Category Archives: Dr. Croft’s Blog

Assess MS

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Multiple Sclerosis is a disease of the brain and nervous system. The body immune systems create a response that destroys the insulation sheath (myelin) that protects nerves. As the disease progresses, it can disrupt the messages carried from the brain to the rest of the body that can potentially become crippling over time. A common presentation interferes with the ability to walk but may initially return to normal for extended periods of time.

Depending on the nerves involved, symptoms may include numbness or weakness that may occur in limbs, electric shock sensations in limbs, and / or tremor or lack of coordination when put to task. Balance issues may be another that may present temporarily. Many of these signs will improve spontaneously at first. Eye complaints may include partial or full loss of vision and may be associated with eye pain. Double vision or blurring of sight may also present. Additional nerve complaints may include slurring of speech, fatigue, dizziness, or bladder / bowel control difficulties.

The typical presentation of MS initially develops varied symptoms over days or weeks but then improve either partially or completely for a duration of months to even years. This is the most usual form of MS that follow such a relapsing / remitting course. About half of these cases will show a steady degree of progression over the next ten to twenty years of the onset known as secondary progressive MS.

The cause of MS is unknown. The usual onset is in those between twenty and forty years old but may vary above or below those ranges. Women are two to three times more likely to develop MS. Those with parents or siblings with a history of disease have a higher risk as well. White people have the highest risk associated. Asian, African, and Native American descent have the lowest risk.

There are other health related issues that may increase the likelihood of MS. Those with low vitamin D levels and minimal exposure to sunlight may be at risk. As well, other autoimmune diseases such as thyroid disorders, pernicious anemia, psoriasis, type one diabetes, and inflammatory bowel disease are shown to have an increased risk as well. And smokers, as with many other health problems, are at a higher risk of developing MS than non-smokers.

With progression of the disease, muscle spasm or paralysis may develop directly. Other effects may include worsening problems with bowel, bladder, or sexual function. Additionally, the onset of depression or even epilepsy may occur. There are associations from infections such the Epstein-Barr virus responsible for mononucleosis, as well as those with Guillain-Barre that directly affects the spinal cord. Conversely, there is no increased risk of developing MS after receiving any of the following immunizations: HBP, HPV, influenza, MMR, variola, tetanus, BCG, polio, or diphtheria. There have been only two reported cases of MS relapse after receiving the COVID-19 vaccine, which were due to exacerbating the known underlying disease rather than causing it.

There are no specific tests that diagnose MS, the diagnosis is made from the clinical course combined with radiologic imaging and nerve studies. As well, there are no medications or treatments that will cure the disease, but there are medications and therapies designed to improve current symptoms and manage the progression of symptom development. Earlier intervention typically leads to best outcomes. Should you have concerns or questions about MS, consult your health care provider.

Bradford Croft, DO
East Flagstaff Family Medicine

Time to Talk About Colon Cancer Again

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Colorectal cancer (cancer of the colon and rectum) continues to be the second leading cancer-causing death of both men and women in the U.S. It is, however, the third most common cancer diagnosed in our country. The only more common cancers in men are that of prostate and lung, and women are breast and lung. According to the most recent statistics of the CDC, 141,125 people were diagnosed with colorectal cancer in 2017 with 52,547 deaths. Of every 100,000 people, there are 37 diagnosed with colorectal cancer and 14 deaths.

Colorectal cancer begins in early stages as growths or polyps that develop in the large bowel. The most common polyps are adenomatous. These are not initially cancer by nature but are likely to turn into a cancer over time. There are also inflammatory, hyperplastic, and villous polyps ranging from minimal to significant risk of evolving into colon cancer. As cancer evolves, one may eventually have complaints of blood in the bowel movement, persisting abdominal pains or cramps, or unexplained weight loss. Although these symptoms are not exclusive to colon cancer, immediate medical help should be sought if these complaints are present. Early on, there may be absolutely no symptoms at all.

Although there are no absolute reasons that individuals develop colon cancer, there are some risk factors to consider. As we age, our probabilities increase. According to the CDC, more than 90% of cancers occur in those over fifty. As such, the general recommendations are that men and women begin routine screening at forty-five years old. There is an increased incidence for those with underlying inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease. If you have a family history (mother, father, sister, or brother) with a diagnosis of colon cancer discovered before age 50, or if you have a genetic syndrome such as familial adenomatous polyposis or hereditary non-polyposis colorectal cancer, you may have an increased risk and require screening earlier than the routine recommendation of 45 years old.

