Meeting Mortality - Chapter 1

A week before Thanksgiving I found a lump in my neck.  I just happened to run my hand over the front of my neck one evening and there it was, a pea sized lump.  Now as the daughter of an oncology nurse, the absolute worst possibilities ran through my head immediately; but I am also a pragmatist.  There were a lot of things that little lump could be - a weird zit, ingrown hair, inflamed lymph node, or any number of other benign things.

Turkey Day came and my little lump was still there. So I went to see the family doctor, Dr. G.  "Wow, how did you even find this?" asked Dr. G.

"I just ran my hand over my throat," I replied.

"Huh, wonder what it is," he muttered with his brows furrowed.

"So do I, doc.  I was hoping you could tell me."

Dr. G scratched his head.  "Well, your thyroid is right there.  Let's get a picture of it and get a better look at things."  He ordered an ultrasound and a nurse scheduled it for the following week.  It didn't show much conclusive, just 'a possible cyst on or near the thyroid'.  Wonderful, I thought, now I have a whole new realm of possible worst cases to dwell on.  

Dr. G wanted better pictures so he ordered a CAT scan.  When the nurse called to schedule that with me I asked her, "At what point can we stop screwing around with pictures and just cut the thing out and send it off for a biopsy?  I can feel it right below the skin.  I figure with an out patient procedure and maybe 4 stitches, we could take the whole thing out to send to a pathologist.  I really want to know whether its malignant." 

The nurse chuckled and said, "I know exactly where you're coming from but no one is going to do a biopsy with out a CAT scan to confirm what's there.  The insurance won't cover it if they do."

Right.....gotta keep the bureaucracy happy.....forgot about that part of medicine.  So I spent a week reading about and dwelling on worst case problems associated with thyroid cysts.

The CAT scan came back as 'a small mass, most likely a cyst, in the epidermal layer'.  I was relieved.  This wasn't sounding so bad now, especially after all the worrying I had been doing.  Dr. G said, "These things sometimes pop up in the skin and there is really nothing to them.  We have two options here.  We could wait and watch it for a change of size or other warning indicators or I can refer to an ENT."  As far as I was concerned the only choice was the latter.

I saw Dr. D, the ENT, just before Christmas.  He looked at the CAT scan and said, "Yep, that does indeed look like an epidermal cyst.  They don't do much really.  We could leave it there and watch it if you wanted.  They do have a tendency to get infected and burst though, so we would want to watch it for changes in size." 

I shook my head, "Doc, I was raised by an RN/OCN.  This thing wasn't there before and now it is.  By definition there has already been a change in size.  Can we just cut it out now?  I'd like it sent to a pathologist for my peace of mind."

Dr. D smiled, "That's what I would do if I were you, take it out before it becomes an issue."

Since there did not seem to be any real reason to hurry about this, I scheduled the procedure after New Year's so my family and I could still go spend a week with my parents for Christmas.  On January 10th, they put me under sedation and Dr. D cut the lump out.  Hubby brought me home and, while I slept the rest of the day, he and the boys went to fill my post-op prescriptions.  I had a total of 5 stitches in my neck; just a scratch really, but fascinating to my children none the less.

Four days later, on Friday morning, I was running errands, driving on a relatively busy street with the kids in the backseat when my cell phone rang. 

"Jenni, it's Dr. D--.  How are you feeling?"

Oh crap, I thought, something is wrong.  If everything was fine, it would be his nurse calling.  "I'm doing OK, doc.  How are you?" I replied as made a quick right turn onto a side street.

"I got your pathology report back.....," Dr. D started and then there was a long pause.

Uh oh, I thought.

"......turns out this thing wasn't a cyst after all...." he continued.  He was still talking but my ears, my eyes, and my brain suddenly all stopped working at once.  I caught another word of what he was saying as I parked the car, "...sarcoma...."  I can't remember what came after that really.  It was something about rare cancer, catching it while it was still very small, and really good odds.  I was still having a hard time getting past that s-word...sarcoma.  That's an ugly scary word. 

