Vol. 125 May 15, 2015 E-cigarettes and Adolescents

May 15, 2015

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                   2
E = M J

 

Seventeen per cent of high school seniors used E-cigarettes in 2014.  E-cigarette use in non–smoking adolescents increased from 79,000 in 2011 to 263,000 in 2013. The current models of E-cigarettes were developed in China in 2003 and introduced to the U.S. in 2007, though Philip Morris had been researching them since the 1990’s. (1)

The original E-cigarettes looked like a cigarette and contained a battery-powered heating element that vaporized liquid containing liquid nicotine which could be inhaled. The amount of nicotine in a single E-cigarette could vary from 36 mg. (about the amount in one Lucky Strike cigarette) to zero. Zero? Yes, zero. People vape those E-cigarettes for their various flavors which are multiple and diverse. “Vape” is the new verb to describe the process. Multiple YouTube videos compare the pros and cons of Smoking vs. “Vaping”. The major pro of vaping according to its advocates is that you can get the nicotine without the tars and other carcinogens.

The newer generation of E-cigarettes don’t look like cigarettes. They can be pen sized (called “pens”) or bigger (called “tanks”), up to 10 -12 inches long. Pens and tanks are rechargeable by the user. Multiple websites offer all kinds of flavors and nicotine strengths of E-liquids.

As E-cigarette use has increased, the use of combustible cigarettes (the traditional ones you light with a match) have decreased among children in grades 8 through 12. Some think this is good news. Others point out that even if E-cigarettes have 10x-100x LESS carcinogens than combustible cigarettes, there are still carcinogens present. Established researchers remark that “not all the ingredients in E-cigarette fluids are known or listed”. Manufactures of E-liquids rebut that by insisting that there are only four ingredients – propylene glycol, glycerin, flavoring, and nicotine – all used in other FDA-approved sprays and vaporized medicines.

E-cigarettes are not regulated by the FDA. The practical consequences of this are that 1) “face-to-face” purchase is not required (as with combustible cigarettes) and 2) there are no restrictions on youth-targeted advertisements. One of the biggest E-cigarette brands, “Blu”, may be best known for its Sports Illustrated swim suit issue ad zooming in on a blue bikinied bottom. “Seduce Juice” is the registered trademark of a variety of E-liquids, all with “snake oil” as a secondary label. Despite the fact that 40 states prohibit the sale of E-cigarettes to minors, they are readily available on the internet.

Do E-cigarettes help cigarette smokers stop smoking? One study of 5,000 attempted quitters in the U.K. suggested that it did help. (2) Studies in U.S. suggest that the use of FDA-approved nicotine vaporizers (Nicorette Quick Mist) prescribed by a physician can help people quit smoking, and many E-cigarette critics recommend that as the preferred method.  Another study showed that E-cigarettes were used by “intermediate risk” students in high schools unlike the use of combustible cigarettes by “high risk” students. Because of that use of E-cigarettes has been called a “harm reduction” strategy. Others citing the same study results suggest that E-cigarettes could act as a gateway to real cigarettes. Neither the American Heart Association nor the American Cancer Society have endorsed E-cigarettes as an aid to stop smoking.

Of course, it didn’t take long for adolescents to learn that if you could buy a rechargeable hand vaporizer and a variety of flavored liquids to put into it, why not put some marijuana juice in it.? And they do. The hashish oil used to charge pens and tanks is highly concentrated liquid THC, the active chemical of marijuana. NPR called pot-vape pens the “crack cocaine of marijuana” a year ago.  Unlike alcohol where a “shot is a shot, 30 ml., 1 oz.” the world over, a single puff from hashish oil is much stronger than a puff from a joint, and the user may not be able to reliably predict its effect. But, there is plenty of advice on how to do so on the internet. The weedblog. com has a colorful infographic explaining “How to Vape MJ rather than Smoke It.”

The contemporary pediatrician has had to add to his or her litany of history questions poised to adolescents over recent years: “Do you smoke cigarettes?”; “Are you attracted to boys or girls?”; “Do you have a gun in the house?”; and now “Are you vaping anything?” (3)

E use could = marijuana squared!

