Posts Tagged ‘autism puzzle’

Observations on Autism Therapies

Sunday, July 17th, 2016

The purpose of biomedical treatment is better health, so that the patient can achieve the goals set by the other professionals. The bedrock of autism recovery lies in the traditional therapies, including Applied Behavioral Analysis, Speech and Language, Physical and Occupational interventions.

At The Child Development Center, we have watched thousands of children who undergo a myriad of treatments, and spoken to the parents who part with their valuable resources of money and time. These are some observations that may help other professionals achieve their goals in a more effective manner.

“Just ignore those negative behaviors.” It depends on the specifics. Sure, an annoying stim or persistent request may diminish over time. But, try overlooking a child who has gotten out of the car seat and is pulling Mom’s hair. Also, advice delivered by providers who only spend 45 minutes is not the same thing as living with a problem  24/7. The child needs to be admonished, placed at arm’s length, admonished, and repeat until they get it. Biting, pinching, punching is never cute or harmless, and must be extinguished at the earliest age.

“Try to reduce the echolalia or scripting.” Let’s get this straight – you’ve been telling the kid to speak for 2 (or more) years, and now your telling them not to speak? That’s too confusing. Scripting is only possible because the intelligent child CAN memorize long paragraphs.
Also, if age appropriate expressive language is supposed to contain, say, 1000 phrases, and the recovering child only has 300, they will probably repeat the same phrase 3 or more times just to take up the space. The content doesn’t really need to make sense.

It’s SPEECH therapy, mostly, not Speech and Language. I have yet to meet a child who is really confused by multiple languages. Spanglish is fine. It’s all communication.”I think that he has speech apraxia.” Or, “I don’t think he has speech apraxia.” Or, “I don’t think that he’s really autistic.” If a person wants to speak but can’t, it’s speech apraxia. If they also exhibit repetitive behaviors and social isolation, it’s ASD.

“He’s falling behind in academics.” Consider the developmental stage. Is the child talking, talking to his toys, taking to other children, playing with other kids? They probably know their letters, numbers, and colors, anyway. However, socialization is paramount.

“She needs more focus and attention, with less hyperactivity and distractibility.” The behavior is mostly due to immaturity. Patience and persistence pays. Watch it… someone is going to want to prescribe stimulant drugs. Administering potent medications to a toddler rarely produces the desired effect.

“He’s anxious.” Given that a child has difficulty connecting, that would be an appropriate response. As they improve, children will observe others at play so that they learn the correct responses. Watch it… someone is going to give antipsychotic drugs. Administering potent medications to a toddler rarely produces the desired effect.

“I can’t help this child… he’s too affected.”
Doesn’t that mean, “You need to hire a better therapist?

Sometimes, setting goals, such as, “The child will put the correct shape into the cup 3 out of 5 times,” is appropriate. Others, such as not wandering, joining circle-time, or answering to their name, should be 100%, if the child is to succeed in a neurotypical classroom.

“Mom or Dad is not doing the right thing.” The parent is not the therapist, so part of a professional’s job is to devise a solution, not criticize.

Autism recovery is molded by hard-working, highly trained professional therapists. The newly emerging epidemic of ASD has created the need to re-think solutions.

Ultimately, we are all trying to achieve the same goals of getting children on the right path.

Acetaminophen And Autism

Sunday, July 10th, 2016
tylenol9

A Tylenol® by any other name; including Xumadol, Paracetamol, Tirol, Calpol, Panadol, etc, etc.

Evidence supporting an another pharmaceutical connection to autism was recently presented in a study entitled, Acetaminophen use in pregnancy and neurodevelopment: attention function and autism spectrum symptoms, which appeared in The International Journal of Epidemiology.

Given our current state of ignorance, support, rejection, and often, polarizing opinions have already surfaced.

The Present Study
The authors concluded, “Prenatal acetaminophen exposure was associated with a greater number of autism spectrum symptoms in males and showed adverse effects on attention-related outcomes for both genders…”

Recent Supporting Evidence
2014: Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders
Conclusion – “Maternal acetaminophen use during pregnancy is associated with a higher risk for HKDs and ADHD-like behaviors in children.”

2014: Associations between Acetaminophen Use during Pregnancy and ADHD Symptoms Measured at Ages 7 and 11 Years
Conclusion – These findings strengthen the contention that acetaminophen exposure in pregnancy increases the risk of ADHD-like behaviors.