Dr. D must have realized he had lost me there for a moment.  "Jenni?"

"Yeah....sorry, doc," I mumbled.

"We need to go back in and do another procedure called a Mohs surgery.  It's the prescribed treatment for this," he said.

"I should probably see an oncologist too," I said.

"We can get one involved but for surgery he would refer you to someone like me or to someone who does a bunch of Mohs procedures, that's typically a dermatologist," Dr. D said.  "I've got a bunch of calls out to find out who in the area has done the most of these.  I know you are scheduled to come in to the office on Tuesday but I want to see you Monday instead.  I'll have everything set up by then."  He was very encouraging, up beat, and on top of things.  Great qualities in a doctor.

"Sure, doc, see you Monday," at least I think that's what I said.  My brain was still screaming, SHIT!

As I hung up the phone, my 5 year old asked, "Mommy, what's on this street?"

"Huh? What, Monkey?" I croaked as I felt my heart climbing into my throat.

"Why are we stopped on this street?  Does someone live here?" he asked.

"I just needed to pull over to answer the phone, kiddo.  Just give me a moment," I said as I rested my head on the steering wheel.  Keep it together,girl, so you can get yourself and the kids home safely.  Good ol' pragmatic me.

We got home. I made lunch. I took my 5 year old to school, and put my 3 year old down for a nap.  Then I started doing a little research.  Research is usually what I do when something scares the hell out of me.  Mohs surgery is pretty straightforward and not terribly scary in and of itself.  I called Dr. D's office back and talked to his nurse.

"What is this thing in my neck called again?" I asked.  "I was not in a place where I could take notes when Dr. D called earlier.  The only part I remember is 'sarcoma'.  Some of those are pretty terrifying so I wanted to make sure I was reading about the right one."

"I would too," she said.  "It's called dermatofibrosarcoma protuberans or DFSP for short."  She spelled it out for me and then paused, "Do you have any questions about it right now?"

"Can I get a copy of the path report?" I asked, knowing that my mom was going to want to see it.

"Yep.  I don't have electronically but I'll make sure to give you a copy when you come in on Monday morning.  Any others?"

"I need to think about this a bit first," I said.

"OK, if you do think of any or need anything else just give us a call.  We'll see you Monday morning."  She was very helpful, up beat, and empathetic. Great qualities in a nurse.


I hung up the phone and listened to the clock on the wall ticking as I stared at my notes on the table.  I have cancer.  This rather sucks.

November is NaNoWriMo!

I literally have 4 draft posts that I am working on for this blog and another 6 draft posts waiting to be finished for my Hynek's Handmade blog; but I just don't have time to work on any of them right now.  It's amazing really that once November 1st hits, I am consumed, busy, distracted, and definitely not in a place to create interesting or remotely useful blog articles.  It has nothing to do with Halloween finally being over, or that November 1st is my wedding anniversary, or that the holiday season is nigh.  It has everything to do with November being National Novel Writing Month (aka NaNoWriMo)! 

Every year from 12AM November 1st to 11:59PM November 30th aspiring writers world-wide are glued to their word processors in a frenzied attempt to write a 50,000 word novel.  That may not sound like much of a challenge to those who have not tried it before but then those are the folks who have not tried it before.  Take my word for it, its a challenge - but a doable challenge.  To hit the challenge mark, you have average 1,667 words of original content a day.  Nothing you may have written prior, outside of November, is allowed. 

Ever since I was a little girl, I have had these wonderful story ideas running around my head but I had never thought about getting any of them down on paper until my friend Marie introduced me to NaNoWriMo in 2007.  I remember my first NaNoWriMo well. I was so excited going in to it.  I outlined my story idea ahead of time (this is OK under the rules) so that I would just be able to write and not worry about where the plot is supposed to go.  It was all very OCD engineer of me and I chuckle to myself when I think about it now.  Once I started, I found that my story kept wandering from the outline, giving me fits about how to force it on the track I thought it should be rather than just letting it evolve.  This resulted in a terrible case of writer's block and I was perpetually behind in my daily word count and very frustrated. Then my computer died so horribly that I had to send it back to HP for repairs. I took it as a sign from God that I was not meant to finish that year.