References:
(1) JAMA Pediatrics 2015 ; 169(2): 177-82
(2) Addiction 2014; 109 (9): 1531-40
(3) Scott E. Hadland, MD MPH, Harvard Medical School, May 6, 2015  Course in Adolescent Medcine


Vol. 124 May 1, 2015 Why Can’t Physicians Prognose Better?

May 1, 2015

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“It’s tough to make predictions, especially about the future.
-Yogi Berra

 

In 2013 seven Italian scientists were convicted of manslaughter and sentenced to six years in prison for not predicting an earthquake. The group of them, the Major Risks Committee (MRC), reassured the populace of L’Aguila which had just experienced a “swarm” (a geo-seismic term) of small tremors that the likelihood of a major earthquake was so small that “no action was needed”. Three weeks later a 6.3 earthquake in the region killed 309 people. Relatives of 29 of the fatalities pressed charges.  Such an outcome demonstrates the dangers of declaring the “unlikely” as “impossible”. In our medical world of close to “zero tolerance for risk” and a “demand for certainty” the risk of incorrect predictions can be daunting.

With all our training, scientific knowledge, and experience you would think that  physicians would be pretty good at predicting survival, aka “making a prognosis”. Several comparison studies have shown that physicians are not really any better than their patients in estimating survival time. Prognosis reliability does vary by diagnosis type and “closeness to the end” (in retrospect, of course, because we can never be sure that we are near the end until the end is here). For example, BOTH physicians and patients are overly optimistic in predicting the time left for lung cancer patients. Physicians’ prognosis of death are correct nearly 90% of the time in non-cancer nursing home patients when death occurs within 7 days later. That percentage drops to 13-16% when actual death occurs 3 – 6 weeks later.  Physicians also tend to be even more overly optimistic than patients about the expected quality of life near the end.

One Harvard explanation of this is as follows:
“Similar to other forecasting experts, physicians face different [non-monetary] costs depending on whether their best forecasts prove to be an overestimate or an underestimate of the true probabilities of an event. We provide the first empirical characterization of physicians loss functions. We find that even the physicians subjective belief distributions over outcomes are not well calibrated, with the loss characterized by asymmetry in favor of over-predicting patients’ survival. We show that the physicians’ bias is further increased by (1) reduction of the belief distributions to point forecasts, (2) communication of the forecast to the patient, and (3) physicians own past experience and reputation.”
 In other words, a physician’s gut feeling is often just “guesswork.”

All of us have heard the story of a patient who was told that he had “a year to live” and the patient went on fishing for cod or bluefish or whatever for another six years. Some of us have suffered the opposite experience. I can not forget the infant boy we diagnosed with hemophilia in the 1970’s and reassured the parents that we, along with modern medical science, could promise him a near-normal life with the use of factor VIII infusions. The patient enjoyed a healthy six years and even learned to infuse himself when only 8 years old. He became one of the first to contract HIV from factor VIII, and he died a teen ager with resistant, intractable pneumonia; a personally wrenching failure of a promise (prognosis) made by modern medicine. Technology and research have corrected that cause, but the memory lingers on.

Studies to identify specific characteristics or elements that could be used to more accurately state a survival prognosis have revealed a mixed bag. None is reliable enough for general clinical use.  If we did have a scientific consensus then the often complex, complicated negotiations of end-of-life care would be a lot easier for both physicians and patients and their families. It would perhaps be less costly for Medicare also.

Of course, despite the decades of study and technological advances we are no better at predicting the actual day a baby is born either … especially within a week of the actual delivery. At least we have “the nine-month consensus” to limit our predictive unreliability for birth dates.


Vol. 123 April 15, 2015 What Does “Board Certified Physician” Mean? What Does It Have To Do With The 2016 Presidential Candidates?

April 15, 2015

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 “Nowadays, medicine is an open-resource team approach. I get all this information in the room with a patient in seconds, and then I use my experience and my knowledge to pull together a plan”

– Dr. Jonathan Weiss, a triple-board-certified physician explaining why he is against a test every ten years to maintain board certification;
NY Times, April 14, 2015, D3

A “board-certified physician” is one who has voluntarily applied for and passed a test of medical knowledge in one of 24 general specialities or over 30 subspecialties.. A non-profit American Board of Medical Specialties (ABMS) composed of physicians was established in 1933 to administer the tests to physicians who apply for the certification after completing their residency training. Each approved specialty board issues a certificate to successful candidates (It hangs on the wall in your physician’s office). Unlike the bar exam for lawyers, physicians are expected to pass the test the first time, though a second attempt is sometimes necessary in some specialties. Most hospitals and many health insurance companies require board certification as a sign of competence as part of their credentialing. States do NOT require board certification for licensure.

