although this is an issue that many folks in this country like to ignore, in a hospital setting this topic is very important. I recently had a case where the gentleman presented from an outside hospital with a perforated colon. Luckily, he was able to get to our hospital in time and to the operating room where they were able to remove a good section of the affected colon. The patient became somewhat hemodynamically unstable during the surgery and they had to stop early and planned for a return to the OR the following day.
The difficult aspect of this case arose when both the son and the second wife appeared and claimed that they had health care power of attorney over the patient. This became quite a conundrum since one family member noted almost diametrically opposite from the other. We referred this case over to our risk management department and they sided with the family member who had appropriate paperwork. Apparently the patient was deemed incompetent and had guardianship transferred to one family member, and the other family member had papers that were signed after the patient was already declared incompetent (likely due to Alzheimer's).
Regardless, the patient became very unstable and the family member who had guardianship made the patient DNR, or do not resuscitate. Everything was being done for this patient, mechanical ventilation, fluids, medications to maintain blood pressure and heart rate (pressors), etc. However, the family member who did have power of attorney did not desire to have chest compressions done. The patient eventually expired.
The entire episode became a family circus when the other family member who did not have guardianship objected to the decisions the other family member made. The moral of the story is that you should have any plan or discussion with your family members in the event that you become critically ill. It is unfair to put the burden on Hospital staff to make decisions that you should have had with your family members. The general public also needs to understand that dying is a natural process, and prolonging life on artificial means leaves little to no quality of life. Are you planning on taking your loved one home on a mechanical ventilator? Or perhaps you could just be like most of America and leave the burden of care up to the hospital...
Monday, April 21, 2008
Wednesday, April 2, 2008
Medical Treatment for Prisoners?
So this week we had a patient coming to us from the state prison. The short story is that this individual was sentenced to prison for larceny. I did not ask for any more details regarding the individual's imprisonment. But the medical story regarding this individual is that a patch was placed during childhood to repair a ventricular septal defect. Apparently this patch became infected and needed to be removed, and this was successfully done during surgery. However, during the case the tricuspid valve of the heart was so terribly infected that it too had to be resected. The repair made to the tricuspid valve did not hold after surgery. At this stage the patient may require additional surgery to repair the initial valve.
But this Prelude brings me to my point. Once you commit a crime and you are sentenced to prison, you essentially become a ward of the state. If you need some kind of medical care, you are guaranteed to get it if you are incarcerated. I think it is more because you are a ward of the state rather than a criminal. Hospitals have no problems accepting patients from the prison system since it is guaranteed revenue for them. Sure, they often send regards to accompany the patients, but there are instances where prisoners have tried to escape from hospitals. Is it really necessary to put the rest of the hospital staff at risk?
From a philosophical standpoint, there is definitely a disconnect here in that you can break the law, be sentenced, and then qualify for medical care you would probably not have received otherwise. The other alternative is that you can be a law-abiding citizen, have no medical insurance, and then be denied medical care that you probably need. Which option would you rather have if you are faced with a life-threatening ailment?
Sure, in medical school we are taught to not pass judgment on patients. But the thing you have to remember is that we are human. Above that, hospital staff generally obey the law rather than break it. So why should I take comfort in treating someone who probably murdered another innocent individual? I thought that these individuals forfeited their rights once they decided to commit crimes against society. So even if they are wards of the state, why should society get stuck footing the bill for their health care when we cannot even cover most law-abiding citizens?
For example, there was a shooting in the past week in Columbus, Georgia, where a grief stricken individual shot and killed 3 individuals. The shooter felt he was targeting a nurse who had taken care of his mother when she had died there in 2004. The unfortunate instance is that the individuals shot and killed had nothing to do with the shooter's mother's care. The shooter was shot in the shoulder and had orthopedic surgery. Why should this individual have deserved surgery? He did after all kill 3 people. This is probably a surgery the med students should have performed, it is definitely not worth the time of anyone else!
So the moral of the story of is if you are uninsured, just go shoplift or embezzles some funds and you can wind up in prison. Afterwards, you can get the chemotherapy or surgery you need...