The following year I gave it another try out of pure stubbornness.  I told myself that if things did not work for me a second year in a row that I would just scrap the whole concept and not torture myself further.  However, this second year I changed my approach to writing.  I started with an outline but I made it far more general and set in sand rather than stone.  I let the story take over.  I let the characters come alive in my head.  Once I did this, the story just sort of wrote itself.  It was amazing.  I met the NaNoWriMo 50,000 word goal a couple of days early that year with my story only half finished.  It was an amazing non-linear creative experience and suddenly I was hooked not just to NaNoWriMo but to writing in general. 

So every year, I participate in NaNoWriMo and almost everything else extra curricular in my life gets put on hold for the month of November.  I am still mothering my children and crafting for my Etsy shop (finishing up a custom order for my Aunt right now).  But the laundry piles up a bit more,  the house work gets ignored more, and family meals get decidedly boring and repetitive.  My hubby is awesome about it all and picks up the slack admirably and only asks for extra Star Buck's coffee beans.  I am so lucky! 

Happy NaNoWriMo!  See you all December 1st......

Make Your Own Instant Oatmeal

OK, I found an awesome idea on Endless Crafting, one of the many blogs I follow.  This fits so well with my whole homemade is best ideal that I just have to share it - Homemade Instant Oatmeal.  Natalie's recipe is simple and I can't believe it's never occurred to me to do this before.  This would certainly be less expensive than the prepackaged instant as well. 

I love oatmeal in the morning.  My kids and husband do not, but I keep hoping the kids will come around.  Mornings are generally pretty busy with getting ready for school etc. so instant oatmeal is very convenient.  Quaker's Maple & Brown Sugar is my preferred flavor and is what I currently have in the cupboard.  A quick look at the ingredients tells me that Quaker is the least offensive of the major brands for instant oatmeal. 

However, it still has artificial flavors and caramel color.  I generally like to avoid the artificial stuff when I can.  It also lists salt and guar gum.  I don't have anything against salt or guar gum per say; both are natural ingredients.  However, there is more of each of these per package than there is oat flour.  This just seems wrong.  I suspect that the guar gum is used as a thickening agent and it must cheaper than oat flour because they use more of it.  Call me odd, but I think I would rather be eating oats in my oat meal instead of crushed guar beans. 

As soon as I use up the stuff in my cabinet, I'll be giving Natalie's Homemade Instant Oatmeal a try.  I am not sure why the powdered milk is in there, except perhaps to make it a 'just add water item'.  Perhaps I can leave the powdered milk out and just use regular milk to make it instead.

Mama Hynek's Game Chili

It's that time of year again.  Hubby and FIL have been on their annual water fowl hunt and I now have fresh goose and duck in the freezer.  I did something a little different this year; I put part of these birds through the meat grinder and divided them into 1 pound packages.  So now I have 5 pounds of ground goose and 5 pounds of ground duck in the freezer in addition to 2 whole geese and 7 mostly whole mallards. 

In the past, I have always put the meat through the grinder on an as needed basis, which is a bit of a hassle if you have to let it thaw first.  It was not as convenient to use said water fowl meat as a substitute in recipes that call for ground beef.  Wait!  Before roll your eyes and make that 'yuck' face, let me assure you that it tastes just fine and the consistency/texture in the recipe is no different.  Goose and duck meat are a fatty dark meat with a nice robust flavor that works well in recipes like lasagna, spaghetti, and chili.  I even took some of the goose and made them into hamburger patties last week.  They tasted great to Hubby and I and the kids ate them without comment.   

I will make one comment with regard to ducks - their flavor varies greatly with species or perhaps the diets of said species.  Mud hens taste like mud and I don't recommend them.  Mallards, on the other hand, are quite yummy and I highly recommend them.

