Thursday, May 21, 2020

The "SalScan" Procedural Research Project: Ultrasound Chest Monitoring of Covid+ Patient

Program credits: Lennard Gettz (chief strategist/coordinator), Michael Thury (Remote instructor), Dr. Robert Bard (Imaging Overreader/Radiologist), Carmen Regallo-Dewitt (Editor), Sal Banchitta (Patient), Elizabeth Banchitta (Patient coordinator) & Terason Ultrasound Inc.* Copyright©2020- IntermediaWorx /NY Cancer Resource Alliance /CPS- Coalition for Professional Safety- All rights reserved.



VIDEOS OF SAL BANCHITTA UNDER THE SALSCAN REMOTE CHEST ULTRASOUND PROJECT







ABSTRACT
In response to the many health concerns of the current Covid-19 pandemic, radiologists and imaging technicians worldwide have presented significant demand for portable imaging in “the front lines” -including pandemic treatment centers, emergency care centers and triage facilities.  As a result of this demand, hospital bedside ultrasound screening of respiratory & cardiovascular disorders are now expanding in popularity to identify disorders that may be related to Coronavirus pathogen response.
Renamed "the modern stethoscope",  the handheld ultrasound provides visual evidence of many organs in their current state or condition.  Matching the many field advantages of the portable nature of ultrasound devices with the surge of tele-health/telemedicine solutions, remote training procedures and e-file sharing capabilities supports the future of immediate data access and diagnostic accuracy.  This report provides a practical overview of the entire remote screening process while providing a full breakdown on each element of the testing process.

1. INTRODUCTION
In April of 2020, a collaborative research project to explore (and design) a working model for remote ultrasound training and diagnostic evaluation was formed with the hopes of formalizing a future strategy of "virtualizing" technology-based health assessments.  Code named "SALSCAN", this concept was formulated between a research strategist & process analyst, a NYC based radiologist, a volunteer patient who tested Covid-19, a portable ultrasound manufacturer* (donor of current portable ultrasound device) and a remote/virtual training specialist to conduct imaging guidance to ensure the patient's proper use of the device.  The developers hoped to formalize this protocol as a nationwide scanning alternative during Covid times, as it was first launched in European triage centers to identify covid-related respiratory disorders [1]

The SALSCAN test program was established to review, record and build conclusive evidence of any/all useful information that may lead to, or reflect the strategic paradigms of real-life applications pertaining to the use of remote personal & portable ultrasound.

2. TESTING PARAMETERS
Objectives of the SalScan test program include:
1) Creating a synergistic work model of the 3 integral participants (the patient, the trainer and the overreader/radiologist) to support a future work plan for any and all remote diagnostic scenarios
2) Blueprinting and monitoring the progress of a working model of a medically monitored self-scanning paradigm (including scan diagrams on the torso, selected probes and frequency settings)
3) Developing any and all instructional guidelines to duplicate the process of this plan
4) Selecting and reviewing portable ultrasound technology with easy-to-use controls for ANY patient
5) Tracking the feasibility of a patient-induced tele-training program to capture ultrasound images for medical diagnosis via tele-medicine
6) Challenging the current web-based communication solutions, including conferencing, file sharing, privacy protocols, media player applications and collaboration (group) reporting capabilities
7) Developing a fully-functioning remote training program (through the use of web-based teleconferencing) to guide the patient on the proper/effective use of ultrasound transducers or probes
8) Assessing the actual ‘learning curve’ of the patient to confirm a formatted lesson plan
9) Evaluating the UI (user interface) of the current technology controls to identify patient’s learning success
10) Reviewing, overcoming and problem-solving all obstacles of the remote connection
11) Develop a fully streamlined data transferring/file sharing portal with the overreader (radiologist) to assess and submit a full report of the patient’s condition
12) Producing a quantitative data-gathering screening program from a home-based unit
13) Exploring and confirming the effectiveness of a portable ultrasound as a screening option for any field (non-hospital) situation- ie. battlefields, the ER, ocean liners, ambulances, space programs, natural disasters, etc.
14) Promoting a safety-conscious program to test for contagious pathogens in the safely & comforts of one's own home without health risks from travel
15) Developing a solid 3-point communication system for a real-time remote diagnostic protocol; synergy between patient, trainer and radiologist
16) Opening many more potential patient types, disorders and scenarios for this level of remote scanning access and telemedicine

This self screening program is an opportunity to beta-test key elements of the remote instructional functions and medical  diagnostic intervention whereby the project planner can successfully track and explore all procedural responses and the many findings set by the dynamics between the 3 parties: the patient, the radiologist and the remote trainer.