As March is Colorectal Cancer Awareness Month, your family physician can help you evaluate your risk and screening options and may provide preliminary testing in office. There are several screening tests. Most involve the evaluation of a stool specimen, such as the guaiac-based fecal occult blood test (gFOBT) which tests for the presence of blood, the fecal immunochemical test (FIT) that measures antibodies that indicate bleeding, and the FIT-DNA test, checking for altered DNA combined with the antibody test. Although a positive screening test is not an assurance of cancer, it is a marker for timely evaluation.

Colonoscopy is a procedure that checks for cancer in the rectum and entire colon. With the patient under sedation, a long, thin, flexible scope is used to painlessly visualize the bowel and remove polyps as well as biopsy areas of suspicion. This is also the procedure commonly used if any of the previous screening tests return as positive. Usually, this screening test is only needed once every ten years as opposed to annually for the less reliable gFOBT and FIT, or every three years for FIT-DNA, commonly marketed as Cologuard.

Additional techniques include capsule endoscopy (swallowing a camera in a pill) and virtual colonoscopy (a series CT radiology pictures combined to provide an image of the bowel). As relatively new procedures, they may not be covered by insurance or available in your area. Along with recommendations from your doctor, check with your insurance coverage to determine which tests may be choices for your screening evaluation.

Bradford Croft, DO
East Flagstaff Family Medicine, LTD

Take It to Heart

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In addition to St. Valentine, February helps to remind us of other things that impact the heart. Multiple factors can influence your risk of heart disease that include several health conditions, your lifestyle, age and family history.   It is important to know your risk factors as some can be changed, others cannot.  As heart disease is still the number one killer of both men and women in the US, these are issues that should truly be taken to heart.

According to the Center for Disease Control, almost half of the US population have at least one of three main risk factors of cardiovascular disease: high blood pressure, elevated cholesterol and smoking.  High blood pressure can silently damage the heart, kidneys and brain among other systems over time.  When the damage comes, its first symptom will usually be a heart attack, kidney failure or stroke.   As there are rarely any physical complaints associated with untreated hypertension, the only way to determine the problem is to check your blood pressure.  If elevated, treatments may include lifestyle changes as well as medication.

Cholesterol is a natural substance in the body, but with elevated levels may cause deposits in the blood vessels over time.  As these plaques occur, circulation can be compromised to organ systems, again leading to damage to brain, heart and kidneys.  And again, its first symptom may present as a stroke, heart attack or kidney failure.  The two major cholesterol subgroups include HDL (good cholesterol), the higher the better, and LDL (bad cholesterol), better lower.  Depending on risk factors, the goals for the cholesterol components may vary among individuals.  A simple blood test can determine your values and imply your risk.

Smoking is well known to increase the negative effects of both hypertension and hyperlipidemia.  The effects of nicotine, either smoking or vaping, will further heighten blood vessel resistance, contributing to worsening hypertension and vascular damage.  High cholesterol will be adversely affected by further lowering HDL, further increasing plaque formation.

Diabetes will compound the likelihood of cardiovascular death.  Management of diabetes is critical to decreasing the risk of cardiovascular disease.  The impact of obesity further worsens adverse cholesterol and elevates blood pressure.  Poor dietary habits, sedentary lifestyle, excessive alcohol intake and uncontrolled anger or stress all are additional contributors as risk factors.  As difficult as it may be, however, all of these risks can be modified and improved with lifestyle and medical intervention.

Some risk factors can’t be changed including family history (following genetic blueprints), age (risk increases with age), gender (males more likely than females, but the odds equilibrate after menopause), and race (African American, Native American and Hispanic American are at higher risk than Caucasian).  Even though these risks cannot be changed, the spectrum and contribution of the additional treatable risks can be addressed and monitored over time to improve the outcomes and minimize the cardiovascular consequences.  If you are not aware if you have any of these risk factors, this would be the month to visit with your primary care provider for screening.  If you do have any of these risk factors, this would be the month to visit with your primary care provider for treatment.  Take it to heart.