But this Prelude brings me to my point. Once you commit a crime and you are sentenced to prison, you essentially become a ward of the state. If you need some kind of medical care, you are guaranteed to get it if you are incarcerated. I think it is more because you are a ward of the state rather than a criminal. Hospitals have no problems accepting patients from the prison system since it is guaranteed revenue for them. Sure, they often send regards to accompany the patients, but there are instances where prisoners have tried to escape from hospitals. Is it really necessary to put the rest of the hospital staff at risk?
From a philosophical standpoint, there is definitely a disconnect here in that you can break the law, be sentenced, and then qualify for medical care you would probably not have received otherwise. The other alternative is that you can be a law-abiding citizen, have no medical insurance, and then be denied medical care that you probably need. Which option would you rather have if you are faced with a life-threatening ailment?
Sure, in medical school we are taught to not pass judgment on patients. But the thing you have to remember is that we are human. Above that, hospital staff generally obey the law rather than break it. So why should I take comfort in treating someone who probably murdered another innocent individual? I thought that these individuals forfeited their rights once they decided to commit crimes against society. So even if they are wards of the state, why should society get stuck footing the bill for their health care when we cannot even cover most law-abiding citizens?
For example, there was a shooting in the past week in Columbus, Georgia, where a grief stricken individual shot and killed 3 individuals. The shooter felt he was targeting a nurse who had taken care of his mother when she had died there in 2004. The unfortunate instance is that the individuals shot and killed had nothing to do with the shooter's mother's care. The shooter was shot in the shoulder and had orthopedic surgery. Why should this individual have deserved surgery? He did after all kill 3 people. This is probably a surgery the med students should have performed, it is definitely not worth the time of anyone else!
So the moral of the story of is if you are uninsured, just go shoplift or embezzles some funds and you can wind up in prison. Afterwards, you can get the chemotherapy or surgery you need...
Sunday, March 9, 2008
Why Dictating Discharge summaries are a waste of time - in Electronic Medical Records
Mathematically there is a great deal of time wasted with dictations, particularly if you are in a system with EMR - you pretty much have to type everything. When you admit a patient you have to type up their history & physical. Progress notes, orders, everything is typed. So every individual has to expend effort typing, and there are no alternatives to it. But the annoying part comes with dictating discharge summaries, why not just paste the sections into a document rather than call a phone number, speak everything we type, and then have to proofread the transcribed version at a later point in time? Think about how many evenings you waste in this process...
If you were to assign a value to the amount of time spent typing we could call it "N". The average person can speak between three and ten words in the same amount of time it takes to type in one. You could then say the amount of time speaking would be the logarithm of N (either lnN or logN depending on if you were the three or ten word speaker). The overall time it takes to *paste* text is 1 since it is [CTRL-V]. Here are the orders of time:
pasting - O{1}
typing - O{N} * O{1}
speaking typed text (also accounting for typing in the info first) - O{N}*log{N} or O{N}*ln{N}
You can see that the greatest time spent is what you see for speaking typed text. Can the GME afford to have everyone wasting log{N} time? The other alternative is to simply say "smooth" when dictating the hospital course. I only have one more month where I will have to dictate anything and this looks the most promising :-)
If you were to assign a value to the amount of time spent typing we could call it "N". The average person can speak between three and ten words in the same amount of time it takes to type in one. You could then say the amount of time speaking would be the logarithm of N (either lnN or logN depending on if you were the three or ten word speaker). The overall time it takes to *paste* text is 1 since it is [CTRL-V]. Here are the orders of time:
pasting - O{1}
typing - O{N} * O{1}
speaking typed text (also accounting for typing in the info first) - O{N}*log{N} or O{N}*ln{N}
You can see that the greatest time spent is what you see for speaking typed text. Can the GME afford to have everyone wasting log{N} time? The other alternative is to simply say "smooth" when dictating the hospital course. I only have one more month where I will have to dictate anything and this looks the most promising :-)
Saturday, February 16, 2008
Patient Advocates
This week's commentary focuses on the concept of patient advocates. These are individuals who were usually affiliated with a hospital with the purpose of advocating terms of the patient's. Generally, or at least on paper, it seems like a great idea. Many times patient families are not up to the task of advocating on the behalf of family members (with the exception of advanced directives, regardless of how futile treatment may be). The one drawback to having these individuals advocate on the behalf of patients is that they are not medically trained and usually not knowledgeable in science in general.
