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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

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


Original: September 30 neoral 25 mg visa zone stop acne -, 2009 Page 61 Revised: June 19 purchase genuine neoral on-line acne regimen, 2019 Inflammatory Bowel Disease Program Patient Information Guide Pregnancy or Breastfeeding: Tell your doctor if you are pregnant or plan to become pregnant discount neoral 25 mg visa acne holes in face. If you have questions about the medicines you are taking, please talk to your doctor, nurse, or pharmacist. Up to 46% of patients will be in complete remission (back to normal, with complete control of inflammation, and a completely healed colon) at 1 year. Many patients with active disease will need to stay on the higher dose of 10 mg twice daily. Patients who respond to 10 mg twice daily and taper down to 5 mg twice daily may still intermittently need to increase to 10 mg twice daily to head off a flare. Small molecules are organic compounds, and in the case of tofacitinib, it is about the same molecular size as sucrose (table sugar). In contrast, antibodies like Remicade or Humira, that are about 500 times larger, cannot be readily absorbed by the oral route, and therefore require injection into the body to be effective. This class of medicines has been proven effective for rheumatoid arthritis, ulcerative colitis, psoriasis, and allergic and atopic dermatitis. While there are some specific side effects, most people do not generally get more infections when they start taking these medicines. All of these proteins amplify and transmit signals from cytokines to change the activity of cells. Small molecules often bind to the active site of enzymes, and physically block their normal activity. Small molecules are so small that they are generally ignored by the immune system. This is different from biologic therapies, which are large proteins that can lead to an immune reaction, and can be recognized as foreign proteins, leading to antibodies that can block the activity of a biologic therapy. As a general rule, most drug companies avoid combining their drug with other drugs in clinical trials, to avoid any risk of drug interactions. Tofacitinib has been tested in combination with methotrexate in rheumatoid arthritis, and did not appear to increase problems or side effects. Many patients in the tofacitinib studies for ulcerative colitis entered the study while on prednisone to control a flare, so we have experience combining tofacitinib with steroids. We do know that other drug combinations, like Remicade plus Imuran, are better than either drug alone in ulcerative colitis and Crohn?s disease. We also know that immunosuppressive drugs like Imuran and methotrexate help protect biologic therapies from formation of blocking antibodies, and that combinations of these drugs with biologics can increase the drug level of biologics, which can be helpful in patients who rapidly clear biologic therapies out of their bloodstream. Chicken Pox: Tofacitinib (Xeljanz) reduces your immunity to the virus that causes chicken pox. Particularly if you have never had chicken pox, or never developed an immunity to chicken pox, you should avoid anyone with active chicken pox while on Xeljanz. Be sure to tell your doctor about all the prescription and over-the-counter medicines you are taking. These include blood counts to watch for low lymphocytes, neutrophils, or red blood cells, and liver tests to make sure there is no irritation to the liver. These are Original: September 30, 2009 Page 65 Revised: June 19, 2019 Inflammatory Bowel Disease Program Patient Information Guide typically tested every 3 months. Your doctor may ask you to take a cholesterol-lowering medication (statin) if your cholesterol becomes very high. This risk is particularly increased if you are also taking methotrexate or steroids at the same time. Other infections can include invasive fungal infections like Cryptococcus and pneumocystis. To reduce infections, it could be helpful to avoid unpasteurized dairy products and juices, and to drink water that has been treated in a city water system or bottled water. This starts to occur about 40 years after the original chicken pox infection, so vaccination for shingles is recommended for everyone at age 50. Tofacitinib is associated with an increased rate of shingles, which can start as early as age 30 in people on immunosuppressive drugs. Non-melanoma skin cancers: increased rates of non-melanoma skin cancers were seen in patients taking tofacitinib. Other cancers: While cancers are rare, cancers have been reported in patients taking tofacitinib (Xeljanz). The most common types of malignancy reported were lung and breast cancer, followed by gastric, colorectal, renal cell, prostate cancer, lymphoma, and malignant melanoma. Pregnancy, Childbearing, and Breastfeeding Pregnancy or Breastfeeding: Tell your doctor if you are pregnant or plan to become pregnant. Tysabri is an antibody that binds to and blocks the alpha 4 integrin protein found on white blood cells. It is an immunosuppressive medicine, which means it partially blocks the action of the immune system but does not turn it off completely. While there are some side effects, most people do not get more infections when taking this medicine. They are found in the blood and in other Original: September 30, 2009 Page 67 Revised: June 19, 2019 Inflammatory Bowel Disease Program Patient Information Guide body fluids. Alpha 4 integrin is a protein that is found on white blood cells, which help fight infection. The alpha 4 integrin protein helps white blood cells to latch onto the inside of a blood vessel and then move from the bloodstream into the cells of the gut and the brain. Once these white blood cells have moved into the gut and the brain they tend to cause inflammation.