One of the founding specialty boards in 1933 was the American Board of Ophthalmology (ABO), which brings us to the 2016 Presidential candidates.

Rand Paul, MD, a recently announced Republican candidate for President, took and passed his ophthalmology boards in 1995.  In 1997 he and 20 other practicing eye doctors protested the ABO’s changing of its certification from “lifetime” to “must be renewed every 10 years.” They argued that this Maintenance of Certification (MOC) test every ten years was “time-consuming for the practitioner, expensive ($1,500-$3,000), and irrelevant to patient care”. They formed a new board, the National Board of Ophthalmology (NBO), that would issue life-time certification for $500. Rand Paul was the lead organizer. He, his non-physician wife Kelley, and his non-physician father-in-law became members of its Board of Directors. NBO was never recognized by the ABMS, was dissolved by the State of Kentucky in 2000, was recreated in 2005 ( that just happened to be 10 years after Rand Paul was initially certified by ABO), and finally was dissolved again in 2011. It certified about 60 physicians in its lifetime.

Rand Paul is not the only critic of the ABMS and the Maintenance Of Certification (MOC) concept. Others have questioned the ABMS certification exams’ ability to evaluate actual clinical decision-making and clinical competence. Others have suggested that the exams’ heavy emphasis on memorized medical facts and pharmaceutical details is irrelevant, when nowadays such details are just a click or two away from the doctor in the exam room via electronic device. In 2013 a prestigious-sounding organization, the Association of American Physicians and Surgeons (AAPS) brought a “restraint of trade” suit against the ABMS for its MOC requirement.

I was impressed by that name, until I Googled it. The AAPS is an ultra-conservative organization established to fend off  “the evils of socialized medicine”. Its positions include “HIV is not the cause of AIDS”, “abortions are associated with breast cancer”, and “childhood vaccinations cause autism”. Rand Paul and his father Ron, also a physician and a past presidential candidate himself, are both members of the AAPS.

“So what” you might think at this point.
Rand Paul’s beliefs and actions indicate to me that he has an excellent ability to create, maintain, and operate within his own reality, one which ignores accepted evidence. Perhaps one could say that very same thing about any politician with whom you disagree, but I don’t disagree with every thing that Rand Paul says.  Physicians are trained to make decisions often using inadequate data. I am surprised that Rand Paul, as a trained physician, can successfully maintain a belief construct that is so at odds with established facts.  Also, he tried, and failed, to develop an alternative governing body of his profession when he disagreed with its policies. It was NOT about trying for better patient care.

These are undesirable attributes in a President of the United States. It also makes Hilary’s real estate shenanigans in Arkansas, her use of more than one email address as Secretary of State, Jeb Bush’s claim to being Hispanic, and Elizabeth Warren’s claim to being Native American look pretty penny ante by comparison.


Vol. 122 April 1, 2015 Athena Health Buys Myspace!

March 31, 2015

hub“Even as the public decries government spying programs and panics at the news of the latest data-breach the daily traffic to sites like Facebook and Twitter—especially through mobile devices—not only stays high, but continues to grow. Both the collective behavior of social sharing, and the technology for analyzing and interpreting social data, are already widely in place. The trick is to actually merge the two—which does not necessitate a whole new system.”

– Victoria Wangia, Professor of Health Informatics, University of Cincinnati
quoted in “The Facebook Model for Socialized Health Care” by Edgar Wilson, The Health Care Blog, 2/26/2015

Athena Health, a major provider of electronic health records (EHR) NOT to be confused with Anthem, has announced its purchase of MySpace, the pioneer social network.

MySpace (original spelling) was the first social network on the internet, but has steadily lost users to its competitor Facebook. Myspace (current spelling) was bought by Justin Timberlake in 2008. Despite efforts to revamp and redirect, Myspace user registrations continued to decline, and it has become a limited network for musical performers. Mr. Timberlake is confident that this move with Athena Health will broaden the scope of his company positively, “I am looking forward to making a more significant contribution to society than singing “D**k in a Box” on Saturday Night Live’s Christmas show”.