One key example takes me back to another month I was working at the VA. I had an individual who was a Jehovah's Witness. For this of you who have not have to deal with these patients, they simply are not allowed to take any blood products because is seen as sacrilegious. You can imagine how much of the nightmare it becomes when they are involved in automobile accidents. With this particular individual it became apparent that he recently had a myocardial infarction. He also had developed a lower GI bleed and his hemoglobin was steadily dropping from approximately 9 g/dL to 6 g/dL (males normally are above 12 g/dL). The individual obviously had made up his mind and would not accept blood transfusions.
Once the patient makes the decision, there is usually nothing I can offer as an alternative. However, the following day I was visited by a patient advocate. This person represented the Jehovah's Witnesses and handed me brochures regarding the alternatives to blood transfusion. This individual was not very knowledgeable on alternatives but he was able to hand me the brochure. One of the more practical alternative as listed in the brochure was the initiation of iron therapy, and we already had the individual on it. We also had the individual on Epogen, but the way it was advertised in the brochure was pretty irresponsible.
For those of you who do not have experience with this drug, it is administered weekly and a one-year supply of the medication can run approximately $30,000. The problem I had with the brochure was not that it suggested it as an alternative, but it was that it was advertised as being readily available like running water. In reality, even the best clinical studies indicate roughly a two week minimum before you can see any increasing hemoglobin, and at that it would be approximately 0.5 g/dL. The patient advocate made it sound like getting this drug would be tantamount to a blood transfusion. It is not.
When the patient's hemoglobin was not increasing as much as he had hoped for, the patient advocate demanded that I give more Epogen. I am not sure whether this individual understood basic math, but he was not willing to wait the time and figured that more of a drug is always better. Every day when I went to talk to the patient I would have to talk to the patient advocate and also let him know that this was the extent of what we could provide. I think it was appropriate for the patient to have someone to ask questions, but for someone to make demands is a little too much to swallow.
This is just one isolated case, there are many more cases at our hospital where patient advocates have come in the way of patient care. It is almost as if the patient advocates seek to minimize the influence of doctors in patient care by trying to fill the heads of the patient's with artificial hopes and outcomes. It is very unfair to anyone in the medical establishment to have to deal with this added variable of complexity. If patient advocates had some element of training or competency in medical science it would be very easy to deal with them. But the majority of them are simply individuals who enjoy making demands. Patient care should definitely be about patients and doctors, it is time to cut out the middleman!
One key example takes me back to another month I was working at the VA. I had an individual who was a Jehovah's Witness. For this of you who have not have to deal with these patients, they simply are not allowed to take any blood products because is seen as sacrilegious. You can imagine how much of the nightmare it becomes when they are involved in automobile accidents. With this particular individual it became apparent that he recently had a myocardial infarction. He also had developed a lower GI bleed and his hemoglobin was steadily dropping from approximately 9 g/dL to 6 g/dL (males normally are above 12 g/dL). The individual obviously had made up his mind and would not accept blood transfusions.
Once the patient makes the decision, there is usually nothing I can offer as an alternative. However, the following day I was visited by a patient advocate. This person represented the Jehovah's Witnesses and handed me brochures regarding the alternatives to blood transfusion. This individual was not very knowledgeable on alternatives but he was able to hand me the brochure. One of the more practical alternative as listed in the brochure was the initiation of iron therapy, and we already had the individual on it. We also had the individual on Epogen, but the way it was advertised in the brochure was pretty irresponsible.
For those of you who do not have experience with this drug, it is administered weekly and a one-year supply of the medication can run approximately $30,000. The problem I had with the brochure was not that it suggested it as an alternative, but it was that it was advertised as being readily available like running water. In reality, even the best clinical studies indicate roughly a two week minimum before you can see any increasing hemoglobin, and at that it would be approximately 0.5 g/dL. The patient advocate made it sound like getting this drug would be tantamount to a blood transfusion. It is not.
When the patient's hemoglobin was not increasing as much as he had hoped for, the patient advocate demanded that I give more Epogen. I am not sure whether this individual understood basic math, but he was not willing to wait the time and figured that more of a drug is always better. Every day when I went to talk to the patient I would have to talk to the patient advocate and also let him know that this was the extent of what we could provide. I think it was appropriate for the patient to have someone to ask questions, but for someone to make demands is a little too much to swallow.
