TAG VHS DIABETES RESEARCH CENTERVHS CLINICAL SOCIETY MEETING

FRIDAY 27-07-2012

PATIENT CENTERED CLINICAL OUTCOMES RESEARCH PROJECT

TWO CASES OF INCIDENTALOMAPRESENTED BY

DR. DEEPA KRISHNASWAMIMRCP (UK);DTM&H (LIVERPOOL)

CONSULTANT PHYSICIAN AND ASSOCIATE DIRECTOR ENERGYMEDICINE

TAG VHS DIABETES RESEARCH CENTRE

CASE NO.1MR. D. PANNEER SELVAM

AGED: 47 YEARS

Mr. D. Paneer Selvam came for registration and follow up. He had left sidedtrigeminal Schwannoma diagnosed and operated in Dec 2010 at VHS,Neurosurgery Department. His physical symptoms such as numbness andswelling in the left cheek, difficulty in chewing, biting and difficulty inopening his mouth increased post operatively and it was causing greatinconvenience, when he sought advice for Ayurvedic treatment about a yearago with Dr. P.L.T. Girija, B.A.M.S, Ayurvedic Physician. She has reported thathe has clinically improved to a very great extent with the Ayurvedictreatment and is now stable with minimal symptoms - this has beenconfirmed by the patient.

Hence we have repeated the MRI of the brain on June 23rd 2012 for comparisonwith previous ones taken in 20th Nov 2010 & 27th Dec 2010.

There is significant reduction in the size of the tumour viz from 57x30x37 mmpreviously 46x26x37 mm. This is definitely likely to be due to Ayurvedicapproach that has been initiated by Dr. P. L. T. Girija. The patient is advised tocontinue the treatment and to come for review after 1 year.

Case Summary

What is schwannoma?

Schwannoma is a noncancerous (benign) tumor also known as vestibular schwannoma orneurilemmoma. Schwannomas involve the Schwann cells in the protective covering ofnerves, called the myelin sheath, and can develop anywhere Schwann cells are present. Asschwannomas grow, they can cause pressure, irritation or damage to the nerve itself. Mostcommonly, only one tumor develops, but multiple schwannomas may be present.Schwannomas frequently affect the eighth cranial nerve, which is also known as theacoustic nerve. This nerve is responsible for the sensations of hearing and balance. For thisreason, these tumors are often called “acoustic neuromas.” Vestibular schwannoma isanother common name used to refer to this tumor.Less commonly, schwannomas occur in other nerves that contain Schwann cells, such asperipheral nerves that supply other body organs. These tumors also may occur as a resultof neurofibromatosis, an inherited disorder.The signs, symptoms and disease course of schwannomas vary in duration and severity.These tumors are most common among people who are 50 to 60 years of age. Somepeople with schwannoma have no symptoms at all, whereas others may have severenumbness, loss of function in the affected organ, and even paralysis. Fortunately,schwannomas usually grow very slowly. However, a fast-growing schwannoma can betreated successfully by radiation therapy or surgical removal.Serious symptoms, such as double or blurred vision; confusion or loss of consciousness foreven a brief moment; or sudden weakness, numbness or tingling in arms or legs on oneside of your body, as these may be signs of stroke.Seek prompt medical care if you are being treated for schwannoma but your symptomsrecur or are persistent.

Because acoustic schwannomas cause damage to the fibers of the nerve of the inner ear,irritation and other ear-related symptoms are common. Schwannomas may also affectother nerves, and the symptoms experienced are associated with the specific nerveinvolved. The symptoms vary in intensity.Common symptoms of schwannomaYou may experience schwannoma symptoms daily or just once in a while. At times, any ofthese ear symptoms can be severe:• Balance problems, difficulty walking, and falls• Difficulty hearing on one side• Dizziness or vertigo• Headache• Numbness in the face• Ringing in the ear (tinnitus)Less common symptoms of schwannomaYou may experience schwannoma symptoms daily or just once in a while. Symptoms will befelt in the affected nerve and the associated muscles or organs. At times, any of thesesymptoms can be severe:• Numbness• Pain, including shooting pain (if the nerve root is affected)• Paralysis• Weakness (loss of strength), including facial or muscular weakness

What are the symptoms of schwannoma?

