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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


The questionnaires in the Netherlands also reflected that pregnant women were willing to cheap 10mg prozac accept a less accurate test to cheap prozac 20 mg on line obtain more information on fetal Version 1 discount 20mg prozac fast delivery. Taking into account the principle of distribution of justice it should be assessed if it would be ethical to spend resources on technologies which have important uncertainties regarding their implementation, adoption and outcomes. Because it is a safe and easy test, which is privately available, there is a risk that the test could also be used for minor conditions or even undesired nonmedical traits. This could lead to women deciding to terminate pregnancies for trivial reasons, such as sex selection. If it is offered directly, it could also happen that women are not appropriately informed and reproductive choices following prenatal screening are made without their really understanding the results. The results of a systematic review showed that the infor mation provided by commercial companies and private health providers is not equally balanced and the need for an invasive test to diagnose aneuploidy is not always underlined [150]. Respondents in several studies have cited fears that given the noninvasiveness of the test, it might end up being offered as a routine procedure, depriving women of a well-informed option, not giving them the real chance to decide if they truly desire this information [167]. Professional societies recommend that a trained provider, such as a genetic counsellor, an obstetrician or a maternal-fetal medicine specialist [140], give the posttest counselling. In 2017, the Institute for Quality and Efficiency in Health Care was commissioned to prepare such educational materials for Germany. Different position statements recommend that counselling should be given both before screening, so as to allow women to make a personal decision to accept or decline screening, and after coun selling, to discuss positive findings with affected women. In this study, as well as the Dutch implementation study (Trident study), women were given written information in addition to oral counselling [146]. The questionnaire completed by 1091 women who participated in this study revealed that women who made an informed choice (78%) had signifi cantly higher educational levels and adequate health literacy. Women with inadequate health literacy experienced higher posttest result anxiety, highlighting that they might benefit from extra infor mation and/or special counselling aids. However, the current work process of the professionals responsible for screening could change substantially as these might be required to provide additional pretest counselling to inform decision making. To date, little information exists regarding the education and training given to these professionals. This study supports that providing professionals with face-to-face training (lesson plan and Power Point presentation) and written factsheets improves confidence and perceived knowledge. Samples should be handled and shipped according to manu facturers’ instructions and according to good laboratory practices. Training might also be required if the system is to be implemented in standard laboratories. However, laboratories must adhere to specific standards for laboratory proce dures and the protection of patient information confidentiality [33]. Standard laboratory equipment, in addition to specific equipment and software, would be required in this case. Experienced sonographers are limited in number or are unavailable in many rural areas. It should not be offered independently as a direct-to consumer test by laboratories [33, 38]. Throughout any prenatal screening programme, screening and diagnostic testing for fetal anoma lies available should be offered by pretest and posttest counselling and an informed consent dis cussion in which the benefits and risks of each option are explained in detail. To ensure that each woman or all parents receive prenatal counselling adapted to their needs, Skirton et al. This study concluded that the information should be provided by an appropriately trained health professional in both verbal and written forms, always bearing in mind the local ethical and legal guidelines and including information about the condition (genetic cause, phenotypic features or risk of aneuploidies, etc. Finally, they recommended that women or parents be given the opportunity to use the information provided on the basis of their personal beliefs. However, important uncertainties remain regard ing the under-reporting of missed cases given the inappropriate verification of negative re sults. Data regarding key safety outcomes are also lacking (increase in the number of chil dren born with major anomalies, elective pregnancy termination for other unconfirmed chromo somal anomalies with uncertain significance, etc. Improved Survival in Down Syndrome over the Last 60 Years and the Impact of Perinatal Factors in Recent Decades. Trends in survival among children with Down syndrome in 10 regions of the United States. Predictors of survival in children born with Down syndrome: a registry-based study. Survival among people with Down syndrome: a nationwide population-based study in Denmark. Characteristics of adults with down syndrome: prevalence of age-related conditions. Position statement from the Chromosome Abnormality Screening Committee on behalf of the Board of the International Society for Prenatal Diagnosis. Performance of methods for meta-analysis of diagnostic test accuracy with few studies or sparse data. The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. Non-invasive prenatal testing for trisomies 21, 18 and 13: clinical experience from 146,958 pregnancies. Single-nucleotide polymorphism-based noninvasive prenatal screening in a high-risk and low-risk cohort. Noninvasive prenatal testing of fetal aneuploidies by massively parallel sequencing in a prospective Chinese population.

