said it was Monday.  Other rooms said Sunday.  Hmmm

A trainee EMT came in to ask some questions as part of his learning process.  Every time DH mentioned the word “Benghazi”, his blood pressure spiked about 40 points or so.  That term became verboten ever after.

My pastor stopped by and we had some nice chats and prayers.

Time passed, tests were done, doctors and nurses stopped by.  Finally, DH was moved to his room upstairs.

About 9 or so I went home and found our dog huddled by the front door – I had left so quickly I hadn’t left her any lights on.  I imagine she was quite worried.

I can’t even remember what I had to eat for dinner but I really wanted something chocolate.  On a whim, I looked in that goodie bag and there was a double-sized brownie.  I think I ate that in record time and it really hit the spot.

Ice

Monday morning (for real!), I checked the weather and found that school was starting late because of icy conditions.  I put on boots and took the dog out.  It seemed to be raining – if it’s raining, it must be warm, right?  So I didn’t really pay attention (and I had other things on my mind!) and completely missed seeing the black ice.

Next thing I knew, I had fallen on one knee, my cell phone in my pocket bruised my other thigh and my left arm hurt where I’d reached out to catch myself.  Luckily, I hadn’t let go of the dog’s leash.

I ended up sitting in a puddle of icy water for a long time, figuring out how to get up.  I finally sort of crawled up the trash can that was sitting in the driveway.

The dog had an abbreviated walk, I changed my wet, cold clothes and headed to the hospital.  I was showing DH my knee and one of the staff bandaged it up for me.  I told him I hadn’t fallen at the hospital and wouldn’t sue but I guess he wanted to be sure.

(Today, Monday February 18, my knee still has a huge lump under the skin and hurts when I touch it, although I’m no longer limping,  The bruise/pain from cell phone finally went away)

The hospital staff decided DH should go to another hospital which is world renowned for its work with heart cases to have a heart catheterization and possible stent.  DH was ready to walk out to my car to drive him to Fairfax Hospital.  He wasn’t thrilled when he was strapped to a gurney and out to an ambulance instead.

I headed over in my car.  They’d changed the entrances to the hospital since the last time I was there and I couldn’t find the “Grey Entrance”.  Finally, after wandering around for a long time, I found it.

I saw DH in the prep room where they got him ready for the heart catheterization – then they rolled him away after explaining all the things that could go wrong.

I went out to the waiting room, got some coffee and a sandwich and hunkered down with my iPad.

Eventually, my beeper went off and I was called back to the room where DH had been prepped.  The surgeon was there this time.  She said that 3 arteries were nearly 100% blocked and they needed to do emergency triple bypass.  They also needed me to convince DH of this since he was figuring he could tough it out.

I started crying but she said I had to get myself together and convince him NOW.  I had to put on scrubs and off I went to the OR.  I got there, DH was on the table trying to figure out the odds if he didn’t do this surgery.  All the medical staff said that he had  a very low chance of survival without the operation.  He still wasn’t sure.  He wasn’t afraid to die.  Tough Guy, Yadda Yadda.

One of the nurses asked me if we had any kids.  I said only one, in NYC.  She said I should call him and get him here ASAP.  She even dialed the number.  I talked to DS at work and he agreed to come right away.  He was pretty scared, too.  He later revealed that he had been crying on the train ride.

I went back to the OR, told DH that DS was coming and that he was going to do the surgery like it or not.  I signed the paperwork and sent him to a very scary surgery.

It was about 4:30 by then and I needed to take the dog out again.  They said I could go home – surgery wouldn’t be over until about 8:00PM or so. Got home, took the dog, made sure that there were lights on, and headed back to the hospital.  Another pastor from my church called.  He said he’d be by the waiting room later.

Two friends from the church office texted me to say they were coming over to sit with me in the waiting room.  They got there about 6:30 and we decided food might be a good thing.  We headed out, following a variety of directions and signs and walked for a l-o-n-g time.

My knee was killing me.  We got to the cafeteria and found out that it was closed.  the 24-hour one was elsewhere.  We finally found that, got some food and my cellphone rang.  The surgeon would be coming out soon to talk to me.

We hustled back to the waiting room and the surgeon came out about 8:00 with good news.  Successful surgery!  DH wasn’t awake yet but we could see him about 9:00PM.