Jonathan Bush, CEO of Athena Health and related to both presidential Bushes, says he is making this move because it is time that health care providers make more innovative use of the social networks. Athena Health, based in Massachusetts, already provides electronic medical record (EMR) capability to health care providers nationwide. AthenaClinicals, its popular cloud-based electronic medical record and billing program, is available on desktop and mobile computers via AthenaNet. Its 2007 initial stock price of $18 is now at $120.

Using well-tested Facebook-like methodology Athena Health will create a wall, “The Health Wall”, in everyone’s Myspace account which will be renamed AthenaFace. This will add new meaning to “updating your status”. “Sick”, “Well”, “Recovering nicely”, “Waiting to find a doctor”, and “A little worried about what is happening to me” will be examples of clickable boxes.

Pop-up ads and informational banners will be health-oriented. Such as:
“Check your immunization score FREE”,
“Need help figuring out your Health Insurance deductible, Obamacare tax credit, or fine?”,
“Find the Nearest Medical Marijuana Dispensary”, and
“Special discounts on fitness club dues”.

AthenaFace representatives neither denied nor confirmed plans to link up with Groupon, another semi-floundering internet company, that provides discount coupons for a whole variety of services and products.

Record entries will be encrypted and saved, of course, though users will have the “Snapshot option” of having certain parts of the record being deleted within 30 seconds of being read. “The Health Wall” will accept postings of pictures and videos which will certainly enhance the robustness of the medical record for skin rashes, wounds, gait disturbances, and seizure disorders.

Efforts to link with relevant mobile apps like “Breathalyzer”, “Fitbit”, “Sleepbot”, “Whazthat!?”, etc. have already begun.  An app to link with Uber for the “Next available doctor to see you” will be in the first upgrade. However, that app, UberDoc, will include a charge. Prices will vary depending on circumstances, so customers will be urged to settle on the price before taking the appointment.

In response to critics who worry about the security of personal information in a combined health care/social network platform Jonathan Bush has stated, “Lots of people are obviously not at all concerned about such privacy issues. They are sexting and sending pictures of their genitalia all over the internet. Why would they care if somebody knew their blood pressure and cholesterol level? ”

But, AthenaFace will have different levels of privacy options that can be set by the user. On the user-sharing side the options will include:
“All”,
“Family and Friends”,
“Just Family”.
“Just (insert name here) ”, and
“Nobody”.

For provider-sharing the options for the customer will include:
“All”,
“Specialists Only”,
“Primary Care Only”,
“Dr.(insert name here)” , and
“Nobody, especially that nosey office nurse who thinks she runs the place.”

Why wait until your physician and hospital catches up with the federal EMR incentives for establishing a patient portal?

Do it yourself with AthenaFace!

Coming soon to your internet browser, but most probably after 2016 … depending on election results.

HAPPY APRIL FOOLS DAY.


Vol. 121 March 1, 2015 Friends Don’t Let Friends … Smoke

February 28, 2015

hub20 established causes of deaths caused by cigarettes:
(Surgeon General Report 2014)
11 cancers – Lip and oral, esophageal, stomach, colorectal, liver, pancreatic, laryngeal, lung, urinary bladder, kidney, and
acute myeloid leukemia
6 vascular – ischemic heart disease, other heart disease, stroke, atherosclerosis, aortic aneurysm, other arterial diseases
2 pulmonary – Pneumonia and influenza, COPD
Diabetes

These diseases account for about 83% of the total excess mortality (higher mortality rates than non-smokers) observed among current smokers.

Several causes of death newly associated with cigarette smoking have recently been added as a result of a study of 1 million men and women over a 10 year period. (NEJM 372;7, Feb 12, 2015)
About 9% of both men and women were current smokers.
42% (women) and 58% (men) were former smokers. (56-70% quit over 20 years ago)
49% (women) and 32% (men) never smoked.