Yet another approach is inchworm locomotion order neoral canada the skincare shop, inspired by observations of geometer moths (31) purchase neoral paypal acne light mask. A semiautomatic sequence of actions is implemented to move the probe like an inchworm purchase genuine neoral line acne on arms, whereby two vacuum anchors located in the proximal and distal ends of the device are sequentially actuated between extensions and retractions of the central body. A human study (32) with 71 unsedated patients demonstrated that this system has a diagnostic accuracy comparable with that of colonoscopy and does not require sedation. However, in 13 cases (18%), the device was not able to reach the cecum, and procedure duration was longer than standard colonoscopy. Only prospective comparative outcome trials will be able to determine conclusively whether a? Currently, 15% to 25% of patients with polyps subsequently have to undergo a conventional colonoscopy for polypectomy (33). It consists of a 173-cm-long endoscope composed of 16 8-cm-long independent vertebrae, and it tapers from 20-mm diameter at the base to 14 mm at the tip, with a 3. Each segment can assume a circular shape in a desired direction, much as a conventional colonoscope tip can. As the human operator pushes the device into the colon, its shape changes under computer control, so that the shaft follows the trajectory of the tip in a follow-the-leader manner, minimizing colon wall interaction forces. Biopsies and therapies are conducted with the scope in passive mode, in which the shape and stiffness of the scope are the same as those of a standard colonoscope. An initial clinical trial on 10 sedated patients revealed a looping rate of 40%, with ?extensive looping in three of the four cases, but the entire intestine up to the cecum was reached in all patients (22). The sheath is covered by double layers of an inverted sleeve that provides the propulsion mechanism. Eight drive wheels in the driving unit grip the inner layer of the inverted sleeve and rotate, causing the inner layer to move forward and making the colonoscope elongate at a position 10 cm below its tip. The overall objective of this mechanism (similar to that of the NeoGuide) is to minimize scope-colon interaction forces and hopefully remove the sedation requirement. A disposable sleeve anchored at the proximal end of the device envelopes the endoscope, protecting it from contamination. The IntraPull mechanism generates a force close to the tip of the scope by pumping compressed air inside the sleeve as a foot pedal is pushed. The material of the sleeve does not allow radial expansion, so the increased pressure inside the sleeve creates a force directed toward the tip of the colonoscope; the tip is pushed forward as the folded part of the sleeve is deployed. Pilot prospective clinical studies on 178 participants reported a success rate of 90% in reaching the cecum with no major complications (e. All the patients were sedated as is routinely done in traditional colonoscopy, so no data about the pain associated with this technique are available (35). That no thinner devices have been reported indicates that these wires (combined with optics and working channels) appear to impose a lower bound of approximately 10 mm on colonoscope outer diameter. The external magnet was held by a 7-DoF robotic arm controlled in real time by the endoscopist. This method of generating a magnetic pull force at the tip allows the tether to be as small and light as possible and means that it does not have to push against the colon wall; consequently, bending stiffness and mass can be signi? The device has been tested in animal trials with promising results, and human trials are planned. The overtube is designed with a 13-mm inner diameter to carry a variable-stiffness pediatric colonoscope. Clockwise rotation of the overtube, which mimics the motion of a corkscrew, pleats the bowel onto the external surface of the tube. A preliminary clinical trial on 22 patients with incomplete colonoscopy because of redundant colons reported a cecal intubation rate of 92% with a median time of 14. A common theme in reducing the pain associated with standard colonoscopy appears to be shifting the location of propulsive force application from the base of the device outside the patient. The latter can result in a better alignment of the direction of the applied force with the desired direction of forward tip motion. Several devices have demonstrated that this method can reduce forces applied to the colon wall during insertion, and these reduced forces are believed to correlate with reduced pain and a reduced risk of colon perforation. Diverse methods for applying tip forces have been proposed, ranging from pneumatic pressure (30, 34, 35) to robotic locomotion (32) to magnetic? An alternative approach toward reduction of looping involves showing the current 3D shape of the scope as