Bradford Croft, DO

East Flagstaff Family Medicine

The Silent Hepatitis C

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Hepatitis is the diagnosis of an inflammation of the liver.  There are a number of different sources, including viral infections, certain medications and irritation from alcohol and chemical exposures.  Hepatitis C is an increasingly common infection showing up in ageing adults, and may exist without any symptoms or complaints for years or decades after the initial infection.  Sources of this infection include any current or remote history of drug injection with shared needles or syringes, or receiving an organ transplant, blood products or transfusions prior to the early 1990’s.  However once this virus had been identified around that era, screenings have been in place to minimize the possibility of transmission of this infection.  There continues to be a risk of infection to health care workers who may experience an accidental needle stick from an infected patient or those using injectable drugs.  There is up to ninety percent likelihood that a person infected with HIV using IV drugs will develop Hepatitis C as well.

There are other common hepatitis infections, including Hepatitis A and Hepatitis B.  Hepatitis A usually will resolve without medical treatment after an acute infection.  Hepatitis B may persist chronically within an infected person, but since the development of both Hepatitis A and B immunizations, the incidence continues to decrease over time for both infections in the past twenty years.  Unfortunately there is not yet an immunization for Hepatitis C.

The CDC estimates that 3.2 million people in the US have chronic Hepatitis C.  Up to twenty five percent of people who became infected will have the virus clear their system without treatment. But many of those with infection will develop chronic liver disease resulting in liver damage, failure, cancer and even death.  For those diagnosed with chronic Hepatitis C, there are several treatments now available that are more effective with fewer side effects than some of the older medications.

There are several blood tests for Hepatitis C.  Some are ordered individually, others may be a part of a panel or screen.  Hepatitis C is also a concern for causing elevated liver function that has no confirmed explanation.  The initial test is usually for the presence of Hepatitis C antibodies in the individual. The presence of antibodies indicates a prior exposure to the infection but does not confirm active or present infection.  A positive screen is usually followed by a second test looking for the presence of the virus in the system.  This ‘viral load’ is also used as a marker to determine the success of treatment.

The incidence of Hepatitis C is increasing in the US population over the past decade. As the “baby boomers” are getting older, be aware of this concern with changes in liver function tests.  If you have a potential exposure to this infection, talk to your family physician if you may be at risk of Hepatitis C.

Bradford Croft, DO

East Flagstaff Family Medicine


Too Bad, so SAD?

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When the days are getting shorter and the temperature colder, do you find yourself getting a little more irritable?  Have a little less energy?  Feel a little more moody?  And if you find that this pattern is consistent year after year, starting every fall and disappearing each spring, you may be suffering from Seasonal Affective Disorder, or SAD.

Seasonal Affective Disorder is a subset of major depression, and may have general characteristics of daylong depression and low energy.  Feelings of hopelessness or worthlessness, as well as no interest in activities that once were enjoyable are common.  Poor sleep patterns, difficulty concentrating, changes of appetite or weight and feelings of agitation are also frequent.  Specific to SAD include craving starches and subsequent weight gain, heavy feelings of the arms and legs, as well as trouble with interpersonal relationships including hypersensitivity to rejection and problems getting along with others.

Although the specific cause is not known, some factors are likely contributing to the development of the disease.  It is season specific, commonly starting as days get shorter and diminishing as longer days return.  The decrease in sunlight may disrupt your circadian rhythm or “bio clock” which sets your wake/sleep cycle.  Disruption of this cycle may lead to depression.  Reduced sunlight can also cause a drop of serotonin which is known to affect mood and contribute to depression.   Melatonin, another neurotransmitter, can be disrupted by a shrinking photo period and will affect sleep patterns and mood.

Females seem to be more likely to suffer from SAD, but males may experience greater severity of symptoms.  Younger individuals are at greater risk for SAD, however the risk does decrease with increasing age.  Those with a personal history of depression or family history of Seasonal Affective Disorder are also more likely to have SAD.  The greater the swing of day/night intervals, the greater likelihood of this disorder as well.

The diagnosis of Seasonal Affective Disorder may be difficult to make.  Health problems and lab tests that contribute to depression need to be investigated.  Additional types of depression may muddy the picture as well and need be considered.  There are some factors that do support the SAD diagnosis if present for over two years.  These include depression that begins during a specific season every year, and ends during another specific season annually, there are no episodes of depression during seasons of normal mood, and there are more seasons of depression than seasons without depression over time.