At the beginning of each hunting season, I rummage around in the deep freeze to locate those packages of frozen game meat that always seems to fall the the back bottom corner, hidden under the frozen veggies, where time and freezer burn would eventually make them inedible if I didn't do such periodic rummaging.  I managed to dig out the remaining 3 pounds of goose meat from last year which I wanted to use up before we added the newly harvested water fowl to the freezer. 

The best way to use up three pounds of meat that I know of is to make chili.  So I ground up what was left of last year's goose and got out my huge stock pot (not merely large but huge!).  I don't normally follow a recipe when I make chili but in the interest of refining my process, I wrote down what I did this time.  If you're interested, here it is. 

I warn you in advance this makes a lot of chili!  I always freeze the majority of it in 1 quart containers so I can pull them out as needed.  This batch made enough to feed a family of four for two suppers and freeze 7 quarts. 

---------------------------------------------------------------
Mama Hynek's Game Chili

3 lbs ground goose, duck, or venison (or some combination thereof)
4 tbs olive oil
1 16-oz bag pinto beans
1 16-oz bag black beans
1 16-oz bag kidney beans
10 cups water
2 medium onions, chopped
4 6-oz cans tomato paste
4 4-oz cans diced green chilies
1/2 tbs garlic powder
1/2 tbs cumin
6 tbs chili powder
1 tbs Morton's Nature's Seasons Blend (this is a salt, pepper, etc. spice blend)
1 tbs oregano

Soak beans overnight in water with 3 tbs of baking soda dissolved in it.  Rinse well and repeat for two more nights. Pour out the soak water.  (Believe me you don't want to cook with it.  Just as FYI - most people soak their beans for one night but I have found that soaking for three nights with baking soda does a much better job of reducing gas issues.)

In huge stock pot, put olive oil in the bottom.  Add ground game meat and brown it completely.  Add onion.  Add soaked beans and water.  Cover and bring to a boil.  Add tomato paste, green chilies, and spices. Stir well, cover, and bring to a boil again.  Reduce heat and simmer for at least 4 hours, stirring occasionally to prevent sticking.  Serve over rice and garnish with cheddar cheese, if desired.

"I Want to Fly!"

 We live in a place that is blessed with birds.  My oldest son loves them, especially the hawks and eagles that we see all the time.  He wants so much to soar with them and gazes after them longingly.  He always says, "I don't have wings, Mommy.  How come I don't have wings?"  How do you explain evolution to a 5 year old?  The only response I can give him is, "Man has been wishing for wings ever since the dawn of time when he saw his first bird, Monkey Boy.  The dream of flying is the main reason that gliders, airplanes, and helicopters were invented."  Then, being a typical mom, I always add, "You do well in school and you can learn to fly some day if you want to."  Internally, I am thinking, "Geeezz, how are we ever going to afford flying lessons for him?"  But I never say this aloud.  If his avid desire to fly persists into his 'tween and 'teen years and his grades in school are good, then I will find a way to make it happen, some how.

The other day, he tied a red bandanna around his neck.  "Mommy, look at my cape!  Now I can go fly."  Then he went bounding out into the yard.  It was a windy day and his 'cape' fluttered out behind him.  He closed his eyes, faced the wind, held up his arms like Superman, and jumped...and jumped...and jumped....  Then, muttering about needing more lift, he tried jumping off the back steps.  Eventually, he came inside, tears running down his face, grabbed my hand and pulled me outside.  "Mommy, how come I can't fly with my cape?  Look...see?  It doesn't work."  He demonstrated.  Then he looked up at the red-tailed hawk that happened to be hovering over head and said, "Mommy, I want to fly like that."  I gathered him into my lap, dried his tears, and we watched the hawk together, talking about how much fun it must be to soar like a hawk.  "Some day, Monkey Boy....  Some day when you are a little older, we'll find a way to get you some flying lessons if that is what you really want."  He went to sit in the grass and watch the hawk some more as I went in to make supper.  "I am going to fly someday, Mommy."  I know you will, my sweet boy, I know you will.