The obstacles of zero physical contact and the scenario of conducting a scan training to the a non-medically familiar individual aimed to draw valuable conclusions dedicated to reproducing this remote screening plan for countless emergency and non-urgent care situations worldwide.

The volunteer patient (Mr. Sal Banchitta) offered his own Covid-test results, his experiences and his complete participation to this technical process research. The program directors were successfully able to conduct a real-time beta test that drafts a complete staging plan on a future of remote virtual ultrasound screening.


click to enlarge
2.5 WHY ULTRASOUND: TESTING FOR "B LINES"
According to Dr Philippe Kory (critical care physician) "When we use an ultrasound on the lungs, we look for something called B LINES. Compare with a base line, the worse your lung ultrasound score was, the higher risk you had of deterioration. It's another type of exam where you could identify the trajectory of a patient, leading to a possible need for an escalation in therapy."


3. ADVANCING THE REMOTE SCAN MOVEMENT & PRE-HOSPITAL ULTRASOUND:
Before Covid-19, TeleMedicine, TeleHospital and other web-based 'tech med' solutions have existed for decades. Teleradiology has been used for over 60 years since film was being passed through a digitizer for direct digital capturing and transmitting globally overnight.  [2] This allowed faster response when it comes to head injuries in rural areas and other trauma events where teleradiology vastly improved other applications in diagnosis and treatment planning.  Today, expanded evidence of remote imaging appear in areas like space travel, emergency response, military deployments- and pandemics.

Emergency response units rely on
remote / portable innovations for 

on-site calls
Pre-hospital ultrasound has many clinical applications that may reduce morbidity and potentially improve outcomes for patients with life-threating conditions.  Remote ultrasound telemedical services were developed nationally by the author (Dr Bard) in 1980 and military field hospital application by Dr Ted Harcke for the US Armed Services in the in the 1990’s for imaged guided removal of foreign bodies. Worldwide, responders have adopted the use of a portable non-invasive, non-radiation ultrasound in their rescue rig.  Remote   For example, in Germany, the use of ultrasound in the field has focused on the FAST exam and cardiac sonography for non-traumatic patients since 2002–2003.  French prehospital clinicians have adopted ultrasound in certain areas as well, including SAMU (Service d'Aide Médicale d'Urgence). The Italian EMS system began incorporating ultrasound into prehospital care in 2005. [3]

Pre-hospital ultrasound is employed in this setting to differentiate reversible causes of pulseless electrical activity (PEA), assess for pericardial, intraperitoneal, and pleural fluid in trauma, and to differentiate between pulmonary edema and emphysema. In the USA, the focus on rapid transport and limiting on-scene time may have contributed to slower adoption of prehospital ultrasound [3]

4. INITIALIZING THE REMOTE SELF-SCREENING CONCEPT AND PROCESS
The patient volunteered himself to be the first test case and self-scanning trainee for a regimen of chest ultrasound scans under the beta-tested REMOTE HOME-SCAN & TELE-RADIOLOGY program. This program adapted key elements of lung ultrasound for a wider set of uses at the safety and comfort of the patient's home for regular ultrasound screening and continued monitoring.
Targets:  Provide the patient and overreader and designated radiologist immediate access to a reliable high-frequency PORTABLE ultrasound scans of LUNGS, HEART, LIVER and KIDNEYS (image- R) - the major organs that may show signs of Covid related disorders.



The "Body Map" followed by the patient (Sal) marking scan target
points of organs as directed by the remote trainer (Mike)
Predictions:  Imaging results are collected from the test subject (Sal) who is assigned to scan himself regularly within a given window of time (6 consecutive days).  In this case, Sal happens to be Covid + but has been recorded to NOT show symptoms.  Use of the ultrasound can either confirm that he is in fact asymptomatic, or may identify any hidden anomalies.