The pastor arrived about 8:30, then DS got there about 8:45.  Finally, they said we could see DH although he still was asleep.  My friends left, pastor and DS went in to see him in ICU, sleeping so peacefully with so many lines attached.  The pastor prayed, then left.  DS and I decided to stay to see DH awake.

About an hour later, the ICU tech said they were going to keep him asleep overnight so we went home.

Monday

Tuesday, January 29 – DS called the hospital fairly early and found that DH was still a bit agitated so they were keeping him under a bit. I took the dog out and we got ready to head back.

I got a call that he was waking up but agitated.  He kept fighting with the nurses on the day of the week.  He kept saying it was Monday, even though it was Tuesday.  Surprise, surprise.  The calendar on the wall hadn’t been changed.  It still read Monday.  No wonder that’s what he thought!

We stayed all day, though nurses, techs, doctor visits and such.  He was in ICU so was monitored very well.  DH was quite confused and repeated himself a lot.  He wasn’t quite sure what had happened.

Monday

Wednesday, January 30.  DH had been moved from ICU into a regular room and we had to follow visiting hours, even though we were family.  We could visit at 11 and had to leave at 1, then back for 6-8.  Actually, this worked out well since I was able to take my first nap since this whole ordeal began.

DH had called DS early in the morning and  said he “needed” his cell phone to make some work calls.  Luckily, DS talked him out of that, saying that he could say some wrong things, given his temporary memory issues.  Thank goodness!  I didn’t want him spending his days talking on the phone.

We got there about 10:45am and they still wouldn’t let us in due to “flu season”.  I’m not sure how we could give him the flu in those 15 minutes before official visiting hours.

I glanced at the whiteboard on the wall where the nurses’ names, doctor’s name and such were written.  Unfortunately, no one had changed this whiteboard since Monday, so that’s what it still said.  <sigh>

We visited – DH got to eat a bit and had started having lines removed.  He thought he might put his shorts on so went into the bathroom to do that.  Unfortunately, he managed to pull the IV out of his hand and bled quite a bit.  The nurse sent him back to bed and said no more of that!

A representative from the group Mended Hearts stopped by with information and a heart-shaped pillow.  They have meetings the first Saturday of the month, so we might go to some of those.

The first pastor dropped by again and we made plans for Friday to pick up DH’s car which was still at the ER.  No one else I know could get it – it’s a standard shift car.

Not much else – visiting, napping, improvements every day.

Not Monday

Finally, it’s not Monday!  Nowhere, nohow.  Just Thursday, January 31 after 4 days of Monday.  Hooray!

DS had a headache so I went to the hospital alone.  He was going to come for the nighttime visiting hours.  As it happened, DH came home this day after lots of testing, last minute X-Ray, discharge notes, complaints about the night nurse…

We got home about 5:00PM.  Yea!

Now the real work began – visiting nurses, medications, doctor visits, rehab.

Since it’s no longer Monday, this post is over 🙂

heart-line

Whew!  There was a lot more after the surgery – visiting nurses, cardiac rehab, so on and on.

I am hugely thankful for my pastors, friends, family, people who brought us dinners, all the doctors, nurses, surgeons, visiting nurses, rehab personal, Mended Hearts, ambulance folks, aspirin, nitroglycerin, insurance, Fair Oaks Hospital, Fairfax Hospital, everyone involved in any way with this escapade.

Five orange pumpkins sit in a row in front of a distressed, wooden background.

The Management of Small Renal Masses and Kidney Cancer

 

kidney-cancer
Earlier detection of small renal masses has led to new treatment options for kidney cancer. Join Johns Hopkins urologist Phil Pierorazio, M.D., as he discusses advances in the diagnosis and treatment of the small renal mass.
Monday, September 12, 2016
7–8 p.m. EST

 

http://ow.ly/Yw1B303JuF1

Menopause sometimes requires a survival guide

Menopause has gotten a bad rap. Women in their 40s and 50s who have any symptoms – from moodiness to insomnia and headaches – may believe that it’s a normal part of aging and there’s not much they can do about it.

Fluctuating hormones caused by the normal decline of ovarian function can trigger the typical symptoms associated with menopause. One approach is to give the body a drug that mimics ovarian function, such as estrogen or hormone replacement therapy. This was a common treatment, until multiple studies showed increased risk of urinary incontinence, stroke, dementia and breast cancer from using menopausal hormone therapy.