The Eagle and the Hawk

I am the eagle, I live in high country,
In rocky cathedrals that reach to the sky,
I am the hawk and there's blood on my feathers,
But time is still turning, they soon will be dry,
And all those who see me, and all who believe in me,
Share in the freedom I feel when I fly!

Come dance with the west wind,
And touch all the mountain tops,
Sail o'er the canyons, and up to the stars,
And reach for the heavens, and hope for the future,
And all that we can be, not what we are.

                                      — John Denver

Ode to Vitamin D

It is that time of year again.  School is back in session.  The kids are swapping germs and bringing their new bugs home to their moms and dads who take them to work to swap with their colleagues who then take them home to their kids.  The virus mutates somewhere along the way and the whole cycle starts over. 

 

Ever since I moved north from Texas in 1999, I have managed to contract at least one upper respiratory virus every winter.  It was usually something that robbed me of my voice, had me carrying around a box of Kleenex everywhere I went, left me popping Sudafed and expectorant every 4 hours, and turned me into a cough drop addict.  Most of the time it would take me 3 or 4 weeks to kick these illnesses completely.  Herbal teas and homeopathic remedies provided some relief but nothing terribly lasting.  Extra Vitamin C, echinacea, and zinc kept things from stretching into 5 or 6 weeks.  In the end, I was left to stoically accept that viruses in the Midwest were different than those in Texas and to hope that my immune system would eventually develop a resistance.



Then, in Fall 2009, my cousin mentioned a new study(1) that she had read about Vitamin D deficiency contributing to illnesses, in particular upper respiratory illnesses.  I looked up the study and did some quick research on Vitamin D dosages (and over dosages) and then bought a bottle of Vitamin D supplements.  I started taking an an extra 1000 IUs per day.  For the first time in 10 years the worst I came down with was a case of sniffles and a slight sore throat which lasted all of 24 hours.  I am definitely a believer. 



Now, following my youngest son's nasty and rather frightening, bout with pneumonia last May, I've started my kids on some children's chewable Vitamin D tablets, just an extra 500 IUs per day.  We have managed to get 3 weeks into this school year and the worst they've had so far has been cough and sniffles that lasted about 3 days.  During the past couple of school years, my oldest son has, within the first week of classes, come down with an upper respiratory virus that has last for a minimum of 10 days.  Now I see the other kids in his class coughing and sniffling and I am feeling pretty good that he is not, at least not yet.

What is Vitamin D and from where does it come?

Vitamin D is actually a group of fat-soluble secosteroids.  The two most important of these are Vitamin D2 (aka ergocalciferol) and Vitamin D3 (aka cholecalciferol).(2)  Nutritionally, it is found in relatively small number of foods.  These are fatty fish (e.g. catfish, salmon, mackerel, sardines, tuna, and eel), eggs, beef liver, fish liver oils (e.g., cod liver oil), and mushrooms.   In fact, mushrooms are the only vegan dietary source of Vitamin D.(3)  The label of my Vitamin D supplement does not specify the source but neither does it stipulate that it's source is vegan.  So if you are vegan, I hope you like mushrooms, lots of mushrooms. In some countries, including the USA, some foods such as milk, breakfast cereals, orange juice, flour, margarine, and butter are fortified with Vitamin D.



In vertebrates, Vitamin D is produced in the skin after exposure to ultraviolet-B (UVB) light, either artificial or from the sun.  Peak synthesis occurs when sunlight is at a UV index greater than 3, which occurs daily in the tropics, daily during the spring and summer months  in temperate regions, and almost never in the arctic circles.(4)  Not all outdoor sunlight exposure is equal.  Overcast skies, shade, and air pollution can block UVB rays by as much as 60%.  UVB radiation does not penetrate glass, so sitting indoors in a sunny window does not produce Vitamin D.  Sunscreens with a sun protection factor of 8 or more also block UVB rays, although practically speaking people generally do not apply sufficient amounts or cover all sun-exposed skin, so it is likely that some Vitamin D production will occur anyway.  Clothing also blocks UVB rays.(5) 

Before we all jump the gun and go get a membership at a tanning salon or start visiting the nearest nudist beach, you should consider that some researchers suggest that 30 minutes of sun exposure to the face, arms, legs, or back without sunscreen from late morning to mid-afternoon at least twice a week is enough to provide to sufficient vitamin D synthesis.(6)  Of course this is a generality.  Dark skinned people need longer exposure times than fair skinned people, obese people need more Vitamin D than skinny people,(7) and everyone's body operates uniquely.  Personally, I prefer not to chance the skin cancer.  I use SPF 30+ sunblock, wear hats, and avoid the intense sun during the heat of the day.