This is just one isolated case, there are many more cases at our hospital where patient advocates have come in the way of patient care. It is almost as if the patient advocates seek to minimize the influence of doctors in patient care by trying to fill the heads of the patient's with artificial hopes and outcomes. It is very unfair to anyone in the medical establishment to have to deal with this added variable of complexity. If patient advocates had some element of training or competency in medical science it would be very easy to deal with them. But the majority of them are simply individuals who enjoy making demands. Patient care should definitely be about patients and doctors, it is time to cut out the middleman!
Saturday, February 2, 2008
Obesity -- part one
Now this might be definitely a long project since there is much to be discussed in terms of obesity. Single-handedly, obesity can raise the costs of health care tremendously over the next 20 years. Why? There are just too many comorbidities associated with being obese.
It all starts with cheap eating, most likely the kind you see at McDonald's and other fast food restaurants across the country. Then you have a lack of exercise, since apparently many people in America do not even want to exercise outdoors and prefer a more sedentary lifestyle. Once you have these two components it tends to feed itself in a vicious cycle that results in the end with an additional 60 or more pounds added to your waistline. Once this happens, you more than likely will have increased your likelihood of developing diabetes. You will also have developed increased atherosclerosis as well as sleep apnea, and it is not isolated to early arthritis or joint pain just from the added stress.
So the simplicity of multiple patient will allow us to see that these problems add up rapidly. First you me to look at diabetes, there is no cure for this disease. Once you develop diabetes it becomes an issue of management most likely for the rest of your life. Management would definitely involve modifying your diet and also introducing exercise in addition to using insulin or other hypoglycemic agents. Medication is not cheap by any means, and one month of insulin or hypoglycemics costs far more than a big Mac meal.
The laundry list for diabetes complications is too long to go into detail. There is a list courtesy of the national Institute of health:
http://diabetes.niddk.nih.gov/complications/index.htm
But I suppose an important comorbidity to discuss is obstructive sleep apnea. Most of what happens with people who are obese is that they have excess weight on the upper airway that results in obstruction. Usually this manifests itself with snoring (although patients never acknowledged that they snore) and and also with people complaining that they wake up abruptly in the middle of the night (usually when the weight compresses enough to obstruct flow once again). Quite often these people should get a sleep study. More information is available here from Wikipedia: http://en.wikipedia.org/wiki/Sleep_apnea.
Another area where sleep apnea can cause significant problems is with surgery. For cases where a patient has to go under general anesthesia, it almost always requires endotracheal intubation and ventilatory support. Putting these people on ventilatory support is problematic from the standpoint of weaning them. More often than not these individuals require longer mechanical ventilation times than ordinary people.
Now although people do not like to bring cost into the equation, you must be able to see that intensive care is much more expensive than having a patient on a regular floor bed. There are many estimates out there for the cost of intensive care, and they range from approximately 3 to 4 times the cost of regular hospital care. Here is an interesting article you can read regarding this topic:
http://www.anesthesia-analgesia.org/cgi/reprint/96/2/311.pdf
Again, does that big MAC with fries look so cheap now? there will be many posts on obesity in the future.
It all starts with cheap eating, most likely the kind you see at McDonald's and other fast food restaurants across the country. Then you have a lack of exercise, since apparently many people in America do not even want to exercise outdoors and prefer a more sedentary lifestyle. Once you have these two components it tends to feed itself in a vicious cycle that results in the end with an additional 60 or more pounds added to your waistline. Once this happens, you more than likely will have increased your likelihood of developing diabetes. You will also have developed increased atherosclerosis as well as sleep apnea, and it is not isolated to early arthritis or joint pain just from the added stress.
So the simplicity of multiple patient will allow us to see that these problems add up rapidly. First you me to look at diabetes, there is no cure for this disease. Once you develop diabetes it becomes an issue of management most likely for the rest of your life. Management would definitely involve modifying your diet and also introducing exercise in addition to using insulin or other hypoglycemic agents. Medication is not cheap by any means, and one month of insulin or hypoglycemics costs far more than a big Mac meal.
The laundry list for diabetes complications is too long to go into detail. There is a list courtesy of the national Institute of health:
http://diabetes.niddk.nih.gov/complications/index.htm
But I suppose an important comorbidity to discuss is obstructive sleep apnea. Most of what happens with people who are obese is that they have excess weight on the upper airway that results in obstruction. Usually this manifests itself with snoring (although patients never acknowledged that they snore) and and also with people complaining that they wake up abruptly in the middle of the night (usually when the weight compresses enough to obstruct flow once again). Quite often these people should get a sleep study. More information is available here from Wikipedia: http://en.wikipedia.org/wiki/Sleep_apnea.