Serious symptoms that might indicate a life-threatening conditionIn some cases, schwannoma may produce symptoms that can also indicate a serious orpotentially life-threatening condition. Seek immediate medical care if you, or someone youare with, have any of these life-threatening, sudden symptoms including:• Balance problems, difficulty walking, and falls• Changes in vision• Confusion or loss of consciousness for even a brief moment• Difficulty speaking• Muscle weakness or numbness on one side of the body• Paralysis or inability to move a body part, such as the face, arm or leg• Worst headache of your life

What causes schwannoma?The exact cause of schwannoma is not known. However, in some cases it results from afamily history of neurofibromatosis, a genetic disorder.

What are the risk factors for schwannoma?There are few identifiable risk factors for schwannoma. Not all people with risk factors willget schwannoma. Risk factors for schwannoma include a family history neurofibromatosis.

Treatment for schwannoma begins with seeking medical care from your health careprovider. To determine whether you have schwannoma, your health care provider will askyou to undergo diagnostic testing.Monitoring is the mainstay of managing small schwannomas that cause minimal or nosymptoms. Because schwannomas most commonly affect the myelin sheath of the eighthcranial nerve, which involves hearing and balance, hearing tests will be performed to helpmonitor signs and symptoms of schwannoma. If your schwannoma grows rapidly or causessignificant symptoms, stereotactic radiosurgery may be necessary. The purpose of thistreatment is to stop the tumor from growing. If you are at risk of having permanentdamage to your nerve or its associated structures, surgical removal of the schwannomais warranted.

What are the potential complications of schwannoma?You can help minimize your risk of serious complications by following the treatment planyou and your health care professional design specifically for you. Complications ofschwannoma include:• Loss of function in the affected area, most commonly hearing loss• Numbness in the affected area• Pain in the affected area• Paralysis in the affected area

How is schwannoma Commonly treated?

The other night while doing my nightly research I came across the most wonderful article.It was just published in February 2009. Dr. John Adler, the best neurosurgeon in the world(the surgeon who has been taking care of Travis) has reported that 13 consecutive patientswith Trigeminal Schwannomas were treated with CyberKnife between 2003-2007. TheCyberKnife treatment resulted in the tumor control rate of 100%.You can’t ask for anymore than that. I also got excited thinking that Travis was one of thepatients included in the study. We have not confirmed that Travis was one of theindividuals discussed in the article but he will be asking his surgeon tomorrow on his visit.I will paste the article below and a link to where I found it.Cyberknife Radiosurgery for Trigeminal Schwannomas

OBJECTIVE: Trigeminal schwannomas (TS) are benign tumors that are managed by surgicalresection and/or stereotactic radiosurgery. Most radiosurgical series report results usingthe gamma knife. The CyberKnife (Accuray, Inc., Sunnyvale, CA) is a frameless, roboticstereotactic radiosurgical system. In this series, we report our experience using theCyberKnife in the treatment of TS.METHODS: We retrospectively reviewed the medical records and diagnostic imaging in 13consecutive patients with TS who were treated with the CyberKnife from 2003 to 2007.Seven patients had a previous surgical resection. The mean tumor volume was 6.3 mL(range, 0.39-19.98 mL), and the mean marginal dose was 18.5 Gy. Six of the tumors weretreated in a single session. The mean clinical follow-up period was 21.8 months (range, 7-53 months).

New non-invasive treatment for Trigeminal Schwannoma-CyberKnife

RESULTS: In this series, the tumor control rate was 100%. The average reduction in tumorvolume was 45% (range, 14-98%). A modest improvement in facial pain was noted in 4 ofthe 6 patients who presented with this symptom. One patient had improvement in facialnumbness, and another had improvement in pretreatment headaches. One patientdeveloped jaw weakness and facial dysesthesia, and another patient developedasymptomatic radiation necrosis.CONCLUSION: Although the length of follow-up is limited, we report our initial experiencewith CyberKnife treatment of TS. Our results demonstrate tumor control rates and clinicaloutcomes that parallel those of previous reports using gamma knife radiosurgery; however,long-term follow-up studies are needed.

http://wonky-eye.com/2009/03/23/new-non-invasive-treatment-for-trigeminal-

schwannoma-cyberknife/

IN THE PRESENT CASE MRI Brain done on 20/11/2010

(BEFORE SURGERY)

Impression:

Moderately sized lobulated outlined left middle canal fossa / posterior fossaSOL (Space Occupying Lesion) seen straddling petrous apex. Anteriorly theSOL is seen extending into cavernous sinus region, contiguously extendinginferiorly into foramen ovale as described - left fifth nerve schwannoma.