the endoscopist advances it into the colon. A recent study comparing this platform with standard colonoscopy reported a signi? With regard to shortening the learning curve, computer-aided or computer-guided techniques (22, 30, 32, 34, 36, 38) have the potential to make colonoscopy easier; nursing staff may even be able to conduct the examinations. Such ease of use would enable the technology to meet the increasing demand for the procedure that will likely result from (a) the growing older population and (b) the willingness of more of the population to undergo screening owing to a reduction in real or perceived pain and discomfort. The control cabinet includes a peristaltic pump, a controller, and a pinch valve that enables control of suction. This has two channels, one that supplies water for irrigation and one that provides suction, and a head that attaches? When attached, ClearPath adds approximately 6 mm to the diameter of the colonoscope. Preliminary animal trials on partially prepared pigs demonstrated effective intraprocedural colon cleaning with no immediate mucosal damage, acute complications (e. An alternative approach for cleaning the colon during colonoscopy is proposed by FritscherRavens et al. It consists of a disposable soft-tipped catheter with a water jet spray that can be advanced, under direct vision, through the accessory channel of the scope into the fecal matter. This way, when water is pumped through, even impacted stool can be broken up into slurry. Trials on unprepared colons of anesthetized pigs demonstrated the effectiveness of this approach, although mucosal trauma, bleeding, perforation, clogging of the colonoscope channels, and electrolyte imbalance may limit its impact.

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Background the purpose of the behavioral health medical necessity criteria is to provide a guide to coverage cheap 100mg neoral visa acne at 40. Behavioral health policy is not intended to dictate to providers how to practice medicine discount generic neoral uk skin care bandung. Providers are expected to exercise their clinical judgment in providing the most appropriate care purchase neoral without a prescription skin care during pregnancy home remedies. To qualify for the chemical dependency benefit, 2009 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 232 these criteria do not imply or guarantee approval. Clinically, these diseases require long-term engagement in care to have the best outcomes for patients. Outcomes research over the past 27 years consistently finds that longer treatment duration leads to improved outcomes. This has led the Department of Veterans Affairs to set performance measures for substance use disorders treatment to continuing treatment for 90 days or more. However, residential care does have a role in the continuum of treatment for patients with addictive diseases. When severe addictive disease and other co-morbidities are present, we believe it is important to provide residential care as a covered benefit for those patients who may need more intensive treatment. It should allow them to better engage in and benefit eventually from continued outpatient treatment, which is central to their recovery. Therefore, effective care plans include relapse prevention strategies as well as actions to take in the event of a relapse. Relapse does not constitute a need for residential treatment; rather, it supports the need for engagement or reengagement in outpatient care and other support activities. Current data reflects that 50% 75% of patients with substance use disorders seeking treatment have cooccurring mental health conditions. Patients with co-occurring conditions are more likely to benefit from residential care. Effective treatment should optimally address both disorders via an integrated care plan. The care plan will help guide treatment in residential care and will inform transition and discharge planning related to follow-up needs. In addition to general medical conditions, attention needs to be given to assessing the patient?s need for detoxification. Medical assessment ideally includes evaluation of the patient?s eligibility for medications to assist with the medical management of cravings and/or opiate replacement treatment (if applicable). Since substance use disorders are chronic disorders, treatment is optimally provided over longer periods of time. Residential treatment may serve as the level of care needed to help youths to stabilize and engage in treatment with the ultimate goal of transitioning to longer term treatment at a lower level of care. Service authorization is based on the member?s contract and these clinical review criteria. When treating children or adolescents under the age of 18 in a residential treatment program, the parents or guardians must consent for the treatment and be included in both the evaluation and treatment planning processes, except for