Fortunately, there is another approach to improving the body’s ability to adjust to hormone fluctuations that doesn’t increase the risk of breast cancer and dementia. This approach looks at the other organ systems that are involved in addition to the ovaries. For instance, hot flashes will be greatly exaggerated in a woman who has blood-sugar problems – even if those don’t show up on a standard blood test.

BIOIDENTICAL HORMONES

Some women use bioidentical hormones instead. While they appear to have fewer immediate side effects, there is no evidence that they have fewer long-term risks.

At a recent functional medicine conference I attended, there were several discussions on how to address hormone “saturation” – the experience many women have after being on bioidentical hormones for several years and then having a return of their previous symptoms. We’re learning that underlying imbalances in gut function, adrenal hormones and blood sugar can have a major effect on a woman’s experience of her perimenopausal years.

IT’S NOT JUST THE OVARIES

Technically, menopause occurs when a woman hasn’t had a period for 12 consecutive months. The symptoms that can occur for years before that are due to the ovaries becoming less predictable in their hormone production. This means that estrogen levels can spike and fall like a roller coaster.

Unfortunately, once a woman knows that her hormones are fluctuating, she is likely to explain away all her symptoms as perimenopausal. But ovaries are not the only glands affected by hormone changes. The pancreas, thyroid and adrenal glands play key roles in determining how easy or difficult the perimenopausal years will be.

The most common, end-stage effect of pancreas dysfunction is diabetes. But long before the body reaches a disease state, there are more subtle effects. For instance, a woman with low blood sugar or insulin resistance will experience more severe hot flashes than a woman with normal blood-sugar regulation.

Following are common symptoms associated with perimenopause and factors that can determine the severity of those symptoms.

• Heavy or frequent periods. These can be worsened by blood-sugar and thyroid imbalances that don’t show up on routine blood work. Checking free and total levels of T3 and T4 as well as thyroid antibodies can be helpful.

• Hot flashes or low libido. Underlying adrenal stress can result in cortisol levels that are too high or too low, or reduced DHEA (precursor to several hormones). Cortisol levels are best tested with multiple saliva samples over a 24-hour period.

• Insomnia. With or without hot flashes, insomnia is often due to chronic stress, which causes the adrenals to produce excess cortisol.

• Mood changes and brain fog. Moods can be affected by the stress hormone cortisol as well as imbalanced neurotransmitters. Neurotransmitters such as serotonin are made primarily in the gut and can be evaluated with a urine test. Low levels of serotonin can also increase overall pain levels.

• Hair loss and weight gain. There may be underlying thyroid stress that doesn’t show up on routine blood work but requires a more detailed look at free and total levels of T3 and T4 and thyroid antibodies.

Once these underlying issues are identified, they can be addressed through food choices, lifestyle factors and specific supplements.

Marina Rose, D.C., is a functional medicine practitioner, certified clinical nutritionist and chiropractor with an office at 4546 El Camino Real in Los Altos. For more information,  visit DrMarinaRose.com.

From http://www.losaltosonline.com/special-sections2/sections/your-health/53300-

Go for new cancer treatments

WHEN it comes to cancer, many healthcare professionals advocate early detection to increase the chances of successful treatment. In reality, this is hardly the case. Although there are no Malaysian-centric statistics, research has shown that almost 50% of cancer patients in Britain are diagnosed late, making treatment less likely to succeed and reducing their chances of survival.

What this means is we need to ensure that patients with late diagnosis are able to access treatment without compromising their quality of life.

Renal cell carcinoma (RCC) or kidney cancer is often diagnosed late. This is because the symptoms for RCC are similar to those of other diseases and may only surface in the late stages. In fact, 49% of patients in Malaysia are diagnosed with RCC when the cancer is in the final stage (Stage IV). A study showed that the five-year survival rate of patients with Stage IV RCC was only 13%.

Kidney cancer is among the top 10 cancers in Western communities. According to the 2007 Malaysia National Cancer Registry Report, RCC accounts for 43.8% of new kidney cancers. However, these statistics are quite dated as it has been nine years since the data was collected.