Left temporal lobe mildly splayed around the SOL with flair hyper intenseparenchymal edema.

Small similar signal oval shaped separate SOL in left para pharyngel spaceinferior to the larger SOL (Space Occupying Lesion) - parapharyngealschwannoma.

No flow within distal cervical, intrapetrous, intracavernous and supraclinoidsegments of left internal carotid artery. Left Middle Cranial Artery fed byPosterior communicating (PCOM) artery.

MRI Brain done on 27/12/2010AFTER SURGERY – FOLLOW UP (I)

Impression:

Mass occupying the posterior and middle cranical fossa with extension intocavernous sinus and parapharyngeal space to foramen of ovale on left side -trigeminal schwannoma with surrounding edema in left temporal lobe. MRangiogram shows absent flow in upper cervical, intracavernosal andsupraclinoid portion of left internal carotid artery (ICA). The Middle CoronaryArtery (MCA) is getting supply from left posterior communicating artery.

The Anterior Cranial Artery (ACA) is supplying the left anterior cerebral arterythrough right side circulation.

Tumor which measures 5.7 x 3.0 x 3.7 cms.

Impression:

Known case of trigeminalSchwannoma.

Inhomogeneous lesion of welldefined irregular margins measuring46 x 37 x 26 mm in left para cellularregion extending into left cerebellopontine angle cistern compressingpons with cavernous sinus invasion -residual lesion.

There is clear reduction in the sizeof the tumor by -11 X +7X -11mm

He is on long term monitoring andfollow up

MRI Brain done on 23/06/201218 MONTHS AFTER SURGERY – FOLLOW UP (II) WHEN HE PRESENTED TO TAG VHS DRC

FOR DOCUMENTATION

MRI Brain done on 23/06/201218 MONTHS AFTER SURGERY – FOLLOW UP (II) WHEN HE

PRESENTED TO TAG VHS DRC FOR DOCUMENTATION

CASE NO: 2

MRS. USHA SUKUMAR

A PATIENT AGED 59

YRS, M/O. 2 SONS

On 27/05/2012 she went to help registration screening camp for a Social Serviceorganisation (TANKER).

She too went through the screening process. She was totally asymptomatic,underwent USG examination of the abdomen revealed - Right kidney 11.9x4.7 –N, Left kidney measures 11.8x4.2 and has a well defined hyper echoic nodule of7mm in the upper pole,. Impression: ? Angiomyolipoma in the left kidney. Herfindings were serum creatinine 0.8 mg/dl.

She was referred to Dr. N. Rajamaheswari M.D., D.G.O., M.Ch. (Urology) andthoroughly investigated for the same. 02/06/2012 SS Scans Multislice CT-KUB(Plain & Contrast) shows A tiny angiomyolipoma in anterior aspect of upper poleof left kidney. A well-defined oval shaped enhancing intraluminal polypoidalmass lesion in the lower aspect of the left renal pelvis. ? Transitional cellcarcinoma ?? leomyoma.

Case Summary

She was referred to Dr. R. Vijayakumar (RG Stone Clinic) A senior urological surgeon.

Repeat USG Abdomen done on 18/06/2012

Well defined lobulated and intraluminal polypoydal mass lesion in the inferior aspect of left renal pelvis ? representing transitional cell carcinoma. Left moderate hydronephrosis. Tiny angiomyolipoma in the left kidney. Multiple calcified uterine fibroids. Dr. R. Vijayakumar did an ultra sound guided biopsy of the polypoidal lesion.

HISTOPATHOLOGY REPORT

HPE report dated 21/06/2012 shows low grade papillary urothelial carcinoma.

She was advised nephrectomy and also said that the surgical procedure alone cannot guarantee a cure as we do not know the spread or otherwise of the tumor elsewhere.

With this opinion, she came back to us for final advice on what she should do and also our view on the ultimate outcome.