How does the body use Vitamin D?

The Vitamin D obtained from sun exposure or diet is biologically inert and must undergo two changes before it is used by the body.  First it is carried in the bloodstream to the liver, where it is converted into a prohormone, calcidiol. The second change takes place in both the kidneys and in the immune system where the circulating calcidiol is converted into calcitriol, the biologically active form of Vitamin D.(8) 



Vitamin D3 aka Cholecalciferol



Vitamin D is essential for to bone strength.  It promotes calcium absorption in the digestive tract and helps maintain adequate serum calcium and phosphate concentrations enabling normal mineralization of bone and preventing hypocalcemic tetany.  It is also needed for bone growth and maintenance.  Without sufficient vitamin D, bones can become thin, brittle, or misshapen, symptoms of rickets, osteomalacia, and osteoporosis.(9)

Vitamin D also plays a significant role in neuromuscular and immune function and reduction of inflammation. It also plays a role in regulating cell proliferation, differentiation, and apoptosis, all of which are important in fighting and preventing cancers.(10)  In the immune system, calcitriol behaves as a cytokine and helps defend the body against microbial invaders.(11)

What are safe doses of Vitamin D?

First know this, I am not a doctor or a pharmacist.  You should talk to yours before you go start or change dosage of any supplements.  This is doubly important if you are on any medication, pregnant, nursing, or undergoing medical treatment for anything.  The only thing I will do is point you to some websites that discuss dosage and talk about why I decided on my own dosage.

 

First, as I mentioned earlier, Vitamin D is a fat soluble vitamin which means that it is stored in the body differently and is easier to over-dose with than a water soluble vitamin, like Vitamin C.  Vitamin D overdose causes hypercalcemia.  Thus, the main symptoms of Vitamin D overdose are those of hypercalcemia.  These include anorexia, nausea, vomiting, polyuria, polydipsia, weakness, nervousness, pruritus, kidney damage, and renal failure.(12) 

A sustained intake of 50,000 IUs can produces toxicity after several months.  However, there can be medical conditions that can make an individuals more sensitive to Vitamin D; thus my cautionary statements.  The U.S. Dietary Reference Intake Tolerable Upper Intake Level (UL or maximum amount that can be tolerated without harm) for infants (birth to 12 months) is 1,000 IUs per day. The UL for children and adults is 2,000 IUs per day.(13)  However, some newer studies indicate that a UL of 10,000 IUs is more appropriate.(14)  These UL numbers are total intake values, dietary, sunlight exposure, and supplemental. 



The Food and Nutrition Board at The National Academies' Institute of Medicine established the Adequate Intake levels (AIs) for Vitamin D based on age alone assuming no exposure to sunlight.  They are 200 IUs for ages birth to 50 years,  400 IUs for 51–70 years, and 600 IUs for 71+ years.(15)  However in 2008, the American Academy of Pediatrics recommended a higher minimum intake of 400 IUs for infants.(16)

In March 2007, a group of vitamin D and nutrition researchers published a controversial and provocative editorial contending that Vitamin D intakes of 400 IUs per day were insufficient to maintain serum Vitamin D levels at optimal levels in healthy adults and that daily intakes of 1,700 IUs should be recommended.(17)  Just as reference, typical diets in the United States provide about 100 IUs per day.(18)

Based on these recommendations and the data presented in the new studies, I have chosen to take an additional 1,000 IUs per day.  This is over and above anything I eat, the 800 IUs in my daily multi-vitamin, and anything I receive via sunlight exposure.  The way I see it, I am most likely getting about 2,000 IUs per day, which is the UL.