2013: Prenatal paracetamol exposure and child neurodevelopment: a sibling-controlled cohort
Conclusion – “Children exposed to long-term use of paracetamol during pregnancy had substantially adverse developmental outcomes at 3 years of age.”

Opposing Opinions
2016: Use of acetaminophen (paracetamol) during pregnancy and the risk of autism spectrum disorder in the offspring.
Summary – “… the empirical data are very limited, but whatever empirical data exist do not support the suggestion that the use of acetaminophen during pregnancy increases the risk of autism in the offspring.”

Dr. James Cusack, research director of Autistica, “…insisted there was “not sufficient evidence” to back the suggestion. “The results presented are preliminary in their nature, and so should not concern families or pregnant women.”

The ‘experts’ say, “Don’t even worry about those studies”
claiming a relationship between Autism and Acetaminophen.
Really?
Where is the proof that it’s SAFE?

Discussion
First available in US in the 1950s, Tylenol Elixir for children became even more popular 30 years later when aspirin was reported as a contributing factor to an often fatal Liver – CNS disorder (Reye’s Syndrome). Interestingly, the authors of a 2007 literature review wrote, “The suggestion of a defined cause-effect relationship between aspirin intake and Reye syndrome in children is not supported by sufficient facts.”

Throughout the globe, there are over 100 names for acetaminophen. Plus, it is an ingredient in hundreds of other over-the-counter remedies. It is widespread and readily available. The increased use of this chemical tracks with the explosion of autism into the 21st century.

The medication can cause liver problems and freely crosses the placenta. There are studies that link pretreatment with Tylenol to address fever associated with childhood inoculations, and an increased risk of ASD. Furthermore, the mechanism of action includes the creation of oxidative stress, which is thought to play a significant role in autism.

Conclusion
What about occasional use? The present research concluded, “These associations seem to be dependent on the frequency of exposure.” However, until further investigations are performed, there could be specific times in pregnancy that are more sensitive than others, regardless of the dose.

A single, relatively uncomplicated question – whether there is an association between Tylenol and ASD – needs to be answered. This is but one example of why numerous other substances in our poisoned environment are so difficult to pin down. And, forget about combinations of substances. Why is the establishment so quick to point out the weakness of the present research, and declare that, “Everything is fine?”

Until more information is collected, conservative advice is warranted. Acetaminophen usage in pregnancy should be placed high on the ‘This Deserves Further Study’ list of important autism associations.

July 4th with Developmentally Challenged Children

Friday, July 1st, 2016

July4While the rest of the country eagerly awaits an exciting and fun-filled day, there are some families who will wonder how to get through the celebration. Here are the top 10 reasons why this can be so challenging.

July4 littleThe trip to see the fireworks may present the first hurdle. The closer the venue is to home, the better. There will be less echolalia, as in “Get there?Get there?” And, if you need to return early, it’s a shorter journey.

July4 little otherProblems at The Beach, The Lake, The Mountain, etc. Dangers abound. Children with sensory issues do not necessarily perceive the experience as pleasurable; and families may be hard pressed to convince a reluctant child otherwise.

July4 littleSleep. Even if you can somehow avoid the hoopla, the neighborhood is awash in sights and sounds that can keep everybody going well into the night.

July4 little otherDangerous smoke bombs, sparklers, and other explosive devices. Parents need to remain constantly vigilant, lest their affected child jumps in to join in the ‘fun’.

July4 littleCrowds. Relatives, friends, neighbors, and strangers are present in sometimes overwhelming numbers. Then, there are pets, clowns, and other terrifying distractions.

July4 little otherParades. Waiting in line and jockeying to improve visibility of revelry that the children may not understand – or even look at – sometimes seems pointless and counterproductive.

July4 littleThe heat, mosquitoes, and outdoor environment can create more than the expected amount of whining, complaints, and rashes.

July4 little otherOff schedule activities. Often, children get used to any type of routine – even in the summertime. This becomes another day to explain why “We can’t do… this or that.”

July4 littleThe food. Many parents have to choose between enforcing a restricted diet, or letting a child ‘cheat’, perhaps leading to aggressive behaviors in the ensuing hours and days.