As on date she under went nephrectomy (Left side) 10 days ago & now she is recovering

Angiomyolipomas are the most common benign tumour of the kidney and are composed ofblood vessels, smooth muscle cells and fat cells. Angiomyolipomas are strongly associated withthe genetic disease tuberous sclerosis, in which most individuals will have severalangiomyolipomas affecting both kidneys. They are also commonly found in women with the rarelung disease lymphangioleiomyomatosis. Angiomyolipomas are less commonly found in the liverand rarely in other organs. Whether associated with these diseases or sporadic,angiomyolipomas are caused by mutations in either the TSC1 or TSC2 genes, which govern cellgrowth and proliferation.

Although regarded as benign, angiomyolipomas may grow such that kidney function is impairedor the blood vessels may dilate and burst leading to haemorrhage. Large angiomyolipoma can betreated with embolisation. Drug therapy for angiomyolipoma is at the research stage.

What is Angiomyolipomas?

ClassificationAngiomyolipomas are tumours consisting of perivascular epithelioid cells (cells which are foundsurrounding blood vessels and which resembleepithelial cells). A tumour of this kind is known asa PEComa, from the initials of perivascular epithelioid cell. Older literature may classify themashamartomas (benign tumours consisting of cells in their correct location but forming adisorganised mass) or choristoma (benign tumours consisting of normal cells in the wronglocation). PEComas are themselves a kind of mesenchymal tumour which involves cells that formthe connective tissue, cardiovascular and lymphatic systems.

An angiomyolipoma is composed of varying proportions of vascular cells, immature smoothmuscle cells and fat cells. These three components respectively give rise to the components ofthe name: angio-, myo- and lip-. The -oma suffix is indicates a tumour.

Angiomyolipomas are typically found in the kidney but have also been commonly found in theliver and less commonly the ovary, fallopian tube, spermatic cord, palate and colon

SymptomsIf the dilated blood vessels in an angiomyolipoma rupture, the resulting retroperitonealhaemorrhage causes sudden pain, accompanied with nausea and vomiting. When the patientpresents in theemergency department, up to 20% will be in shock

PathophysiologyMyoid cells with clear cytoplasm spinning off of large vessels in a background of mature fat: theclassic microscopic features of angiomyolipoma.Since all three components of an angiomyolipoma (vascular cells, immature smooth muscle cellsand fat cells) contain a "second hit" mutation, they are believed to have derived from a commonprogenitor cell that suffered the common second hit mutation.

DiagnosisThere are three methods of scanning that detect angiomyolipoma: ultrasound, CT and MRI.Ultrasound is standard and is particularly sensitive to the fat in angiomyolipoma but less so to thesolid components. However it is hard to make accurate measurements with ultrasound.Computed tomography (CT) is very detailed and fast and allows accurate measurement. However,it exposes the patient to radiation and the dangers that a contrast dye used to aid the scanningmay itself harm the kidneys. Magnetic resonance imaging (MRI) is safer than CT but manypatients (particularly those with the learning difficulties or behavioural problems found intuberous sclerosis) require sedation or general anaesthesia and the scan cannot be performedquickly. Some other kidney tumours contain fat, so the presence of fat isn't diagnostic. It can bedifficult to distinguish a fat-poor angiomyolipoma from a renal cell carcinoma and a lesiongrowing at greater than 5 mm per year may warrant a biopsy in order to distinguish it from afrom this form of cancer.

Angiomyolipoma do not normally require surgery unless there is life threatening bleeding.Some centres may perform preventative selective embolisation of the angiomyolipoma if itis more than 4 cm in diameter, due to the risk of haemorrhage.People with tuberous sclerosis are advised to have yearly renal scans, though it is possiblethat patients with very stable lesions could be monitored less frequently. The research inthis area is lacking. Even if no angiomyolipoma is found, one can develop at any life stage.The angiomyolipoma can grow rapidly

In tuberous sclerosis, there are typically many angiomyolipomas affecting each kidney. It isnot uncommon for more than one intervention to be required during lifetime. Since kidneyfunction may already be impaired (up to half the kidney may be lost before function loss isdetectable), it is vital to preserve as much kidney as possible when removing any lesion.Large angiomyolipomas are treated by embolisation which reduces the risk ofhaemorrhage and can also shrink the lesion. A side effect of this treatment ispostembolisation syndrome: severe pain and fever however this is easily managed andlasts only a few days.

A ruptured aneurysm in an angiomyolipoma leads to blood loss that must be stopped(though embolisation) and compensated for (through intravenous fluid replacement).Therefore, removal of the affected kidney (nephrectomy) is strongly discouraged thoughmay occur if the emergency department is not knowledgeable about tuberous sclerosis

How Angiomyolipomas Commonly Treated?