With my kids, I am, of course, more cautious.  A smaller intake for smaller people.  I calculate that they are receiving 1,000 IUs per day across diet, multivitamin, Vitamin D supplement, and sun exposure.  This is half the UL for their age group.  Add to that the fact that I cannot always get them to eat the vitamins each day, I am not worried in the least.  I am however, very happy having healthy children when everyone else around them is hacking up a lung. 

I am sure that  we'll all come down with some kind of virus that knocks us on our butts.  It's unavoidable.  However, if the extra Vitamin D makes it easier for our immune systems to handle what we might contract, then it's doing its job.  My goal, to keep my kids and myself out of the hospital due to pneumonia or anything else that tries to take up residence in our chests and have fewer illnesses overall. 

Footnotes

(1) Archives of Internal Medicine. "Association Between Serum 25-Hydroxyvitamin D Level and Upper Respiratory Tract Infection in the Third National Health and Nutrition Examination Survey." Adit A. Ginde, MD, MPH; Jonathan M. Mansbach, MD; Carlos A. Camargo Jr, MD, DrPH. (2009) 169(4):384-390. (http://archinte.ama-assn.org/cgi/content/abstract/169/4/384)

(2) Institute of Medicine.  Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride.  (1997) (http://www.nap.edu/openbook.php?isbn=0309063507&page=250)

(3) National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D.  (http://ods.od.nih.gov/factsheets/vitamind.asp)

(4) The American Journal of Clinical Nutrition. "Environmental factors that influence the cutaneous production of vitamin D." MF Holick. (March 1995) 61 (3 Suppl): 638S–645S. (http://www.ajcn.org/cgi/reprint/61/3/638S)

(5) National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D.  (http://ods.od.nih.gov/factsheets/vitamind.asp)

(6) National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. (http://ods.od.nih.gov/factsheets/vitamind.asp)

(7) National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. (http://ods.od.nih.gov/factsheets/vitamind.asp)

(8) Journal of Clinical Endocrinology & Metabolism.  "Update in Vitamin D."  J.S. Adams; M. Hewison (Feb 2010) 95 (2): 471–8. (http://jcem.endojournals.org/cgi/content/abstract/95/2/471)

(9) National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. (http://ods.od.nih.gov/factsheets/vitamind.asp)

(10) National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. (http://ods.od.nih.gov/factsheets/vitamind.asp)





(11) Journal of Clinical Endocrinology & Metabolism. "Update in Vitamin D." J.S. Adams; M. Hewison (Feb 2010) 95 (2): 471–8. (http://jcem.endojournals.org/cgi/content/abstract/95/2/471)  

(12) Merck Manual of Diagnosis and Therapy, Professional Edition.  "Vitamin D."  Larry E. Johnson, MD, PhD, editor.  (April 2007) (http://www.merck.com/mmpe/sec01/ch004/ch004k.html#sec01-ch004-ch004k-BABBBEAE)
 
(13) Merck Manual of Diagnosis and Therapy, Professional Edition. "Vitamin D." Larry E. Johnson, MD, PhD, editor. (April 2007) (http://www.merck.com/mmpe/sec01/ch004/ch004k.html#sec01-ch004-ch004k-BABBBEAE)
 
(14) National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. (http://ods.od.nih.gov/factsheets/vitamind.asp)
 
(15) National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. (http://ods.od.nih.gov/factsheets/vitamind.asp)
 
(16) Pediatrics. "Prevention of rickets and vitamin D deficiency in infants, children, and adolescents."  C. L. Wagner; F. R. Greer.  (January 2009) 123(1):197. (http://www.ncbi.nlm.nih.gov/pubmed/18977996?dopt=Abstract)

(17) National Institutes of Health Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. (http://ods.od.nih.gov/factsheets/vitamind.asp)

(18) Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride.  (1997) (http://www.nap.edu/openbook.php?isbn=0309063507&page=250)