In this way p63 was found to effective 20mg prozac be the gene in croarray-based comparative genomic hybridization; volved in the ectrodactyly–ectodermal dysplasia Sismani et al order prozac 10mg otc. This cation of genes involved in monogenic disorders is gives reliable results prozac 20 mg on line, though never 100% reliable, linkage analysis; its aim is to map the locus where the provided the disease locus is known,the clinical diag putative gene, mutated in the involved monogenic nosis is correct, the disease is homogeneous, a suffi disease, is located. Linkage analysis is based on the cient number of family members are available and re fact that when two loci are sufficiently close together combination does not occur. It involves study of the segregation of not finding the mutation does not necessarily 3. Also carrier testing is reliably erally threatened by energy deficiency or intoxi possible for autosomal and X-linked recessive disor cation. Then ders, the term neurometabolic diseases is in one to two cells are biopsied and examined while the creasingly used (Moser 1998). After the results logical mechanisms of these disorders include are known only the healthy embryos are implanted in energy failure, substrate deficiency, intoxication, the uterus. An im it is performed are cystic fibrosis, spinal muscular portant decision to be made is whether the disor atrophy, haemophilia and fragile X syndrome. In gener droxyglutaric aciduria and D-2-hydroxyglu al, metabolic diseases are recessive disorders without taric aciduria clinical symptoms in heterozygous individuals. Most neurometabolic dis logical signs and symptoms in the majority of inborn orders show progressive neurological features errors of metabolism. From a clinical point of view, the following three categories can be distinguished: 122 Chapter 3 Causes of Congenital Malformations Table 3. Many inborn errors of metab Johnston 2001), clinically characterized by a severe olism fall into this category. In many patients, multisystem disorders are: the corpus callosum is absent (Dobyns 1989). In a) Congenital disorders of N and O-linked gly Lesch–Nyhan syndrome, hyperuricemia and a char cosylation acteristic neurobehavioural syndrome with motor b) Mitochondrial encephalomyopathies dysfunction and self-injurious behaviour is found c) Lysosomal storage disorders (Jinnah and Friedmann 2001). Pyruvate dehydroge eases caused by defects in the synthesis of the glycan nase deficiency is the best studied neurometabolic moiety of glycoconjugates or in the attachment of disorder (Brown et al. In addition to many examples of disorders in the metabolism of organic other organs, the brain is affected in 10 of the 11 acids are fumarase deficiency (Remes et al. Altering the sterol content of membranes may identified (Jaeken and Carchon 2001). Perturbations in cholesterol home ing to pontocerebellar hypoplasia, is shown in Clini ostasis may result from a defect in the normal Sonic cal Case 3. O-linked glycosylation defects form the hedgehog signalling network and cholesterol biosyn underlying mechanism of certain lissencephalies thesis (Cohen and Shiota 2002; Chap. Mevalonic such as Walker–Warburg syndrome, Fukuyama con aciduria, caused by deficiency of mevalonate kinase, genital muscular dystrophy and muscle–eye–brain an enzyme located proximally in the cholesterol disease (Barkovich et al. The patient showed pro Disorders of Cholesterol Biosynthesis found psychomotor retardation,ataxia,a dysmorphic Defects of cholesterol biosynthesis (Fig. Abnormal sterols are known orders all show complex malformation syndromes 124 Chapter 3 Causes of Congenital Malformations Clinical Case 3. Microscopic ex Congenital Disorders amination of the brain stem revealed severe atrophy of Glycosylation of the inferior olives (Fig. Distinct dentate nu synthesis of the glycoconjugates or in the attachment clei were found. In the of glycans to macromolecules (Jaeken and Matthijs cerebrum, some nodular heterotopia were found 2001; Jaeken et al. This case was kindly provided by Gerard van Noort (Laboratory for Pathology East-Netherlands, En schede,The Netherlands). A 15-year-old boy, with psy chomotor retardation of unknown aetiology and se vere scoliosis,died after a severe bronchopneumonia. At autopsy,an extensive necrotic bronchopneumonia References and signs of aspiration were found. The endocard showed fibrosis and the liver was steatotic and mildly Jaeken J, Matthijs G (2001) Congenital disorders of glycosyla fibrotic (Fig. Brain examina D (eds) the Metabolic & Molecular Bases of Inherited Dis tion showed no obvious malformations of the cere ease,8th