Virtual (web) access:  Through complete remote access, the professional ultrasound trainer (Mike Thury) operates the scanning software (via Teamviewer™) while instructing the patient via video conferencing (Zoom™) on how to properly operate the hand held probes and the ultrasound.

Data Collection Routine:  After each scanning session, the patient and trainer shall save all daily scan images collected- both on the portable device and on a cloud-based backup. Once a given number of days has been satisfied, the designated medical radiologist (Dr. Robert L. Bard, NYC) shall access the device to collect & review all image files for a through analysis.



Communication between the three parties (Image below): Through the use of TeleMedicine and online access of the device's controls and its saved files, the patient has unlimited personal use of a high frequency portable ultrasound while being remotely guided by a certified ultrasound instructor to scan specific organs of concern.  The remote Chest Ultrasound test puts the patient in the drivers seat to safely monitor and receive diagnoses of their own condition.






























5. REMOTE ULTRASOUND BENEFITS FOR ALL PATIENT TYPES
The constant evolution and upgrades in portable ultrasound innovations has made it possible for any patient undergoing treatment to track their own progress on a regular schedule (from home) without the hindrance of traveling to a doctors office.   For patients suffering chronic conditions, personal access to a portable ultrasound with remote access to a designated clinical team represents the next generation of patient diagnostic care. [4]

During his training and scanning period, the patient's participation provided the SALSCAN program with important procedural data toward the foundation for this upcoming national screening initiative. Our program developers' goals aim to support the global use of ultrasound imaging devices for the many non-hospital applications where access to large-format devices are simply not available.  Use of the ultrasound can either confirm the patient is in fact asymptomatic, or may prove to be useful as an early detection device by identifying any hidden anomalies.

5.1 Covid-19 is a multifocal, multiorgan disease meaning that a unit would require variable probes and equipment settings. The settings used in this scan series that included the lungs, liver, kidneys and heart utilized safety protocols for mechanical index (MI) and thermal index (TIS) employing curved array probe for lung, liver and kidneys and sector scanner for heart and lungs. Different transducers are available on many units but this study did not involve the application of the linear probe since the regions insonated were appropriately covered by the sector and curved array, or linear transducer if necessary.


5.1.1MI: The Mechanical Index
MI is of possible clinical interest if the beam focus is close to the surface of lung tissue. MI has the following characteristics:

• Potential bioeffect: Any possible mechanical or non-thermal mechanisms - although the likelihood of adverse consequences from these causes is not well understood, such risk may be highest in the presence of gas-saturated structures such as lung tissue.
• Mode type: Calculated for all modes of operation.
• Tissue type and location: Soft tissue at all locations in the scan field.
• Acoustic parameter: Maximum negative (rarefactional) ultrasound pressure at focus.

5.1.2 TIS: The Soft Tissue Thermal Index
TIS is of interest in the absence of bone, either at the tissue surface or near the beam focus. Applications of clinical interest include general abdominal examinations, first-trimester scanning before fetal bone has ossified, and cardiology. TIS has the following characteristics.
• Potential bioeffect: Thermal heating of soft tissue due to absorption of ultrasound. The TIS value is the ratio of the current probe power to the reference level that would cause
a 1ºC temperature rise in soft tissue.
• Mode type: Relevant for all modes, in both scanned and non-scanned modes.
• Tissue type and location: In scanned modes, soft tissue at the surface is of concern. In non-scanned modes, heating of soft tissue along the beam axis between the surface and focus is considered.
• Acoustic parameters: For scanned modes, the associated intensity at the surface is usually related to surface tissue heating. For unscanned modes, the maximum derated power through a 1-cm2 area anywhere along the beam axis is the basis for estimating tissue heating: unscanned beams less than 1cm2 in area at the surface are assumed to contribute only to surface heating, and the calculated effects are combined with those of scanned modes to estimate total soft-tissue heating at the surface. Unscanned beams larger than 1 cm2 at the surface are assumed to heat tissue only near the focus. Total heating effects at the surface and focus are compiled separately, and the larger value is
reported as TIS.