Another area where sleep apnea can cause significant problems is with surgery. For cases where a patient has to go under general anesthesia, it almost always requires endotracheal intubation and ventilatory support. Putting these people on ventilatory support is problematic from the standpoint of weaning them. More often than not these individuals require longer mechanical ventilation times than ordinary people.
Now although people do not like to bring cost into the equation, you must be able to see that intensive care is much more expensive than having a patient on a regular floor bed. There are many estimates out there for the cost of intensive care, and they range from approximately 3 to 4 times the cost of regular hospital care. Here is an interesting article you can read regarding this topic:
http://www.anesthesia-analgesia.org/cgi/reprint/96/2/311.pdf
Again, does that big MAC with fries look so cheap now? there will be many posts on obesity in the future.
Saturday, January 26, 2008
HIV Positive
So apparently there are many patients that come to our hospital who are HIV-positive. Being on the pulmonary consult service this month I have had my share of interacting with patients who are HIV-positive and develop terrifying pneumonia. There apparently is a great deal of misinformation out there regarding the disease. Much of it has to do with the fact that people are still in denial that having unprotected intercourse can put you at great risk. Although statistically male to female transmission has a higher percentage, anybody is really at risk. Would you really put yourself at risk in general if you knew? Other signs that practitioners use to have a suspicion for a patient being HIV-positive is whether or not the patient has had a recurrent pneumonia, whether they are practicing unsafe sex (which nobody ever admits to), whether they are sharing IV needles, and some of the other signs such as unexplained weight loss.
Here are some other signs you can refer to, courtesy of the National Institutes of Health:
http://www.niaid.nih.gov/factsheets/hivinf.htm
One thing we commonly do that the hospital is put the patients and respiratory isolation because we are sometimes unsure about whether or not they may have tuberculosis superimposed. Usually the patients are released from respiratory isolation after ruling out the presence of tuberculosis (by obtaining sputum samples, chest x-ray, PPD, etc.). After confirming the diagnosis (via serology tests including ELISA), the tough aspect becomes dealing with the patient and having to tell them the prognosis for their condition.
I understand that there is always a reason to be optimistic in medicine, but how optimistic can one be without being overly optimistic? In other words, how optimistic can one be without having to put false hopes within the minds of patients? For example, the antiretroviral HAART therapy runs on the order of $20,000 per year or more. Almost all the patients we have coming through our service cannot afford it. We have instances where we will discharge patients with three medications on their list, and they will only be able to obtain one due to costs. This is just for antibiotics, not for antiretroviral therapy. I do realize that there are programs set up with the pharmaceutical companies to provide the medications via an assistance program, but I do not think long-term many of these patients will qualify for treatment for as long as they will need it. This is especially problematic because the age bracket at which people are being diagnosed varies as low as teenagers and infants (born to HIV-positive mothers).
Now getting back to the disease. If the patient does not actively take steps to take treatment to combat the replication of the virus, then there is no stopping progression to full-blown AIDS. In essence, you could say that having the disease is a death sentence since you are continually trying to play catch up to the virus. There are strains of the virus that are becoming resistant to some of medications that we have available today. This is courtesy of the World Health Organization: (http://www.who.int/drugresistance/hivaids/en/).
Rather than put false hopes into the minds of patients here, I decided to be upfront and honest with them and explain that if they are not able to take anti-retroviral medication, and they will likely progress to full-blown AIDS and could develop a catastrophic respiratory infection. I also encourage patients to discuss it with their families, currently there is a great stigma associated with having it. One of my patients became rather combative when I suggested it, but then I responded that the best thing they can do right now is educate others so that they can help prevent the spread of HIV. There is always anger with knowing that you have developed such a disease, and you cannot help but empathize. However, I do not understand why they try to project their anger at the world when in fact this disease is completely preventable. If people did not have such risky habits, then this is one less doctor-patient conversation we would need to have.