Advances in medical research have led to new treatment modules. A revised healthcare policy should ideally be aligned with innovation in cancer treatments. Despite new targeted therapies being approved for use in the US and Europe, these therapies are still limited in most parts of South-East Asia, including Malaysia. And even if they are available in the market, patients have to purchase the drugs from private medical facilities, excluding the majority of Malaysians (75%) who seek treatment at government hospitals.

In the treatment for RCC, there is only one drug approved in the government formulary. More options are needed because a single drug may not be right for every patient. For those who are not able to respond to this particular treatment, access to an alternative drug is often a lengthy and uncertain process. For some patients, the options available to them are so dismal, there is almost a case of no option at all.

In developed countries, drug choices are fully funded by the government, leading to patients having equal access to various drugs of treatment that best suit them. In Malaysia, drug choices are limited. Patients may have to pay out-of-pocket to access these treatments, putting them in a financial dilemma of cost versus survival.

In fact, a recent study by Universiti Malaya showed that 5% of cancer patients and their families were pushed into poverty, and that cancer resulted in “financial catastrophe” for almost half of the patients who suffered from economic hardship.

The policy of approving new drugs is based on an analysis of the quality of life years patients gain versus the cost of the drug. Unfortunately, drug affordability is determined by pharmaceutical companies based on the affordability of developed countries. This leads to a mismatch in drug affordability in a country like Malaysia, where Malaysians have a diverse range of economic situations. Furthermore, no matter how clinically effective a drug is touted to be, no drug has been approved in the government formulary in recent years.

Cancer is set to be a major burden of disease worldwide and the leading cause of morbidity and mortality. It is imperative for policy makers to review and update the targeted cancer therapy treatments currently available in the national formulary so that efficacious medicines are accessible to the majority of the population in public hospitals.

We hope increased funding will be made available to assist patients in their treatment, allowing them to live longer with a better quality of life and without putting them at risk of financial catastrophe.

While Malaysia’s public healthcare system continues to evolve to meet the needs of a growing and aging population as well as alarming rate of non-communicable diseases (NCD), let us be aware of the imperative need for this country to also keep abreast of breakthrough therapies available for patients and to champion for these therapies to be accessible at our public hospitals.

Cancer does not discriminate. Every patient, regardless of their economic status or cancer stage, deserves access to treatment.

DATUK DR MOHD IBRAHIM ABDUL WAHID

Medical Director, Beacon International Medical Centre

Vice President of College of Radiology (COR) Malaysia

Sciatica

sciatica

 

I’ve veered off-topic yet again with a bit about sciatica.  I’ve dealt with this for years and years and had a bunch of opinions from a lot of people on what to do, what to take.  For me, nothing seems to help except waiting it out for about a week, then it settles down.  I’ve tried heat, cold, Tylenol, prescriptions, exercises, sitting, standing, lying down…

Just wait a week.  Right now, I’m on day 6, so I have high hopes for tomorrow.

I do notice that sitting is marginally worse than lying or standing.  I guess that maybe compresses the nerve more?  I do have a bit of Oxycodone left over from my knee pain (which I still have – luckily, on the same leg – just not as badly), so I take 1/2 of one to help me sleep at night.

kidding1
Whenever I think of Oxycodone, I’m reminded of the night that I was diagnosed with kidney cancer.  I’d just been admitted to a room and someone came to visit me.  She offered to buy my Oxy from me.  I was stunned.  Then, she said she was just kidding.

Um, no.  I can’t think of anyone who would even think of buying Oxy who didn’t have some kind of issue – even as a “joke”.

 

 

Some info from the Mayo Clinic

Sciatica refers to pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg. Typically, sciatica affects only one side of your body.

Sciatica most commonly occurs when a herniated disk, bone spur on the spine or narrowing of the spine (spinal stenosis) compresses part of the nerve. This causes inflammation, pain and often some numbness in the affected leg.

Although the pain associated with sciatica can be severe, most cases resolve with non-operative treatments in a few weeks. People who have severe sciatica that’s associated with significant leg weakness or bowel or bladder changes might be candidates for surgery.

Pain that radiates from your lower (lumbar) spine to your buttock and down the back of your leg is the hallmark of sciatica. You might feel the discomfort almost anywhere along the nerve pathway, but it’s especially likely to follow a path from your low back to your buttock and the back of your thigh and calf.