There are treatments for Seasonal Affective Disorder, but must be used with caution if there is a concern for additional underlying bipolar depression.  Light therapy (phototherapy) involves exposure to a special type of light.  The light source mimics the natural light of the outdoors and seems to influence the brain chemicals linked to mood.  After days to weeks of consistent periods of exposure, this treatment seems to have a positive effect with most people suffering from SAD.  Consult your doctor regarding light therapy treatment, as you need to assure the proper equipment for efficacy and safety.  A common medication for preventing SAD is bupropion, an antidepressant.  This may be considered for severe SAD, and is usually started every year before the onset of symptoms and continued beyond the usual seasonal recovery time before stopping the prescription.  Psychotherapy can help control negative thoughts and behavior as well as assist developing healthy coping skills and stress management.  Of course, should you identify with these symptoms, please consult your health care provider as soon as possible.

Bradford Croft, DO

East Flagstaff Family Medicine

A Head of Trauma – TBI

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Traumatic brain injury (TBI) is caused by an acute bump, blow or penetrating head injury that disrupts the normal brain function. If you ever “saw stars” because of head trauma, even without loss of consciousness, you may have experienced a mild concussion.  The source of the experience is due to the physical bruising of the brain against the inside of the skull.  Likely, you recovered without a problem.

Not every blow to the head results in TBI.  Those that do may have a wide range of severity from mild, a brief change in consciousness or thought process, to severe, a prolonged period of unconsciousness or coma.  The lasting effects of TBI are also quite variable, lasting from days or weeks in many cases to prolonged, causing lifelong consequences.

TBI contributes to one third of all trauma related deaths.  Although three out of four TBIs are mild, there are 153 people who die every day from sustaining a severe TBI.

According to the CDC, the leading cause of TBI resulting in ED visits, hospitalization and death is from falls, accounting for almost half of all reported cases.  The young, up to age 14, and the elderly, those over 65, are a greater risk than the general population, accounting for fifty-four and seventy-nine percent of all TBI cases respectively.  The sources of TBI related trauma that result in death are the greatest in ages 65 and older from falls, 25 to 64 years old from intentional self-harm, 5 to 24 years old from motor vehicle accidents, and 0 to 4 years old from assault.

There are four categories of concussion symptoms.  “Thinking and remembering” may present as difficulty with reasoning, feeling slow mentally, difficulty concentrating and difficulty remembering new information.   “Physical effects” may include fuzzy or blurry vision and headache, nausea and vomiting, sensitivity to noise and light, dizziness, balance problems and feeling tired and no energy.  “Sleep patterns” may include sleeping more than usual, less than usual or difficulty falling asleep. “Emotional and mood changes” may include irritability, sadness, emotional lability and nervousness or anxiety.  Some symptoms may be noticed immediately, whereas others may not show up for weeks to months after the incident.  If presenting symptoms are subtle, they may initially be overlooked by family, physicians and even the patient.

Those with a history of previous concussion are at greater risk to have another and may also find it takes longer to recover with repeated incidents.  With the recent attention from the NFL, it is also known that repeated brain trauma may lead to Chronic Traumatic Encephalopathy (CTE), a disease with progressive development of any of the concussion symptoms previously discussed.

Those who experience milder forms of TBI should consult their health care provider as soon as possible.  It is important to get adequate rest and limit activity.  Protection from additional trauma is critical.  Physical activity may need to be restricted for a period of time.  Medications should be reviewed, and alcohol should be avoided.  Severe TBI which may include loss of consciousness should be evaluated emergently.  It should also be treated after the acute phase with a formal rehabilitation program to improve the likelihood of better long term outcomes.  More information is available at this link: 

Bradford Croft, DO

East Flagstaff Family Medicine


Breast Cancer Awareness

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Many of us are aware that breast cancer is the second most common cancer-causing death in women, surpassed only by lung cancer.  The U.S. Department of Health and Human Services notes this disease affects one of every eight women throughout their lifetime.  But with early detection and treatment in initial stages, the five-year survival rate is ninety-nine percent.  As October is National Breast Cancer Awareness month, this is a time for all women to consider their risks.