July4 little otherThe Fireworks! Really loud noises and flashing lights that may terrify even neurotypical youngsters. Not fun for all.

Our national holiday is supposed to be a joyous family affair, and is often remembered fondly. Parents hope to pass the experience on to the next generation. In certain circumstances, the atypical child presents novel tribulations – including more than a few that couldn’t have even been imagined.

A Better Approach to Autism and ADHD

Sunday, June 26th, 2016

When faced with the diagnosis of autism or moderate-to-severe attention deficit/hyperactivity disorder, parents have limited choices. Some may be financially out-of-reach, others could be unproven or even risky. It appears that the available options fall into these categories:

question-mark littleNot to treat
Honestly, when the major concern is ADHD in very young patients, this could be the best alternative. Children may simply need time to gain skills, such as self-control and socialization, that come with maturity. Furthermore, if gains can be achieved by holding the child back a grade, or ‘settling’ for a non-gifted classroom, medical intervention may be overkill.

However, if behavior includes repetitive movements and restricted interests, speech delay or social isolation, the sooner that intervention is begun, the better – with or without a formal diagnosis.

The traditional disciplines, including Occupational, Physical, Speech, and Behavioral Therapies, are the proven place to start.

On the medical front, two major approaches have emerged. The protocols are pictured in the diagram below.

Bomb©theautismdoctor

arrow small downTraditional approach – Top Down
Conventional medical treatment involves dropping a pharmaceutical bomb, to see who ‘gets better’ when the dust settles. Parents should be particularly concerned when the neurologist or psychiatrist prescribes potent central nervous system drugs for youngsters under the age of 5.

“What is the specific diagnosis? Has an adequate workup been performed? What are the risks? Won’t these drugs affect my developing toddler’s brain? How long will my child have to take this stuff?” are all valid questions. And, if the medication is unsuccessful, there’s frequently a switch to another one, in no particular scientifically justifiable order.

When the right drug is given to the right patient, it is truly a wonderful thing. However, the success rate, especially with the initial choice, is low. The risks include alterations in sleep, linear growth, appetite and weight change, and increasing negative behaviors. None claim to induce speech, sociability or maturity.

arrow small upModern approach – Bottom up
The biomedical perspective addresses the multiple individual signs and symptoms that affect people on the spectrum. After a thorough history and physical examination, laboratory evaluation of the patient helps identify specific areas that need medical attention.  Then, the safest interventions that are most likely to address aggression, low tone or ‘fog’ are chosen. Often, that may involve improving gastro-intestinal health or nutritional deficiencies.

Enabling mechanisms that unlock a human’s (?) innate ability to speak becomes paramount. Understanding the response to treatment that is displayed by certain behaviors; including aggression, focus, attention, and sleep are tricky, (?) necessary, (?side-) effects of the treatment regime itself.

Discussion
It takes more of the supplements at the bottom of the diagram to achieve apparent symptomatic relief than those dropped from above. Probiotics are ingested to improve the micro-biome and bowel function, proteins enhance mitochondrial efficiency to enable better motor (and oral-motor) functioning, and dietary changes lift the veil. About such a protocol, parents often say, “They got things started.”

As prescriptions ascend toward nuclear intervention, the risks and side effects become more serious, while the improvements are only as observable as the objective of desired behaviors. So, if compliance is the goal, but fails to assist with speech, the parent may be missing a key developmental opportunity.

Conclusion
New parents are forced to make so many critical decisions. Among the bravest are those who seek answers for the tidal wave of Spectrum youngsters. Often, they believe that there is nowhere to turn.

That has forced an increasing number of families to become more knowledgeable than their doctor about autism. This diagram can be helpful for families and health care professionals as they formulate decisions for children with developmental diagnoses.

Happy Fathers Day – An Autism Perspective

Sunday, June 19th, 2016

Dear Dad,

I don’t speak much (or at all), so you might not hear me say how much I appreciate all that you do. Fathers and kids are supposed to be outside and playing together on a day as special as this. I can do that! Maybe I’m not playing catch or kicking the soccer ball, but I’m having a good time.

I might not show as much love or affection as other children, so you may not see me trying to get your attention and praise. But, some of my stims are doing exactly that – getting your attention. I know that you are trying to figure me out, so thanks for being patient.