ed. The cerebellar atrophy was present in findings in two patients with the carbohydrate-deficient gly the vermis as well as in the hemispheres. Cardiac malformations are common form erythroderma and limb defects, is character (Liu et al. Desmosterolosis shows a variable phenotype poplasia, especially of the vermis (Cherstvoy et al. Their enzymatic abilities include roles as oxi disease, originally descibed as occurring only in chil dases, in ether lipid synthesis, and in cholesterol and dren older than 1 year of age and in adults (van der dolichol biosynthesis. Moreover,typical in sum disease, which are now thought to represent volvement of the pontine tegmental white matter was variants with different severity of the same disorder observed. The disease Myelination is the final phase in the development of is chronically progressive, with in most patients the cerebral white matter. Death occurs after a outwards from the oligodendrocyte cell body, are be variable period of a few months to a few decades. Primary absence of central myelina the developing brain is vulnerable to various vascu tion has not been described so far. The cause of is presence of myelin even at adult age (Koeppen and chemia or hypoxia may be maternal, placental, fetal Robitaille 2002). Early in gestation, prototype of a central hypomyelinating disorder general hypoxia may lead to very severe brain (Fig.

Spastic paraplegia type 4, dominant

A properly designed program must include both straight-leg buy cheap prozac 20 mg line, hip-dominant exercises and bent-leg hip dominant exercises to buy prozac toronto properly balance the lower-body muscles buy prozac on line. Most of the exercises in this chapter will initially use 146 Designing Strength Training Programs and Facilities 147 the 8-10-12 body-weight progression, meaning that body weight is used for the first three weeks but the number of repetitions increases each week, from 8 to 10 to 12 reps. External resistance may be used when appropriate or obstacles of greater difficulty can be substituted. Cook Hip Lift the Cook Hip Lift was covered in the core chapter 4, but it is important to again remind coaches or trainers that it is important to begin by distinguishing between hip range and movement of the lumbar spine. It is amazing how quickly we can buy into an exercise without fully evaluating the movement, its’ cost and its’ space requirements. Louie Simmons and his West Side Barbell philosophy have made many into reverse hyper believers. I now have two reverse hyper machines taking up space and getting very little use. At the end of the day, the reverse hyper machine is still a single-station, single-joint machine. I want my foot on the ground or at least pushing against something when I perform hip extension exercises. Ideally the reverse hyper is performed by extending the hip with the glutes and hamstrings. In many cases, reverse hypers may in fact feed the dysfunction by allowing lumbar extension to substitute for hip extension. Again, it is important to remind yourself that the objective of powerlifting is to lift as much weight as possible. The reverse hyper is seen as a primary assistance exercise for deadlifts, and deadlifts only require that the load moves from A to B. One reason I dislike conventional deadlifts is that when done heavy, they are rarely done well. As a former competitive lifter, I have watched thousands of deadlifts and when the load gets heavy, it gets shifted to the spinal erectors. This makes the lumbar extension component of the reverse hyper very attractive as an assistance exercise for powerlifting, but not for athletes. Foot-Elevated Hip Lift the foot-elevated hip lift is an excellent progression from the Cook hip lift and has become a staple of our program. This is a great example of the blurry line between core stabilization and posterior chain strength. An exercise that began as a core movement becomes a strength exercise for the posterior chain. The foot can be elevated on an aerobic step, a balance board, a foam roller, or a medicine ball to increase the difficulty of the exercise. A two-dimensionally unstable surface such as a foam roller causes the hamstrings 148 Designing Strength Training Programs and Facilities 149 to be used in two separate but important functions. The hamstrings assist in hip extension while also working eccentrically to prevent knee extension. The medicine ball is the most difficult due to the three-dimensional instability it introduces at the hip. The hamstrings must work at two joints, while the hip stabilizers work to prevent hip adduction and abduction. The key is that the athlete