Early detection is critical to best outcomes.   There are many common changes that may be found such as lumps, nodules or changes in skin tissue.  Many of these findings, however, may not be breast cancer.  But early familiarization performing a monthly breast self-exam is beneficial beginning in early adulthood.  Your primary care provider will routinely perform a clinical exam as a part of your annual wellness physical.  Most abnormal finding may require additional evaluation in conjunction with your physical.  Direction for performing a self-exam should be included in your visit if you require instruction.  As well, there is a wealth of information and instruction online, including and

As women get older, there is an increasing incidence of cancer with age.  As well, women who have a family history of breast, uterine, ovarian or colon cancer, have been on hormones, or those who have never had children or not had children until later in life are at greater risk.  There is also a laboratory evaluation known as BRCA gene mutation testing to determine a significant increased risk of cancer, especially if there are multiple family members with a history of breast cancer.  There are as well, increased risks associated with smoking, daily alcohol consumption, prior radiation therapy and obesity.  Common misconceptions that do not increase the risk include underwire bras, antiperspirant use and implants.

The most common imaging study to aid in breast health is the mammogram.  It is normally included as a preventive health benefit by most insurance carriers.  Then National Cancer Institute recommends annual screening mammograms in all women 40 to 74.  Those with family history should consult your physician.  The benefit of early detection is to see subtle changes that are not yet large enough to be felt on exam.  And comparative views each year may be able to confirm stability or detect a subtle change.  Additional studies that may be indicated in breast evaluation include ultrasound, MRI and, if needed, biopsy.

There are many organizations promoting awareness, walks for cancer, fundraisers, research, support and education.   So ‘guys’, encourage the women close to you to participate in breast cancer awareness.  And please, ‘gals’, you as well, starting with the one in the mirror.

Bradford Croft, DO

East Flagstaff Family Medicine

Flu Season – Coming Soon!

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It is, once again, time to consider our health concerns as days are growing shorter.  Social distancing and health hygiene may be beginning to wane as we become more complacent with pandemic precautions.   We still need to beware of the influenza season once again this winter. Last year, our health awareness provided less opportunity for influenza, but it will still be present and potentially deadly once again this year, particularly if we let our guard down.  Things you should know…

Influenza is a respiratory infection that causes fever, cough, sore throat, and nasal congestion.  Additional symptoms include headaches, muscle aches and fatigue.  Although these complaints are similar to the common cold, the severity is typically much worse.  Not only can the intensity be serious enough to cause weeks of lost work or school, but the infectiousness can be so powerful as to impact a workplace or school from a single source.  Influenza can cause complications which kills thousands of Americans every year, more commonly those with chronic health problems, the elderly and very young.  However, anyone can suffer a complication of this illness, sometimes requiring hospitalization with significant lost time from daily routines, or even resulting in death.  Fortunately, there is treatment for influenza with early intervention.

A severe outbreak may commonly last up to eight weeks regionally and can often infect one out of every three people in a community.  Hand washing and hygiene are always important, but the single best prevention of influenza is the seasonal immunization.  Appropriate for almost everyone six months or older, it is especially important for those with any chronic disease such as asthma, COPD, diabetes, heart, kidney or liver disease, and any kind of cancer.  Also, those who are overweight or 50 and older are at a significant risk as well.

The influenza immunization recommendation from the CDC for the 2021-2022 season includes only quadrivalent injectable vaccines.  This year vaccines have been updated to match the expected circulating viruses and are provided as the inactivated influenza vaccine (IIV), the live attenuated nasal spray (LAIV4) and the recombinant influenza vaccine (RIV).

For those interested, the updated protections for this year’s likely infections include:

*Egg-based H1N1: A/Victoria/2570/2019 (H1N1) pdm09-like virus;

*Cell/recombinant H1N1: A/Wisconsin/588/2019 (H1N1) pdm09-like virus;

*Egg-based and cell/recombinant H3N2:  A/Cambodia/e0826360/2020 (H3N2)-like virus;  B/Washington/02/2019- like virus (B/Victoria lineage);

B/Phuket/3073/2013-like virus (B/Yamagata lineage).

* Updated Strains

Annual flu vaccines are commonly covered by most health insurance programs at no cost to patients.  These immunizations are usually readily available at county health clinics, most retail pharmacies, and many family doctor offices.  You should have your immunization by the end of October.  Of course, the sooner the administration, the sooner you are protected for the entire influenza season which may go well into the spring.  It can take up to two full weeks to acquire immunity from the shot.  Talk to your health care provider soon.  Now is the time to prevent the flu!