5.2 the role of the patient includes turning on the unit and applying gel to the areas to be scanned.  Wifi internet is activated for real time connectivity. The sonogram unit activated by the patient will then be used by the remote trainer through video or audio/video conferencing to guide the procedure
5.3 the role of the remote trainer/technician is to view the probe position on the patient and adjust the perpendicularity of the sound beam on the televised image VIDEO ?????  Breathing and other respiratory maneuvers may be adjusted at this time such as investigation of the inferior vena cava when pericardial effusion is discovered or aberrant ventricular wall motion is present.  All imaging functions of the probe such as patient ID input, M mode, Doppler, video are remotely carried out by the trainer during the live scanning session. Routinely 2-5 second videos are recorded for review and verification of the event.

5.4 The role of the physician radiologist is to verify the image quality, probe placement, depth of penetration and confer with the trainer if adjustments are necessary. Ideally this interaction occurs at the initial or second visit. Most patients will have normal findings therefore 12 hour intervals is adequate for observation.  Any aggravation of the symptoms (dypnea, palpitation, oxygen concentration decrease) calls for 4 hour scan intervals and real time physician input. Adverse outcomes may occur at any time and in any organ system. It is recommended that the heart, liver and renal structures be interrogated daily as well since delayed onset of ventricular inflammation (myositis) or large vessel thromboembolic phenomena are increasingly common. If neurologic sequelae occur the linear probe may image the carotid artery in the neck and the ophthalmic artery/vein complex. The sector or phased array cardiac probe has sufficient penetration to assess the intracranial arteries (transcranial Doppler ultrasound) and check for impending stroke or venous thrombosis.

5.5 Overall pulmonary function clinical assessment relates to the A-lines and B-lines. The high percentage of normal pleural A-line appearance implies that there is no significant pleuro-pulmonary pathology as is expected in patients on bedrest. B-line increase may call for hospitalization while the conversion of B-lines to A-lines highlights improvement. Bedside point of care remote diagnostic criteria are not available for non pulmonary organs. In the “sal scan” project A-line pattern was uniform for 14 days and our patient returned to normal activity. He is currently donating his plasma for the benefit of others.



6 REMOTE CT AND SONOGRAM FUSION DIAGNOSTICS
After initial experience with the outpatient remote ultrasound program, the scope moved to remote CT reviews and finally, combined reporting of lung ultrasound with lung CT with the option of image guided treatment using fusion of both modalities (fusion is covered in chapters 3 and 8) at distant locations throughout the United State on inpatients. On one encounter during the month of June, remote CT review by a radiologist supported the clinical impressions by overworked clinical colleagues.

Below are the pertinent data:
6/24/20                                               CT INITIAL FILM         FOLLOW UP
THICKENED PLEURA                               5/5                               1/5
GROUND GLASS OPACITY (GGO)         5/5                               2/5
SUBPLEURAL CONSOLIDATON            5/5                               1/5
TRANSLOBAR CONSOLIDATION          5/5                               0/5
MULTILOBAR CONSOLIDATION           5/5                               0/5
PLEURAL EFFUSION                                N/A                             0/5


KORY #5 BEFORE AFTERDATE REPORT
Kory arrows traction bronchiectasis

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SALSCAN PROJECT- STATEMENT OF CONCLUSION
1) The SalScan Remote Screening project started on April 15, 2020 for six (6) consecutive days.  It collected complete ultrasound video images of the patient's Lungs (from various angles), heart, liver and kidneys each day.

2) As of June 1, 2020, the SalScan project concluded its imaging, multi-testing and research efforts showing a non-symptomatic Covid Positive case.  This supports conclusive data available in current medical reports from nationwide testing.

3) The SalScan project integrated the results of the patient's (1) original Covid test and (2) an independent AntiBody test.
* The Covid Positive test result assumed the connection with the patient's heavy Flu-like and respiratory symptoms in early January-Feb. and may have functionally recovered by April as our imaging scans have indicated no present physical traces of pathogen response in the major organs scanned
* The patient's recent antibody test indicated positive (+) results, suggesting the validity of the initial Covid test and its diagnostic result.  Based on current scientific reports, this presence of antibodies suggest a likelihood of infection by Covid-19 pathogens in the recent past and that the patient's immune system has built up a protein defense to fight the virus. (image below)

* Our 6-day scan series recognizes his path to recovery (from his noted symptoms from earlier months) as images gathered on April, 2020 have concluded NO visual trace of pathogen response or infections.