or client must be instructed to think about raising the hips by squeezing the glute while keeping the abdominals drawn in. In truth, these lifts may be safe and beneficial when performed correctly with an appropriate load. The unfortunate reality is that most athletes perform both of these exercises with too much weight and with questionable technique. The good thing is that, unlike squatting, very few athletes seem to miss deadlifts if they are taken out of the program. I feel that the single-leg versions impact the back significantly less and, impact the glutes and hamstrings significantly more. In addition, the muscular systems that were discussed earlier are trained far more effectively in the single-leg versions. If I can obtain better muscular specificity and less lumbar load, I think that is an improvement. Beginning loads will be less than fifty percent of the comparable load in the two-legged version. The deep longituidinal sub system is engaged in this exercise so the peroneals and anterior tibialis both must work extremely hard to provide stability to the ankle and consequently to the hip. Single-leg hamstring work is obviously more functional than double-leg hamstring work, and single-leg hamstring work that challenges balance and proprioception is 150 Designing Strength Training Programs and Facilities 151 the most beneficial. This is another exercise that can be used as a part of the warm-up or as a loaded strength exercise. Charles Poliquin has frequently used the phrase “varying the exercise without changing it”. As Poliquin has often recommended the essence of the exercise remains the same, but the exercise is different enough to allow different loads and slightly different neurological patterns. It allows greater loads than the single arm version and will provide greater Figure 8. This makes the exercise an excellent progression from the single dumbbell version. From a functional standpoint, however, the two dumbbells or straight bar may actually make the exercise less functional. I do not find this to be of great concern as the greater loads on the hip extensors offset the loss of the linkage from glute max to lat across the thoracolumbar fascia. The important point is that the athlete or client is able to move to a level 2 exercise with an increased load from the level 1 exercise.

Spasmodic torticollis

The elderly patient has more persistent ventricular dysfunction and congestive heart failure after surgery and has worse post operative survival buy generic prozac 20mg on-line. The asymptomatic or mildly symptomatic patients degenerative calcific disease of the normal trileaflet valve buy prozac discount. The optimal Mitral stenosis bridge to order 20mg prozac with mastercard surgery for patients with pulmonary edema and car Symptomatic mitral stenosis is now more common in the eld diogenic shock are inotropes and vasoconstrictors. Elderly patients with severe aortic stenosis and mitral leaflets and considerable subvalvular fusion. Percutaneous mitral balloon advanced cancer and neurological deficits from cerebrovascu valvotomy may be considered in these patients who are at lar accidents, as well as in deconditioned and debilitated increased risk of surgery but procedural success is low (less than patients. There is no exact method to consider all the Elderly patients generally do poorly with surgery for mitral relevant factors to identify high and low risk patients. Mitral valve surgery has been documented to be per medical management, and the mortality and morbidity associ formed with acceptable early and midterm outcomes if repair is ated with surgery. There is limited indication for surgery are generally used in the elderly, but consideration must always in an attempt to preserve ventricular function because the aim be given to match durability of bioprostheses and longevity of of surgery in the elderly is to improve quality of life, not to pro the patient to avoid the need for late reoperation. Extreme calcification may necessitate aortic root replacement Impact of small prosthetic valve size on operative mortality in elderly and in this situation a stentless porcine root prosthesis would patients after aortic valve replacement for aortic stenosis: Does gender be advised rather than a mechanical valved conduit, to avoid matter J Am Coll Cardiol possible enlargement of the annulus to implant a satisfactory 2000;35:731-8. Effect of gender and coronary artery disease on operative either porcine or pericardial. Aortic valve replacement in Guidelines for the management of patients with valvular heart elderly patients: Influence of concomitant coronary