I sense things in a different way from others so the foods that everyone eats at this time may not be OK for me to eat. Even if they were, that Dr. Udell has taken away all of the good stuff! Someday I hope to tell you that I know how difficult it is to prepare a GF/CF barbecue.

Lots of people can be a problem for me, so ball games or crowded parks are not my favorite place. Thanks for understanding my issues, and taking us to the beach or just playing by the house so I won’t have a meltdown.

I don’t make friends very well and neighbors or even relatives increase my anxiety, so there won’t be a busy household on your special day. Thanks for keeping me safe and helping me work things out at my own pace.

Everyone is fussing around you today, so I know that they think that you are special, too. Somewhere, inside, I am just like every other kid who loves their Dad, even if I’m not sure what day it is.

Love you, Dad,
Your sons and daughters

Thanks to all the Dads of autistic children for your endurance and support.

Happy Father’s Day

Sincerely,
Brian D. Udell MD

 

The Importance of Genetic Testing for Autism

Sunday, June 5th, 2016

Although ASD patients share common signs, such as speech apraxia, repetitive behaviors, and social isolation, the wide range of differences in their personalities and abilities demands exploration, as well. The answers will require a better understanding of our genes, which are the most basic building blocks of structure, function, and subsequent behaviors.

Copy Number Variation (CNV)
It’s 2016. The human genome has been mapped, and is even available online. During fetal early infant development, as cells divide and grow, tiny pieces of a chromosome may be missing, duplicated, inverted or transposed.

Genes exist on chromosomes, so variations in the ‘normal’ pattern, could certainly explain alterations in development. Abnormalities help identify susceptible individuals in our toxic environment.

A ‘chromosomal microarray’ test has frequently been part of the work-up for autism, as doctors searched for ‘Fragile X’ syndrome, which had been believed to be the most common genetic cause. That is old-fashioned thinking, and problems with the other 45 chromosomes are ubiquitous. If your child has had this ‘lab’ in the past, have it reviewed by a competent, modern genetic expert. If the child hasn’t had one, it is the best initial evaluation, and much more likely to yield useful information than an MRI or EEG.

GeneGene Testing
This represents an analysis of sections on chromosomes that code for specific products. There now exists the technology to identify many possible gene candidates for autism, with more appearing every year. Results serve as state-of-the-art information to identify certain patients who have significant deviations from typical development.

This examination can be particularly important with the 20% – to – 60+% of cases of ASD associated with some type of convulsion. Patients are often diagnosed with idiopathic epilepsy, which is merely doctor-speak for seizures of unknown origin.

The high cost of such laboratory examinations precludes routine use. However, companies are aware of such limitations, and seem to do a good job of assisting families overcome this obstacle, especially in those patients who demonstrate extreme problems.

MTHFRSingle Nucleotide Polymorphisms (SNPs or ‘snips’)
At an even more granular level are regional changes within genes. Such chemical variations are common in the population and can explain individual differences. Even a single alteration in the composition of DNA may explain why one person is able to detoxify while another is not. It even becomes more complicated as we examine how changes in one area affect expression in another region.

A common example in autism is the variation that occurs in the MTHFR genes that code for the enzyme that activates folic acid (to tetra-hydro-methyl-folate). This is one of the few useful ASD findings from the popular test, 23&me.

Discussion – What good is this information?
Even today, results can detect situations in which potential treatments and avoidance of unnecessary pursuits are elucidated. The polarizing questions of whether/when/who/which vaccinations could effect the incidence of autism might even be more clearly understood, from this point of view.

The additional knowledge from such testing yields more information about future development, including risks of other conditions, such as thyroid, heart disease or cancer.

In extreme cases, the information may help guide decisions about future offspring or screening of other family members.

Importantly, the lack of a measurable abnormality may motivate a family to attempt conventional and alternative treatments with even more vigor.

Conclusions
We cannot let the insurance companies slide on this one. They are the ones who stand to save the most; although at present they see no tangible reduction, because they aren’t adequately paying for necessary services in the first place.

Rather than give up hope, such additional information should provide even more incentive to explore treatment for ASD patients.

Our better understanding will lead to more targeted and therefore effective protocols for this modern epidemic.

Folate Issues and Autism

Monday, May 30th, 2016
popeye

Highest level in food is spinach, but multivitamins and Ready-to-Eat cereals represent greatest intake.