youths who have been living outside of the family home and the parents are unavailable, unable, or unwilling to provide consent to treatment. Admitting a selfconsenting youth is a determination made by the program to which the youth applies, based on information obtained by the program, and the program must document efforts to locate and engage the parents in the treatment process. In addition to general medical conditions, attention needs to be given to assessing the youths need for detoxification, and ideally includes evaluation of the patients eligibility for medications to assist with the medical management of cravings, and/or opiate replacement treatment (if applicable). Back to Top Date Sent: 3/24/2020 233 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History recommendations related to residential treatment). Clinical recommendations must be documented in writing and must contain objective clinical information. Clinical criteria do not factor in family, employer or legal mandates or requests for treatment. Clinical criteria are intended to evaluate the impact of the substance use disorder on the affected individual (via a bio-psychosocial assessment) and to guide decision making related to care strategies. Evidence and Source Documents References for Adult Residential Treatment: 1) Mojtabai R, Graff Zivin J. This study was a data analysis from the Services Research Outcomes Study, surveying 3,047 clients in 99 drug treatment facilities across the United States. No long-term differences in abstinence or reduced drinking between outpatient treatment and residential treatment. Patients randomized to either outpatient or day hospital treatment fared equally well. Patients with mid-level psychiatric severity did fare better with the higher level of care. Despite differences in baseline severity between groups, patients randomized or non-randomized fared equally well in either treatment intensity. Patients randomly assigned to either hospital-based day treatment or community-based treatment fared equally well, while costs were lower in community-based programs. This study extends similar findings from a report on 6-month outcomes from a randomized trial assigning 188 clients entering a therapeutic community to either day treatment or residential treatment. Both groups had similar improvements over time with those in residential treatment having greater improvement for psychiatric symptoms and social problems. Patients with high severity dual disorders had better alcohol, drug and psychiatric outcomes and higher health care costs. Moderate severity patients generally had similar outcomes whether they were matched to low-intensity treatment or not.

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Insertion of spinal instrumentation is reported separately and in addition to arthrodesis cheapest neoral acne 2 weeks before period. Instrumentation procedure codes 22840-22848 are reported in addition to the definitive procedure(s) purchase neoral visa acne 5 days after ovulation. Do not append modifier ?62 to spinal instrumentation codes 22840-22848 and 22850-22852 buy neoral no prescription skincare for over 60. A vertebral segment describes the basic constituent part into which the spine may be divided. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies, which contains the intervertebral disk, and includes the nucleus pulposus, annulus fibrosus, and two cartilagenous endplates. List 22840-22855 separately, in conjunction with code(s) for fracture, dislocation, arthrodesis or exploration of fusion of the spine 22325-22328, 22532-22534, 22548-22812, and 22830. Codes 22840-22848, are reported in conjunction with code(s) for the definitive procedure(s). Code 22849 should not be reported with 22850, 22852, and 22855 at the same spinal levels. Codes 31233-31297 are used to report unilateral procedures unless otherwise specified. The codes 31231-31235 for diagnostic evaluation refer to employing a nasal/sinus endoscope to inspect the interior of the nasal cavity and the middle and superior meatus, the turbinates, and the sphenoethmoid recess. Any time a diagnostic evaluation is performed all these areas would be inspected and a separate code is not reported for each area. If using operating microscope, telescope, or both, use the applicable code only once per operative session. Surgical bronchoscopy always includes diagnostic bronchoscopy when performed by the same physician. For endoscopic procedures, code appropriate endoscopy of each anatomic site examined. Additional second and/or third order arterial catheterizations within the same family of arteries supplied by a single first order artery should be expressed by 36218 or 36248. Additional first order or higher catheterizations in vascular families supplied by a first order vessel different from a previously selected and coded family should be separately coded using the conventions described above. Pulse