Another issue to examine is how would people who contract HIV be affected when you are within a socialized medicine program? Let's be honest, regardless of who wins the presidential election, there is a strong national movement to transform the health care system to accommodate every citizen in this country. With that, you can bet there will be some cost benefit ratio analysis. Would a nationalized medical program support financial payment for antiretroviral therapy that costs on the order of $20,000 per year or more per person when the overall mortality benefit might be marginal?
In closing, I think one of the biggest mistakes for the candidates is not discussing health care plans in detail. Is it absolutely possible to cover every person for virtually every condition without having any kind of reduction in benefits? The only organization that I know that can do everything on a fixed budget is the military, and their active duty population tends to be much healthier than the overall national population. Perhaps some questioner in the audience can address the candidates on this issue so that people will come to the realization that full coverage for everybody will not be the simple solution that they make it out to be in campaign stumps.
Here are some other signs you can refer to, courtesy of the National Institutes of Health:
http://www.niaid.nih.gov/factsheets/hivinf.htm
One thing we commonly do that the hospital is put the patients and respiratory isolation because we are sometimes unsure about whether or not they may have tuberculosis superimposed. Usually the patients are released from respiratory isolation after ruling out the presence of tuberculosis (by obtaining sputum samples, chest x-ray, PPD, etc.). After confirming the diagnosis (via serology tests including ELISA), the tough aspect becomes dealing with the patient and having to tell them the prognosis for their condition.
I understand that there is always a reason to be optimistic in medicine, but how optimistic can one be without being overly optimistic? In other words, how optimistic can one be without having to put false hopes within the minds of patients? For example, the antiretroviral HAART therapy runs on the order of $20,000 per year or more. Almost all the patients we have coming through our service cannot afford it. We have instances where we will discharge patients with three medications on their list, and they will only be able to obtain one due to costs. This is just for antibiotics, not for antiretroviral therapy. I do realize that there are programs set up with the pharmaceutical companies to provide the medications via an assistance program, but I do not think long-term many of these patients will qualify for treatment for as long as they will need it. This is especially problematic because the age bracket at which people are being diagnosed varies as low as teenagers and infants (born to HIV-positive mothers).
Now getting back to the disease. If the patient does not actively take steps to take treatment to combat the replication of the virus, then there is no stopping progression to full-blown AIDS. In essence, you could say that having the disease is a death sentence since you are continually trying to play catch up to the virus. There are strains of the virus that are becoming resistant to some of medications that we have available today. This is courtesy of the World Health Organization: (http://www.who.int/drugresistance/hivaids/en/).
Rather than put false hopes into the minds of patients here, I decided to be upfront and honest with them and explain that if they are not able to take anti-retroviral medication, and they will likely progress to full-blown AIDS and could develop a catastrophic respiratory infection. I also encourage patients to discuss it with their families, currently there is a great stigma associated with having it. One of my patients became rather combative when I suggested it, but then I responded that the best thing they can do right now is educate others so that they can help prevent the spread of HIV. There is always anger with knowing that you have developed such a disease, and you cannot help but empathize. However, I do not understand why they try to project their anger at the world when in fact this disease is completely preventable. If people did not have such risky habits, then this is one less doctor-patient conversation we would need to have.
Another issue to examine is how would people who contract HIV be affected when you are within a socialized medicine program? Let's be honest, regardless of who wins the presidential election, there is a strong national movement to transform the health care system to accommodate every citizen in this country. With that, you can bet there will be some cost benefit ratio analysis. Would a nationalized medical program support financial payment for antiretroviral therapy that costs on the order of $20,000 per year or more per person when the overall mortality benefit might be marginal?
In closing, I think one of the biggest mistakes for the candidates is not discussing health care plans in detail. Is it absolutely possible to cover every person for virtually every condition without having any kind of reduction in benefits? The only organization that I know that can do everything on a fixed budget is the military, and their active duty population tends to be much healthier than the overall national population. Perhaps some questioner in the audience can address the candidates on this issue so that people will come to the realization that full coverage for everybody will not be the simple solution that they make it out to be in campaign stumps.
A new start
So this is my opportunity to start blogging. Apparently I used to make fun of people who did blog but then decided to change my mind. I thought I should be able to collect all of my ideas dealing with residency and problems within the healthcare system and I get to see that aren't readily discussed in the media but are still important to the country. I will likely devote my efforts to blogging about daily issues and raising questions which hopefully someone reading this can use. Feel free to post feedback and let me know what you think. Thank you for stopping by.
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