Recent media attention regarding an association between supplemental folate (= folic acid) and the incidence of ASD has stimulated a fair amount of interest, with questions by patients, professionals, and acquaintances.

Findings presented this month by Johns Hopkins’ researchers showed that high levels of the vitamin increased the risk of autism, as did an excess of B12; and the combination increased the chances even more.

Folate
Highly processed foods are stripped of many nutrients, including folate. Additionally, antacid preparations decrease the absorption of many B vitamins.

Folate needs to be supplied in our diet to make and repair DNA, in order to promote cell division and growth, and to produce healthy red blood cells and prevent anemia. Symptoms of folate deficiency include weakness, nerve damage, confusion, cognitive deficits, headaches, mental depression, sore or swollen tongue, peptic or mouth ulcers, heart palpitations, irritability, and behavioral disorders.

First reported in the 1990’s, women who took daily supplementation around the time of conception and throughout pregnancy with a small amount (< 1/2 mg.) of folate experienced a decreased rate of central nervous system birth defects and developmental problems (review), including ASD .

Additional issues
Over 10 years ago, low folate levels in the cerebrospinal fluid were reported as a cause of autism, and there was a positive response to treatment with the active form of the vitamin.
Shortly thereafter, a proposed mechanism and discovery of antibodies against folic acid, especially in the CNS, were similarly implicated as a cause of developmental delay.
Plus, genetic alterations in the pathway leading to the active form of folate have been associated with an increased incidence of autism, as well.

Conclusion
Clearly, the addition of folate has been a major factor in decreasing the incidence of severe birth defects, such as spina bifida (opening in the spine), meningomyelocele (protruding sac), and hydrocephalus (water on the brain).

This latest study raises questions regarding ‘too much of a good thing’. Considering that ASD has reached epidemic numbers, it is time for doctors to begin screening women for folate and B12 levels, before and during pregnancy.

Kids on the Calendar Year Cusp

Sunday, May 22nd, 2016

May is a key month for parents, administrators, teachers, pediatricians, and therapists to confer about whether Junior should start in PreK, or move on to Kindergarten. Which child should repeat 1st grade? Is the youngster ready for VPK? How about Middle school? What about those children whose birthdays fall between the cracks?

Having watched infants grow up for the past forty years, observing thousands of children who have developmental challenges, and  been part of raising two successful offspring of my own, I have formulated some questions that parents can use to assess school readiness.

As you consider the answers to these questions, you may see a pattern that helps you lean one way or the other to make the most successful choice.

  1. Maturity. I’m not talking about academics or IQ. Does your child play with other children of the same age appropriately? When a stranger enters the room, is the toddler likely to cry or run away? Can you leave the room without a meltdown?
  2. Compliance. Some youngsters at The Child Development Center have an incredible memory, are able to assemble complicated puzzles, and enjoy providing details about dinosaurs, or trains, for example. However, when the adult says, “Everyone in circle time,” they resist. The child who requires multiple prompts will do better with a reduced need for such a requirement; learn in a appropriate classroom setting with younger kids or a smaller teacher/student ratio.
  3. Self-control. As toddlers progress, tantrums should become less frequent, last for shorter periods, not include violence (against self or others), and become less dramatic. Parents often display some denial about this issue. “The teacher made him do this,” or, “Another kid took his favorite toy.” It’s the child response to that behavior that should be considered in order to guide the family to the appropriate setting.
  4. Abilities. I ofter hear the comment, “I know he can do <some given task> if you wants to!” The ability to perform, and the resulting behaviors – even when a task is non-preferred – is paramount. Ask yourself if the gross and fine motor skills that are expected in the next grade are appropriate to your child’s abilities. Then, choose the grade, school, setting, and available resources to get the child up to speed. Their ability to succeed has a great deal to do with future self esteem.
  5. Listen to the professionals who evaluate your child, but be aware of each one’s priorities. Administrators desire a smooth semester, teachers want children who listen, therapists often like to predict level of appropriate function. Parents know their children’s capabilities the best.
  6. Child’s size and sex. The smaller child who has all of the above capabilities will usually find a way to fit in. Indeed, the other students usually include, and even protect. But a child who is too large for a given grade may become a bully, or even be bullied, if they are not able to keep up. Plus, no doubt about it, girls are more advanced than boys.