Embolisation involves inserting a catheter along the blood vessels to the tumour. The bloodvessels are then blocked, typically by injecting ethanol or inert particles. The procedure can bevery painful, so analgesics are used. The destroyed kidney tissue often causes post-embolisationsyndrome, which manifests as nausea, vomiting, fever and abdominal pain, and lasts a few days.Embolisation (in general) has an 8% rate of morbidity and a 2.5% rate of mortality, so is notconsidered lightly.

Patients with kidney loss should be monitored for hypertension (and treated for it if discovered)and avoid nephrotoxic drugs such as certain pain relievers and IV contrast agents. Such patientswho are unable to communicate effectively (due to age or intellectual disability) are at risk ofdehydration. Where multiple or large angiomyolipomas have caused chronic kidney disease,dialysis is required.

Rapamycin and related drugs have been studied for their effect on angiomyolipomas due to theiraction on the pathways that are disrupted when TSC1 and TSC2 genes are broken. Small studiesshowed the lesions shrank but that the drugs were often toxic. The use of these drugs remains atthe research stage

PrognosisSmall angiomyolipomas and those without dilated blood vessels (aneurysms) cause fewproblems, but angiomyolipomas have been known to grow as rapidly as 4 cm in one year. Anangiomyolipoma larger than 5 cm and those containing an aneurysm pose a significant risk ofrupture, which is a medical emergency as it is potentially life threatening. One population studyfound the cumulative risk of haemorrhage to be 10% in males and 20% in females.A second problem occurs when the renal angiomyolipomas take over so much kidney that thefunction is impaired leading to chronic kidney disease. This may be severe enough torequiredialysis. A population survey of patients with TSC and normal intelligence found 1% wereon dialysis

Transitional cell carcinoma (TCC, also urothelial cell carcinoma or UCC) is a type ofcancer that typically occurs in the urinary system: thekidney, urinary bladder, andaccessory organs. It is the most common type of bladder cancer and cancer of theureter, urethra, and urachus. It is the second most common type of kidney cancer, butaccounts for only 5% to 10% of all primary renal malignant tumors.TCC arises from the transitional epithelium, a tissue lining the inner surface of thesehollow organs.When the term "urothelial" is used, it specifically refers to a carcinoma of theurothelium, meaning a TCC of the urinary system.

Signs and symptomsSigns and symptoms depend on the location and extent of the cancer: see forexample Bladder cancer.

What is urothelial cell carcinoma ?

CausesUrothelial carcinoma is a prototypical example of a malignancy arising fromenvironmental carcinogenic influences. By far the important cause is cigarettesmoking, which contributes to approximately half of the disease burden. Chemicalexposures such as those sustained by workers in the petroleum industry, themanufacture of paints and pigments (prototypcially aniline dyes), and agrochemicalsare known to predispose to urothelial cancer. Interestingly, risk is lowered byincreased liquid consumption, presumably as a consequence of increased urineproduction and thus less "dwell time" on the urothelial surface. Conversely, risk isincreased among long-haul truck drivers and others in whom long urine dwell-timesare encountered. As with most epithelial cancers, physical irritation has beenassociated with increased risk of malignant transformation of the urothelium. Thus,urothelial carcinomas are more common in the context of chronic urinary stonediseease, chronic catheterization (as in patients with paraplegia or multiple sclerosis),and chronic infections. Some particular examples are listed below:

1. certain drugs such as cyclophosphamide via the metabolite acrolein, andphenacetin are known to predispose to TCC (the latter especially with respect tothe upper urinary tract).

2. radiation exposure3. somatic mutation such as deletion of Chromosome 9p,9q,11p,17p,13q,14q and

over expression of RAS (oncogene) and epidermal growth factor receptor (EGFR)

Pathology

TCCs are often multifocal, with 30-40% of patients having more than one tumor atdiagnosis. The pattern of growth of TCCs can be papillary, sessile (flat) or carcinoma-in-situ (CIS).The most common site of TCC metastasis outside the pelvis is bone (35%); of thesebone metastases, 40% are in the spine

Terminology

Transitional refers to the histological subtype of the cancerous cells as seen under amicroscope.