Causes of deaths newly associated with smoking (with relative risk compared to non-smokers)
(1.0 is the mortality risk of a non-smoker)
ischemic disorder of intestines – 5.6 (nearly 6 times that of a nonsmoker)
liver cirrhosis – 3.6
cancers of unknown sites – 3.2   ( 2-6% of all cancers)
hypertensive heart disease – 2.9
all other digestive disorders – 2.6
renal failure – 2.1
all infections –  2.2
prostate cancer – 1.2

Most of the remaining 15-17% of excess mortality of smokers over nonsmokers is accounted for by these newly designated diseases.

The relative risks of death for smokers went up as the number of daily cigarettes smoked went up.
The relative risks went down among former smokers as the number of years since quitting went up.

How do people stop smoking?

YES
Conscious decision “cold turkey” (after being scared to death by statistics like this) – 4-7% success rate
nicotine replacement therapy (NRT) –  gum,patch, aerosol, lozenges
prescription medication – Wellbutrin, Chantix (always needs to be combined with support or cognitive therapy – even just telephone
counseling) 25% success rate at 6 months
support groups – NA, quitnet.com, Great American Smokeout

 MAYBE
hypnosis, acupuncture, mind-body practices, herbals
E-cigarettes – the jury is still out; no consistency of ingredients among brands is one problem in evaluating health risks.

NO
filter cigarettes – do not reduce nicotine inhaling; actually can increase craving
magnet therapy – “a small magnet on each ear”
chewing or other oral tobacco

The addiction to nicotine and to marijuana can be mapped using functional MRIs to the same part of the brain – the part of the brain that “lights up” with cocaine ingestion.  Some treatment programs and several research projects are honing in on this “dual addiction” of cigarettes and joints.

Interestingly, ingestion of the most common food “addictions”, ice cream, pizza and french fries, also maps to this same part of the brain.  Maybe as we get fatter and happier as a nation by using these substances other than tobacco, we will smoke less cigarettes, and live longer!


Vol.120 February 15, 2015 Disillusioned …Again and Again

February 14, 2015

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 “Scratch any cynic and you will find a disappointed idealist.”
― George Carlin

Maybe it is just that time of year, the record snowfall, the frigid temperatures, the lack of sun, but I feel like the world as I have known it is crashing down around my ears. Brian Williams has fallen off his pedestal, Bill Cosby is canceling shows all over the place, Tiger Woods is not coming back, Jon Stewart is leaving The Daily Show, Steven Colbert has already left, the towns are running out of sand and salt, and the trial of Dominique Strauss-Kahn, former head of the International Monetary Fund, has come up with the unique defense of his “aggravated pimping” “at a sex parties with “you can’t tell the difference between a prostitute and a naked socialite”.

So many of the truths we have held dear in medicine, science, politics, and society are being revealed as mere illusions. To wit:

  • Cholesterol need no longer be a nutrient of concern”. So sayeth the “nation’s top nutrition advisory panel” after 40 years of telling us just the opposite! High cholesterol levels in your blood do increase your risk for heart disease, BUT dietary cholesterol contributes only about 10% of that level. Of course, the panel couldn’t just leave it at that. According to them the REAL danger lies in foods heavy with trans fats and saturated fats. However, if you follow recent arguments in the literature closely enough you will see that there is some debate about which are the “good fats’ and which are the “bad fats.” Maybe we’ll have  to wait another 40 years for consensus.
  • Mississippi and West Virginia, among the poorest states in our country, have the best rates of measles immunization, and it is because they are the ONLY states that refuse to accept a waiver from immunizations on the basis of parental beliefs when children enter school. Mississippi’s measles vaccination rate is 99.7% for entering kindergarten students. West Virginia is at 96%. Epidemiologists have established a 94% immunized rate for measles as necessary to sustain “herd immunity”. In California and Arizona ( where thousands of Super Bowl visitors came and went back to their own states) the rates are 90.7% and 91.4% respectively.
  • Spewing sulphur gas into our high atmosphere could help block sun radiation and help cool off a warming earth. Isn’t sulphur one of those toxic pollutants given off by burning coal and other fossil fuels? Well, yes, says the National Academy of Science, but the computer models of blocking the sunlight with released sulphur have such a positive logic about them that “we should test it in some small pilot studies”.
  • Four out of five bottles of supplements taken off the shelves of GNC, Walmart, Walgreens, and Target in New York did NOT contain ANY of the herbs listed on their label. Ginseng pills “for physical endurance and vitality” contained only powdered garlic and rice. Ginkgo biloba for “memory enhancement” contained powdered radish, houseplants, and wheat. That label even claimed that it was wheat- and gluten-free! The FDA can only target products that have dangerous ingredients. It took the NY State Attorney General’s office to reveal this harmless ingredient sham, aka “profit by placebo” (NY Times, Feb. 3, 2015, pg.1)
  • Half of the health information and recommendations given on The Doctor Oz Show and The Doctors is false. Not only did 80 recommendations from each TV show picked at random from the 900 recommendations identified have NO evidence to support them, but many were even contradicted by evidence. In typical academic, “English speak” the authors suggest that “consumers and clinicians should be skeptical about these TV show recommendations”. (BMJ 2014 Dec. 17, 2014, 34)