grafting on late disease. Ann Thorac Surg Porcine bioprosthesis in the elderly: clinical performance by age 1995;60(Suppl 2):S443-6. Mitral valve surgery in deterioration in elderly patient populations with the Carpentier Edwards standard and supra-annular porcine bioprostheses: the elderly. Circulation Porcine bioprostheses in the elderly: Clinical performance by age 1989;80:I49-56. Aortic valve replacement in patients aged eighty years and older: Early and long-term results. Outcomes 15 years after valve bypass grafting and/or aortic or mitral valve operation in patients replacement with a mechanical versus a bioprosthetic valve: > or = 90 years of age. Increasing numbers of women with heart mined by this retrospective study has been assessed in a disease will be contemplating pregnancy as a result of advances prospective multicentre study of pregnancy outcomes in in the diagnosis and treatment of heart disease during child women with heart disease (16). Most studies are case series and there are few large greater than 30 mmHg by echocardiography), and reduced sys cohort studies. There is a need for large prospective observa temic ventricular systolic function (ejection fraction less than tional studies and randomized clinical trials. The predictors of primary cardiac events were incorpo rated into a revised risk index in which each pregnancy was assigned one point for each predictor when present. The esti Physiological changes during pregnancy mated risk of a cardiac event in pregnancies with zero, one and the changes in circulatory physiology during pregnancy are greater than one points was determined at 5%, 27% and 75%, well delineated and place increasing demands on the cardio respectively. The evaluation and management of Poor maternal functional class or cyanosis has been known valvular heart disease in pregnancy demands an understanding to also be predictive of adverse neonatal events (15,17). In the of these normal physiological changes associated with gesta prospective study, the five predictors of neonatal events were tion, labour, delivery and the early postpartum period. The fetal or neonatal death rate with none of the constant through the remainder of the pregnancy. There are decreases in peripheral vascular both neonatal and cardiovascular complications (18-20). During labour and delivery, pain maternal cardiac status and risk of cardiac complications dur and uterine contractions result in additional increases in car ing pregnancy have been classified as low risk, intermediate diac output and blood pressure. The hemodynamic changes of pregnancy may • small left to right shunts; not be fully resolved until the sixth postpartum month. Pregnancy is also associated with a hypercoagulable state • repaired lesions without residual cardiac dysfunction; with increased concentration of clotting factors, rapid platelet • isolated mitral valve prolapse without significant turnover and depressed activity of the fibrinolytic system. Systolic function of the left ventricle is preserved with normal contractility and ejection fraction. Functional tricuspid, pulmonary and mitral insufficiency Intermediate risk: are often identified (14). However, pregnant • mitral stenosis or aortic stenosis; women with valvular heart disease remain at risk for cardiac morbid events such as congestive heart failure, arrhythmias or • mechanical prosthetic valves; stroke. Risk stratification and counselling of women with valvular • severe pulmonic stenosis; heart disease is best accomplished before conception (15). The • severe pulmonary hypertension; most common morphology of aortic valve disease during preg nancy is bicuspid aortic valve. Percutaneous balloon valvotomy • Marfan’s syndrome with aortic root or major valvular may provide short term palliation until valve replacement can involvement; be performed. In addition, the noncompliant, hypertrophied ventricle is sensitive to falls in Specific valvular lesions preload (as may occur due to inferior vena cava compression in Obstructive valvular lesions are most affected by the hemody late pregnancy, vasodilator effects of anesthetic agents, peri partum blood loss or bearing down maneuvers), leading to namic changes of pregnancy. Regurgitant lesions (aortic due to the physiological fall in systemic vascular resistance. Chronic rheumatic valvular disease should be managed Aortic regurgitation, similar to mitral regurgitation, is also individually according to the site and severity of the lesion. This is related to the reduced Mitral stenosis is the most common valvular lesion encoun systemic vascular resistance and increased heart rate.