generators are placed in a subcutaneous "pocket" created in either a subclavicular or underneath the abdominal muscles just below the ribcage. Electrodes may be inserted through a vein (transvenous) or they may be placed on the surface of the heart (epicardial). The epicardial location of electrodes requires a thoracotomy for electrode insertion. Version 2019 Page 100 of 257 Physician Procedure Codes, Section 5 Surgery A single chamber pacemaker system includes a pulse generator and one electrode inserted in either the atrium or ventricle. A dual chamber pacemaker system includes a pulse generator and one electrode inserted in the right atrium and one electrode inserted in the right ventricle. In certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle (biventricular pacing). Epicardial placement of the electrode should be separately reported using 33202-33203. Like a pacemaker system, a pacing cardioverter defibrillator system also includes a pulse generator and electrodes, although pacing cardioverter-defibrillators may require multiple leads, even when only a single chamber is being paced. A pacing cardioverter-defibrillator system may be inserted in a single chamber (pacing the ventricle) or in dual chambers (pacing the atrium and ventricle). These devices use a combination of antitachycardia pacing, low energy cardioversion or defibrillating shocks to treat ventricular tachycardia or ventricular fibrillation. Pacing cardioverter-defibrillator pulse generators may be implanted in a subcutaneous infraclavicular pocket or in an abdominal pocket. Removal of a pacing cardioverter-defibrillator pulse generator requires opening of the existing subcutaneous pocket and disconnection of the pulse generator from its electrode(s). A thoracotomy (or laparotomy in the case of abdominally placed pulse generators) is not required to remove the pulse generator. The electrodes (leads) of a pacing cardioverter-defibrillator system are positioned in the heart via the venous system (transvenously), in most circumstances. In certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle (bi-ventricular pacing). In this event, transvenous (cardiac vein) placement of the electrode should be separately reported using code 33224 or 33225. Epicardial placement of the electrode should be separately reported using 3320233203. Electrode positioning on the epicardial surface of the heart requires thoracotomy, or thoracoscopic placement of the leads. Removal of electrode(s) may first be attempted by transvenous extraction (code 33244). However, if transvenous extraction is unsuccessful, a thoracotomy may be required to remove the electrodes (code 33243). Use codes 33212, 33213, 33240 as appropriate in addition to the thoracotomy or endoscopic epicardial lead placement codes to report the insertion of the generator if done by the same physician during the same session. When the "battery" of a pacemaker or pacing cardioverter-defibrillator is changed, it is actually the pulse generator that is changed. Replacement of a pulse generator should be reported with a code for removal of the pulse generator and another code for insertion of a pulse generator. Repositioning of a pacemaker electrode, pacing cardioverter-defibrillator electrode(s), or a left ventricular pacing electrode is reported using 33215 or 33226, as appropriate. Replacement of a pacemaker electrode, pacing cardioverter-defibrillator electrode(s), of a left ventricular pacing electrode is reported using 33206-33208, 33210-33213, or 33224, as appropriate.

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Immunologic tests Parasitology 74 Relevance to Ethiopia:the parasite is not recorded in Ethiopia 100mg neoral visa skin care 35. Trypanosoma gambiense Geographical Distribution: West and western central Africa discount 100mg neoral fast delivery acne facials, extending from Senegal across to Sudan and down to Angola discount neoral 25 mg on line skin care essential oils. Trypanosoma brucei complex (group) Trypanosoma brucei brucei (infective to animal but not humans) and the human pathogens Trypanosoma brucei rhodesiense (causing acute trypanosomiasis) and T. Metacyclic trypomastigotes: In the mid and fore gut of the Glossina (tsetse flies) Morphology: has trypomastigote and metacyclic trypomastigote stages Life cycle: It requires two hosts to complete its life cycle, species of Glossina as an intermediate host and man and other animals as a reservoir host. Trypanosoma gambiense is a saliverian trypanosome in which the trypomastigotes develop in the mid and fore gut of the insect vector so that infection is acquired through inoculation of the metacyclic trypomastigotes into the subcutaneous tissues with the saliva. In the blood vessels the metacyclic trypomastigots transforms into trypomastigots stage. There is multiplication of the parasites in the mammalian host and the insect vectors. The parasites can also be