The pain can vary widely, from a mild ache to a sharp, burning sensation or excruciating pain. Sometimes it can feel like a jolt or electric shock. It can be worse when you cough or sneeze, and prolonged sitting can aggravate symptoms. Usually only one side of your body is affected.

Some people also have numbness, tingling or muscle weakness in the affected leg or foot. You might have pain in one part of your leg and numbness in another part.

Read more at http://www.mayoclinic.org/diseases-conditions/sciatica/basics/definition/con-20026478

Is blood in your urine cause for concern?

blood_urine

Oh, yes!  This was my very first indication that I had kidney cancer.  Here’s part of my story…

From https://cushingsbios.com/2016/05/09/maryo-10-years-cancer-free/

April 28 2006 I picked up my husband for a biopsy and took him to an outpatient surgical center. While I was there waiting for the biopsy to be completed, I started noticing blood in my urine and major abdominal cramps. I left messages for several of my doctors on what I should do. I finally decided to see my PCP after I got my husband home.
When Tom was done with his testing, his doctor took one look at me and asked if I wanted an ambulance. I said no, that I thought I could make it to the emergency room ok – Tom couldn’t drive because of the anesthesia they had given him. I barely made it to the ER and left the car with Tom to park. Tom’s doctor followed us to the ER and became my new doctor.

 

The News Item that inspired this post:

The sight of blood in your urine is enough to make anyone panic. It doesn’t always indicate a serious problem, but it’s important you get it checked out with your doctor.

Blood in the urine is known as hematuria. There are two forms of hematuria:

Gross hematuria – This is when you can see blood in the urine. The urine may look pink, red, or cola-colored due to the presence of red blood cells (RBCs). Most of the time, other than the change in appearance in urine, most people do not have other symptoms.

Microscopic hematuria – This is when you cannot see blood in the urine but it can be detected when examined under a microscope. Most people with microscopic hematuria have no symptoms.

Causes of blood in the urine:
When a person has hematuria, the kidneys or other parts of the urinary tract allow blood cells to leak into the urine. Anyone, including children, can be at risk for blood in the urine, and it can occur as a result of many common conditions. Some of those include:

Menstruation
Vigorous or strenuous exercise
Sexual activity
Urinary tract infection
Kidney infection
Kidney or bladder stones
Injury
Family history of kidney disease

More serious problems that could be causing blood in your urine might be:

Kidney or bladder cancer
Polycystic kidney disease
Irritation or swelling in the kidney, prostate in men, or another part of the urinary tract
Blood clots
Sickle cell disease
Enlarged prostate
Medications – the anti-cancer drug cyclophosphamide (Cytoxan) and penicillin can cause urinary bleeding.

Diagnosing hematuria
Hematuria is diagnosed with a urine sample called a urinalysis. The urine sample is collected in a special container at a doctor’s office and usually tested in a lab for analysis. The lab technician places a strip of chemically treated paper called a dipstick in the urine. If RBCs are present, patches on the dipstick change color. When RBCs are noted, then the urine is further examined under a microscope to make the diagnosis of hematuria.

Depending on the circumstances, the doctor may order further testing such as a urinalysis, blood test, biopsy, cystoscopy, or a kidney imaging test.

Treating hematuria
Hematuria is treated by addressing its underlying cause. If no serious health problem is detected, no treatment may be necessary. If your hematuria is caused by a urinary tract infection, it will be treated with antibiotics. A urinalysis should be repeated within 6 weeks after antibiotic treatment ends to be sure the infection is gone.
Dr. Samadi is a board-certified urologic oncologist trained in open and traditional and laparoscopic surgery and is an expert in robotic prostate surgery. He is chairman of urology, chief of robotic surgery at Lenox Hill Hospital and professor of urology at Hofstra North Shore-LIJ School of Medicine. He is a medical correspondent for the Fox News Channel’s Medical A-Team and the chief medical correspondent for am970 in New York City. Learn more at roboticoncology.com. Visit Dr. Samadi’s blog at SamadiMD.com. Follow Dr. Samadi on Twitter and Facebook.

Read more at http://www.foxnews.com/health/2016/06/23/is-blood-in-your-urine-cause-for-concern.html