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Most cases are of viral aetiology and occur as part of common colds and influenzal syndromes purchase prozac 10mg without prescription. The most important cause of bacterial pharyngitis is that due to order prozac cheap group A beta haemolytic streptococci (Streptococcus pyogenes) generic prozac 20mg mastercard. World Health Organisation 97 We need your help to keep Kiwi hearts beating When you support the Heart Foundation you make a difference to the lives of thousands of New Zealanders. For every one of these people, many more are afected – husbands, daughters, brothers, friends, me, you. Help us fight the disease that cuts short too many lives and too many stories before they’re told. Your donations are crucial to our ongoing work – funding vital research, helping people make healthy living choices, and running community programmes that encourage Kiwi heart health. This section also will cover and End-Stage Problems in Young Adults— surgical procedures. Ailawadi, of the Exhibit Hall Opening Reception Challenges in the Management of complex procedures that appeal to both private University of Virginia Health System in Mechanical Cardiopulmonary Support in the Sunday, 4:30 p. Designed to be gentle on the aorta and easy to insert, Soft-Flow arterial cannulae help you proceed with confdence during cardiac surgery procedures. Medtronic Full Page 4C * Sof t-Flow Page 3 Arterial Cannulae Available for sale in United States only Changes Yours then, yours now. For a listing of indications, contraindications, precautions, warnings, and potential adverse events, please refer to the Instructions for Use. And under the Bylaws from Europe and the United Annual Meeting and Exhibition initiatives, exciting developments from the changes adopted by the membership last year States will face off Sunday in Houston, Texas. Meeting and in November 2016 at the help you keep track who can bring you up to date on the Society’s All the scientifc sessions at this 53rd Southern Thoracic Surgical Association of what’s happening many efforts on Capitol Hill. Kuppuswamy Naidu Memorial Hospital locations, exhibitor champion the specialty in Washington. Brown Convention Center technology and products, and it offers the perfect opportunity to see Learning Lab Theater. Check the front page left-hand column in each issue for a quick and meet with colleagues and friends. Tech-Con is the most effcient way for Scientifc Posters every cardiothoracic surgeon to know what Hall B3 their practice is going to look like in a couple of years. The adult thoracic sessions will discuss during which entrepreneurs will pitch their cardiac sessions will look at Saturday precision thoracic surgery, innovative cardiothoracic surgery products to 4:30 p. Fazzalari, of the University contract negotiations during “Recent Trends Cooney in Bloomfeld Hills, Mich. Surgeons Arkansas Baptist Hospital and Clinic in employee models and professional service on his background in contracting and need to keep pace with changing trends as Jonesboro, are co-moderators. Heaton, a health care business In the second half of the session, health a Company. It can take up to 8 weeks to grow, receive reduced registration rates at these infections so you have to be aware of the problem and future Annual Meetings and many other associated with the have it be part of your differential to make educational events throughout the use of heater-cooler the appropriate diagnosis. To learn help your colleagues, the Society, and latency period of up to 60 months, Dr. Allen diagnosed because we were not aware of it more about the heater-cooler situation, go to the specialty. The surgeon procedure with preliminary data worldwide “We will explain innovative be a challenge. Increasingly, surgeons who performed the operation will from which we can all learn,” are using a variety of educational then defend the chosen therapy and Dr. Ozaki the implant, specifcally where to put the suture present innovative techniques that have had a have lively interaction because is from Toho University that anchors the device in the left ventricle. Bhat will address behind “What’s New in the Management of Children’s Hospital of Philadelphia, will show both the ethical aspects and the hard data on Pulmonary Vein Stenosis. Baylor College of Medicine in Houston, is a his talk will be a mix of science and clinical Hospital of Wisconsin in Milwaukee, will the program contains three basic formats: leader in the use of a pulmonary artery band to applications,” Dr. A variety of topics will “This simple operation has turned out to “Novel Use of Expandable Valves. Another Tuesday session, with about the latest, most innovative research in the European Society of Thoracic Surgeons, the feld. Ferguson Lecture will be given by Ralph Connect on LinkedIn reduction surgery for emphysema, and W. Abbott the Society of Thoracic Surgeons of these infections and develop measures to On behalf of the Society’s leadership and Medtronic gratefully acknowledges the following lower the risk of occurrence. Jude Medical abstract submissions for the 2017 meeting this list is accurate as of January 5, 2017. Ethicon Zimmer Biomet Thoracic after a hiatus last year, and the response was Joseph E. We have all chosen to belong to a community with a single passion: helping patients live longer, healthier and more productive lives. Big ideas with the power for change are the cornerstone on which Edwards Lifesciences was founded. From the frst successful artifcial heart valve to today, replacing a heart valve through a single catheter – or helping clinicians monitor a patient’s heart and fuid levels to help guide treatment. Edwards, Edwards Lifesciences and the stylized E logo are trademarks of Edwards Lifesciences Corporation or its afliates. Surgeons ideas, collaborate, Two presentations in the frst part of the is designed to shed some light on staging, have the potential to improve outcomes for adult and focus on areas in symposium will try to put in perspective which is setting up that valve for the next valve and pediatric heart patients by sharing lessons cardiac surgery where two options for replacing aortic valves— procedure if it is going to be percutaneous,” Dr. As aortic valve replacement has become Arbor, will present data from his institution while the second part will look at issues related a congenital heart surgeon from Norfolk, Va. You now have a trustworthy resource We now have Sunday more long-term to share with your patients.


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