4) The SalScan Program was designed as a PILOT to beta-test the blueprint of future Chest Ultrasound Screening, Remote Personal Screening and Virtual Overreading programs.

5) The SalScan Pilot successfully supported the comprehensive breakdown of the 3-member virtual/remote diagnostic paradigm, whereby this test proves the ease of use of the device and its comprehensive application of web-based communication and file sharing technology.

6) As the SalScan volunteer patient continued to maintain a non-symptomatic state (after July) under a twice confirmed Covid Positive test diagnoses, initiating the use of a personal ultrasound screening helped validate the patient's recovery and/or non-critical status.  This also provided necessary peace of mind to the patient seeking to affirm the direction of his clinical test results.

7) Additional imaging studies, medical (lab) reports and peer-reviewed data shall continue on a quarterly basis due to any possible recurrence that may arise.  Probability of recurrence has been clearly documented in recent medical journals and news reports.

8) The current pandemic and the growing list of treatment communities are poised to receive this report as part of Dr. Robert Bard's global advocacy to expand the medical use of portable ultrasound in "the front lines" of health responders community.

9) The SalScan virtual remote self-screening protocol, its staging plans, chest ultrasound mapping, scheduling and training process is a comprehensive program design that can be translated to serve any individual undergoing critical care, patients who are recovering from treatments at home or are in remote areas where regular radiology visits may prove to be a hardship to the patient.

"Remote Personal Imaging" (L-R): Sal Banchitta,  Actual heart
scan image | Mike Thury (remote technical trainer,  Terason Ultrasound)
 Len Gettz- program dir. |  Dr. Robert Bard- monitoring radiologist


The "SalScan program" is a research project developed by Dr. Robert L. Bard, IntermediaWorx Inc, The New York Cancer Resource Alliance, AngioFoundation (501c3) Research Group under strict partnership guidelines and each reserve exclusive copyrights to the program.  Publishing rights are granted exclusively to: Prevention101.org in perpetuity. No part of this publication, its contents, graphic assets or concepts may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the producers and publishers aforementioned, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law.


Resources:
1) Global Medical Allies Share Lung Ultrasound Solution for COVID-19 Triage |  ITN Imaging Technology news (April 6, 2020) https://www.itnonline.com/content/global-medical-allies-share-lung-ultrasound-solution-covid-19-triage
2) The Evolution of Telehealth: Where Have We Been and Where Are We Going? - https://www.ncbi.nlm.nih.gov/books/NBK207141/    Copyright 2012 by the National Academy of Sciences. All rights reserved.
3) Use of ultrasound by emergency medical services: a review | US Natl. Library of Medicine (PMC)- Nov, 2011: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657261/
4) Recent Developments in Tele-Ultrasonography | US Natl. Library of Medicine (PMC) Apr-Jun, 2018 : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6320468/





TECHNICAL CONTRIBUTORS

ROBERT L. BARD, MD, PC, DABR, FASLMS
Project Overreader- Advanced Imaging & Diagnostic Specialist
Dr. Bard received the 2020 nationally acclaimed Ellis Island Award for his lifetime achievement in advanced cancer diagnostic imaging. He co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital imaging technology and has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered sonograms, Power Doppler Histogram, sonofluoroscopy, 3D/4D image reconstruction and the Power Doppler Histogram  are safe, noninvasive, and do not use ionizing radiation. 



MICHAEL THURY, RDCS, RVT, FASE

Michael is the current Global Product Manager for Terason Ultrasound (Burlington, MA). Commercially he has spent the last 19 years training physicians, clinicians and distribution partners around the world on the uses and benefits of ultrasound. He has been recognized numerous times for outstanding clinical and sales excellence both at Terason and GE Healthcare. Michael holds a AAS in Cardiovascular Technology from Southeast Technical College and is a South Dakota native.