Bradford Croft, DO

East Flagstaff Family Medicine

Human Papilloma Virus

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The Human Papilloma virus is responsible for almost all cervical cancers and some cancers of the vagina, vulva, penis, anus, and oropharynx.  Averaging 34,800 cases per year in the United States, these cancers are not as common as colon, prostate, breast, and lung, all running almost ten-fold over HPV.   It is significant to know that this cancer is both readily screened as well as commonly immunized.  This provides a double opportunity for surveillance and treatment not known to any other cancer.

As a sexually transmitted disease, most cases of HPV have no symptoms.  Upon contracting the infection, the body can clear many of this family of viruses within a year or two spontaneously.  There are different strains of virus that may lead to precancers as well as cancer outright.  Those strains of HPV include types 16, 18, 31 33, 45, 52 and 58.  There are also strains 6 and 11, not leading to cancer but responsible for venereal warts.  All nine viruses are responsive to the 9vHPV immunization.  The most common cancers listed are oropharyngeal and cervical.

HPV vaccines are the most common way to impact cancer prevention, usually administered during early adolescence, ages 11 or 12.  Unfortunately, only about half of these eligible individuals have received their vaccines.  There is a process of catch-up vaccines provided to those at risk up to age 26 not previously vaccinated.  Although there is controversial benefit to vaccinate those into their mid-40s, the benefit if immunization diminishes into the older age groups.

Cervical cancer is the only HPV cancer that routine screening is recommended.  The age group for screening is suggested for women ages 21 to 65 in three different subgroups.  Women 21-29 should be screened with Papanicolaou (Pap) smears every three years.  Those 30 to 65 are recommended to have either a Pap every three years, an HPV test every five years or both a Pap and HPV every five years.  The progression of persisting infection to precancers and eventually cancer is a slow, years duration process.  Even if there is no evidence of early infection, the insidious process of infection dictates the need for ongoing screening later in life.  For more information about HPV, contact your primary care provider.

Bradford Croft, DO

East Flagstaff Family Medicine

Smell the Flowers, or Maybe Not…

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Asthma is a disease of the lungs that causes difficulty breathing.  It is a very common disease in children, although some may have symptoms that persist throughout their lifetime.  Others may develop it as an adult.  The symptoms of asthma are wheezing, shortness of breath, tightness in the chest, and commonly a nighttime or early morning cough.  Although the disease of asthma may not be always active, it is constantly present.  It only becomes prevalent when the lungs become irritated.  Unfortunately there is no cure for asthma, but there are a number of medications that can treat it.  It is also commonly seen to run in family bloodlines.

All wheezing is not necessarily asthma, but common recurrences of these symptoms that are associated with the presence of upper respiratory infections may provide suspicion.  Other triggers of asthma include respiratory allergies, inhalant exposures and, for some, physical exercise or exertion.  Anyone with asthma should avoid tobacco smoke.  There are tests such as spirometry or pulmonary function tests that can be ordered to help decide if asthma may be an underlying health problem.

The air channels in the lungs start with a large main airways, or bronchi.  As these airways branch out through the lungs, the size becomes smaller and smaller until they terminate at the alveoli, similar to branches of a bare tree.  When an acute asthma attack occurs, the airways in the lungs become inflamed, the airways congest and spasm making it difficult to breathe from restricted air flow.  If triggers are recognized, avoidance is extremely important if possible.  Some irritants cannot be avoided however, such as seasonal pollens.

There are medications for asthma.  The initial treatment usually starts with “rescue” inhalers that are used when symptoms occur.  These work by relaxing airway spasm and opening the channels.  If the need for this medication continually increases over time, there are additional medications taken on a daily basis to help reduce flare ups from the start.  These medications typically reduce chronic inflammation and airway spasm and thickening.  These long term control medications do not help acute exacerbations, but many times can markedly reduce the frequency and severity of asthma attacks.  It is important for those taking asthma medication to use it properly.  Some patients may reduce or stop their prescription when symptoms are controlled thinking their asthma is resolved, but put themselves at great risk for exacerbations of a potentially fatal disease with improper use of their prescriptions.

Bradford Croft, DO

East Flagstaff Family Medicine