Conclusion
This advice not only pertains to decisions concerning those who are developmentally delayed and challenged, but neurotypical children, as well. Especially for those whose birthdays put them ‘on the cusp’ between grades, considering such issues and responding appropriately can be even more important than academic concerns.

Mothers Day Wishes

Sunday, May 8th, 2016

helpMomThis is dedicated to all of the incredible Mothers who deal with ASD and the associated symptoms every day. You are not alone.

We’re not seeking miracle cures
Just small miracles.

I wish that I had more time for…

My affected child, the other kid(s), my husband, myself.

Something is just not right with my child, I wish we could figure it out.

If he would only get ready in the morning, Such a battle.

If she would just say “yes” once in a while.

If they will just stop fighting all of the time.

If he could only remember what he just read.

If he would only have some friends.

The family doesn’t’ seem to understand our problems.

We haven’t taken a vacation since…

If she wasn’t so disruptive in school.

If we could just figure out how to get him to focus.

He keeps saying the same thing over and over.

Those ‘stims’ are driving us crazy.

If we could all only get a good night’s sleep.

He has had diarrhea ever since I can remember.

He eats so little, I’m afraid he’s not getting enough.

She seems to be sick all of the time.

The rashes don’t ever seem to go away.

When do you think she will say “mama”?

There used to be some words, but now there’s not even eye contact.

She doesn’t ever play with us.

I wish she would stop biting her arms.

I wish he would stop hitting his mom.

When do you think he will be able to crawl?

She couldn’t stand until she was 2.

I don’t know what he wants.

If the doctors would only figure out what is wrong. If they would only listen.

How is my child going to make it in: preK, K, first grade, middle school, high school, life?

We’re not looking for miracle cures, just small miracles.

Thanks for allowing us to help
Sincerely,
Dr. Udell and the staff at
The Child Development Center of America

Medical Academy of Pediatric Special Needs 2016 Spring Conference

Sunday, May 1st, 2016

Practitioners, such as myself, find that it is necessary to attend the bi-annual Medical Academy of Pediatric Special Needs conference for two important reasons. First, to listen to experts from all over the world present their knowledge and latest research. Second, to network with, and learn from, other like-minded practitioners.

What I Liked Best
This year, I chose the ADHD path. The workups that were presented tended to be somewhat complex, and perhaps unattainable for many patients. The bottom line was to get a medical evaluation. The differential diagnosis ranges from thyroid to PANDAS. Mostly all agreed that stimulant and psychotropic meds should not be the first line in treatment. One professor spent some time questioning the diagnosis, itself, and how the modern world has contributed to the epidemic.

What I Liked Least
Traveling all the way to Costa Mesa, CA. Course work is 8 hours per day, so no time for Disneyland, etc.

This Year’s Major Focus
Mitochondrial function continued to play a big role in the presentations. The advanced courses involved lots of methylation, detoxification, and energy production diagrams. The newest twist has been the addition of genetic testing to better determine the cause(s) of inadequately functioning biologic pathways. Single nucleotide polymorphisms (SNPs) and ‘epigenetics’ were the buzzwords – how individual genes interact with the environment and within the individual leading to dysfunction and downstream signs and symptoms.

Topics That Were Discussed in Passing
Microarray genetic testing, covering multiple genes, did not play a big part in this year’s talks. Discussions about childhood immunizations underlie a great deal of the members’ conversations; specifically the lack of solid scientific evidence for safety in high risk populations. Attendees are not against vaccinations, by the way. Lyme disease was discussed in general, and as that inflammatory process relates to other infectious-metabolic conditions.

Subjects Not Formally Presented
GcMAF and nagalase levels. Some patients have indicated that a useful, safe supply may become available, so that will help determine future use. As well, chlorine dioxide, hyperbaric oxygen treatment, helminths, medical marijuana, and stem cell therapy were not offered by this year’s presenters.

Conclusion
It is disappointing to return from such conferences without that ‘magic bullet’. Just standing around, listening to Sid Baker speak about how he got interested in autism, or asking him how the ‘ion cleaning’ footpath worked, is worth the price of admission, however. This science started with Dr. Baker, and he continues to be an inquisitive, gentle force for hope, 40 years later.

In the absence of a sufficient population of scientists who are willing and available to address this modern epidemic of childhood developmental problems, this meeting stands as a bastion against the current state of ignorance.

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Brian D. Udell MD
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