Parasitology 75 transmitted through blood transfusion, and congenitally. Major symptoms are chancer, fever, haedache, sweating, post cervical enlargement of the lymph node(winter bottom?s sign), splenomegally, hepatomegally, meningoencephalilis, Parasitology 76 inability to speak, progressive mental dullness, excessive sleeping, weight loss, coma and death if untreated. Trypanosoma rhodesiense Geographical Distribution: East Africa, Central Africa, and Southern Africa, extending from Ethiopia down to Botswana. Morphology: has trypomastigote and metacyclic trypomastigote stages that are morphological similar to trypomastigote and metacyclic trypomastigote stages of T. The disease is transmitted naturally by wood land and savannah tsetse flies and also by blood transfusion. It is a zoonosis and has low prevalence, sporadic form of infection, and more prevalent in male than in females. Vector control: -By spraying vehicles with insecticide as they enter and leave the tse-tse fly infested area, -By using and maintaining insecticide impregnated tse-tse fly traps, -By selectively clearing the bush and wood areas especially around game reserves, water holes, bridges, and along river blanks. Thick or thin stained blood films or buffy coat from Micro-haematocrit or capillary tube centrifugal concentration technique. Relevance to Ethiopia Animal trypanosomiasis (Nagna or gendi) always has been a problem in many parts of Ethiopia (Tedla S, A. The species of vector of trypanosomiasis are to be found in Ethiopia are: 1) From the palpalis groupGlossina fuscipes fuscipes and G. The seven adminstrative regions infested are Shewa, Gojam, Welega, Illubabor, Kefa, Gamo Gofa and Sidamo. Although the belt is quite extensive in Ethiopia the Sleeping sickness foci are limited to Gambela (the areas along Baro, Gilo and Akobo rivers), Gamo Gofa (from Mursi-Bodi district), Kefa (from maji), and Welega (from the settlement area in the Anger-Didesa valley). Trypanosoma cruzi Geographical distribution: Central and South America Habitat: Amastigotes: Intracellular forms in the reticuloendothelial cells and tissues of brain, muscles, Lymph nodes, liver, Spleen, bone marrow, etc. Promastigotes: Transitional stage Epimastigotes: In the mid-gut of the insect vector (bug) Trypomastige: In the mid-gut of the vector and; in the blood circulation and intercellular spaces of man. Metacyclic Trypomastigote: In the mid gut and in the faeces of the insect vector Parasitology 79 Morphology: Has all the developmental stages of haemoflagellates Amastigote stages are similar to amastigote stages of Leishmania species. Less commonly trans-placental transmission occurs with a fetus being infected from an asymptomatic mothers. It can occur also if viable parasites (even very few) penetrate the skin, conjuctiva, or mucous membrane. Life Cycle In most infections, metacyclic (infective) trypomastigote contained in the faeces of an infected bug (Triatoma) penetrate the skin through the bite wound or enter through the conjunctiva of the eye or the membrane of the mouth or nose. The trypomastgotes invade the reticuloendothelial cells near the point of entry and multiply intracellularly as amastigotes. The amastigotes develop into Trypomastigotes which are released into the blood when the cell ruptures. The trypomastigote become amastigotes and multiply, forming masses known as Pseudocysts. Within the pseudocyst, a proportion of amastigote become elongateed and develop first into epimastigotes and then into trypomastigotes which ar released into the blood when the host cell ruptures. Some of these trypomastigites continue to circulate while the majority infect further tissue cells. Parasitology 80 By way of the blood and lymphatic system, the parasites reach tissue cells of the heart, nerve, skeletal muscle, smooth muscles of the gastrointestinal tract and else where. The life cycle is continued when a triatomine bug vector ingests circulating Trypomastigotes in a blood meal. In the vector, the Trypomastigotes transform in to epimastigotes which multiply by binary fission in the gut of the vector. Prevention and Control: Vector control, improvement of housing, treatment and health education. Xenodiagnosis (in chronic and subacute infections where their number in the blood is usually very few). If trypanosomes are ingested they will multiply and develop into epimastigotes which can be found 25-30 days later in the faeces or rectum of the bug 3. Culture of blood on blood agar slopes in the later stages of infection when facilities for xenodiagnosis is not available. Identify hemoflagellates for the presence or absence of the following developmental stages in their life cycle: Amastigote, promastigote, epimastrogte and trypomastiogte 5. How can you differentiate between species of African sleeping sickness since both species have similar diagnostic morphology?


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