Is there any hope for us optimists?   Well …

  • Crime rates in Boston have plummeted during this cold snowy weather. Homicide is down by 70%, rape by 50%, and vehicle theft by 46%. I guess everyone is staying inside, wearing lots of clothes,  and skipping the shoveling needed to steal a car. Rates for violent crimes in New York City, which had less snow and higher temperatures, all increased during the same period.

Vol. 119 February 1, 2015 Watching The Super Bowl Could Be Harmful To Your Health

January 31, 2015

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Sudden cardiac arrest among fans is a well-documented occurrence at exciting sports events.

 

 

  • Two fans dropped dead this summer as the Argentina soccer team beat Netherlands in a 4-2 shoot out to break their 0-0 tie. The 16 year old boy collapsed in front of a giant TV screen the mayor had set up in the village square as the winning goal was scored. The 49 year old died during the post-game celebration.
  • A 2010 European study of 190 major soccer arenas revealed that there was 1 sudden cardiac arrest in the stadium every 5-10 matches.
  • An American study of heart attacks after the 1980 and 1984 Super Bowls showed that, on the day of the game and for several weeks after, men had 3 times the number of heart attacks then expected; a jump from 1 to 3 in 100,000. Further analysis showed that the rate was higher in the fans whose favorite team lost and was lower in fans whose team won!

The presumed mechanism is the outpouring of adrenaline during peaks of excitement which causes heart muscle to go into contractile spasm or ventricular fibrillation. Either one is lethal if not stopped. The European study felt the problem was significant enough to make 6 recommendations for soccer stadiums to ensure that stricken fans could get immediate access to life-saving medical care.

Is there anything that you can do to reduce your risk? Unless you are already taking daily aspirin to reduce your risk of a heart attack DON”T start now. Aspirin has real risks of causing intestinal bleeding AND, truth be told, there is NO evidence that daily aspirin prevents your first heart attack (“primary prevention”). Its beneficial effect is well proven only in reducing the chances of you having another one (“secondary prevention”).

Alcohol is a well-known contributor to high blood pressure (not the best thing for a heart), so if you are truly worried you could take that rather drastic step.

Us coach potatoes can take some solace in the fact that we are not the only ones with increased risk for sudden cardiac arrest.

  • Endurance athletes (“continued exercise for 3 hours or more”) have about the same risk, 1 in 50,000, of acute heart attack or sudden cardiac arrest within 24 hours of completion. (1)
  • A 1999 study of 38 Austrian athletes in a 143 mile bicycle race with 18,000 feet of altitude change revealed that 34% of them had elevated heart enzymes in their blood at completion; an absolute sign of heart muscle damage. The winner had the highest level! (2)
  • A subsequent study of participants in the Hawaiian Ironman Triathlon found that 11% had signs of heart damage at the end. Of course, this is not new. Remember that Pheidippides, the first marathon runner, dropped dead just after delivering his message.

It is interesting that these studies involved only men. Because heart attacks are still the number one killer of women and that 46% of the last Super Bowl audience were women, perhaps it is time to broaden the study population.

I used to collect articles about the dangers of running in order to support my resistance to popular peer pressure at the time, so I am personally heartened to know that the risk for sudden cardiac arrest during a sporting event is about the same for both couch potatoes and players.

References:
1.  Jour Am Coll Card 28:428, 1996
2.  Am Jour of Card 87:369, 2000


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