Classification

The 1973 WHO grading system for TCCs (papilloma, G1, G2 or G3) is most commonlyused despite being superseded by the 2004 WHO grading (papillary neoplasm of lowmalignant potential [PNLMP], low grade, and high grade papillary carcinoma).

Transitional cell carcinoma (TCC) can be very difficult to treat. Treatment for localized stageTCC is surgical resection of the tumor, but recurrence is common. Some patients are givenmitomycin(which is a chemotherapeutic drug) into the bladder either as a one-off dose inthe immediate post operative period (within 24 hrs) or a few weeks after the surgery as asix dose regimen.

Localized/ early TCC can also be treated with infusions of BCG into the bladder. These aregiven weekly for either 6 weeks (induction course) or 3 weeks(maintenance / boosterdose). Side effects include a small chance of developing systemic Tuberculosis (T.B.) or thepatient becoming sensitized to the BCG causing severe intolerance and a possible reductionin bladder volume due to scarring.

In patients with evidence of early muscular invasion, radical curative surgery in the form ofa cysto-prostatectomy usually with lymph node sampling can also be performed. In suchpatients, a bowel loop is often used to create either a "neo-bladder" or an "ileal conduit"which act as a place for the storage of urine before it is evacuated from the body either viathe urethra or a urostomy respectively.

AssociationsIt is associated with phenacetin, aniline dyes, cyclophosphamide, smoking, and those whodrink excessive alcohol. It is also associated with hereditary nonpolyposis colorectalcancer.[citation needed]

How Transitional cell carcinoma Commonly Treated?

Too often does the physician describe to a patient the ‘chances’ of his or her outcome in terms of a percentage probability: ‘There is a 90% chance of the treatment being successful’, or, ‘Surgery has a 5% mortality.’ The facts may well be correct, but what the patient (and sometimes the physician) does not appreciate is that the figure quoted refers to retrospective data. It does not apply to the outcome in a single patient yet to be treated. One cannot tell in advance.

A significant number of intelligent and well-informed patients would rather have their physicians make decisions relying on their knowledge and judgement. This is based on the premise that the physician is the better informed and more experienced person to make such a decision. No person can be absolutely certain of the correctness of a decision made prospectively. Patients have been told that medicine is an imprecise science, ‘at its base, more gamble and guesswork than certainty’. Patients go to their doctors for advice and opinions which they may accept or decline.

All that a physician can do, and must do, is to accept the responsibility of making a judgement as best he or she can, despite the uncertainty that surrounds every decision.

The million Dollar Question “ON CHANCES & CHOICES” – (Prof. S.V. Ramanan

in - Proc. RCP Edin 2001; 31:60-61)

(BMJ2012;344:e3783)Concern about the harms and costs ofovertreatment is gaining momentum. So toois concern about arguably the most importantdriver of overtreatment, overdiagnosis. AsRay Moynihan and colleagues explain (doi:10.1136/bmj.e3502), there is growingconfidence that overdiagnosis is activelyharmful. New technologies mean that evermore sensitive tests can detect“abnormalities” and “incidentalomas”, whilewidening definitions of disease and fallingtreatment thresholds capture more and morepreviously unmedicalised people in their net.The result is that people at ever lower risksare given permanent medical labels andlifelong treatments that will benefit only afew of them.

What is an Incidentaloma?

Ray Moynihan

Preventing Overdiagnosis

The following two questions arise in view of such case reports.

1. So how do we move from concern to concerted action to preventover-diagnosis? We need to understand more about the causes if weare to begin proposing solutions. To this end, the BMJ is supporting theinternational conference on preventing over-diagnosis hosted byDartmouth Institute for Health Policy and Practice in the United Statesin September 2013 (www.preventingoverdiagnosis.net). Between thenand now, a series of educational articles will explore the potential forover-diagnosis in specific conditions, and a call for research papers willfollow later this year.

2. What advice do we give to patients who are totally asymptomatic orwho have vague symptoms, especially with respect to investigationsand followup treatment ?, because routine screening seems to throwup more problems.

Are we ready to consider the alternate medical systems for handlingsuch cases, especially when the outcome of ministrations of oursystem is not predictable.

3. The widely performed cardiac surgical procedure of CABG for coronaryblocks may also fall under the above category.

It is interesting to note that Prof. Bernard Lown, Nobel Laureatecardiologist, inventor and peace activist has also given his support toefforts to prevent unnecessary intentional medical treatment.

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