PIERRE KORY, M.D., M.P.A.
Technical Advisor- Bd. Certified Internal Medicine/Critical Care & Pulmonary Medicine. 
He served as the Medical Director of the Trauma and Life Support Center at the University of Wisconsin where he was an Associate Professor and the Chief of the Critical Care Service. He is considered a pioneer and national/international expert in the field of Critical Care Ultrasound and is the senior editor of the widely read textbook “Point-of-Care Ultrasound” (winner of the President’s Choice Award for Medical Textbooks from the British Medical Association in 2015).  Most recently, Dr. Kory joined the emergency volunteer team during the early COVID-19 pandemic in NYC at Mount Sinai Beth Israel Medical Center. He is also a founding member of the Front Line COVID-19 Critical Working Group (flccc.net) composed of 5 critical care experts that devised the COVID-19 treatment protocol called MATH+. (www.covid19criticalcare.com/)

* TERASON ULTRASOUND: donor of the 3200T remote / portable ultrasound device used in this beta test.

The "SalScan program" is a research project developed by Dr. Robert L. Bard, IntermediaWorx Inc, The New York Cancer Resource Alliance, AngioFoundation (501c3) Research Group under strict partnership guidelines and each reserve exclusive copyrights ©2020 to the program.  Publishing rights are granted exclusively to: Prevention101.org and Awareness for a Cure in perpetuity. No part of this publication, its contents, graphic assets or concepts may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the producers and publishers aforementioned, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. For permission requests, write to the publisher, addressed “Attention: Permissions Coordinator,” to: nycralliance@gmail.com

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The "Wild West" PPE Industry + A special feature on COUNTERFEIT RESPIRATORS

Written by:  Dr. Robert L. Bard & Cheri Ambrose
Edited by: NYCRA NEWS publishing team

Months into the Coronavirus Pandemic, health responders everywhere continue to struggle to protect themselves from contamination as cases continue to pile up in hospitals across the country. Understanding viral self-protection is job #1 for companies like American Health Supply Company- a 20+ year old supplier of Personal Protective Equipment (PPE) to healthcare practices and medical centers. To help identify how PPE's work, and various options available to the healthcare worker, we interviewed chief distributor and CEO, Jayson Dauphinee.  "From masks, face shields, gowns, nitro gloves and hazmat suits, we use all our existing contacts and constantly seek out new manufacturers who carry FDA certificates. The "name of the game" is getting only certified products for our people- because anything less would be adding risk to injury for all users."

The supply chain industry, especially those coming out of China, Hong Kong, Taiwan, Korea is a mixed bag when it comes to quality.  A big part of a distributor's job is sifting through bootlegs and counterfeit items. Where human lives that are at risk, discerning who's who is in and of itself a lifesaving job.  New and seasoned manufacturers showcase in international trade shows mixing reputable with questionable ones as far as their quality and follow-through.  Dauphinee claims honorable producers usually introduce themselves by sending sample products for integrity testing and copies of their certifications.   

N95 vs KN95- WHAT'S THE DIFFERENCE?
Mayors, Governors and health officials nationwide are now suggesting anyone in public to have protective face coverings of any kind (scarves, bandanas and surgical paper masks) as a bare-bones safety solution to the contagion. This call is a desperate responses to the limited supply of FILTRATION GRADE PPE MASKS.

The most widely publicized face mask in the service field is the N-95.  Due to the high demand, healthcare people are suffering a shortage of this mask, forced to surrender to alternative (and lesser quality) products.  According to Mr. Dauphinee, the KN95 is the same product -as identified by the EPA when it comes to the 95% effectiveness of its triple micron filtration.  "N" means manufactured in the U.S.  The USP code that K and 95 is China code. Then there's an AF94 from Korea. and the FFP2 is the Euro code. They all have the same 94.6% rating with that .3 micron filtration.


















These filter masks are typically made of spun bound non-woven polyethylene built up one cylinder layer on top of another. Above that is a melt blown layer of polyethylene filtration, then on top of that is going to be another one of the spun bound polyethylene. Next is a P E wire, which is a metal free, and that kind of holds everything together. Then on top, you're going to have a cotton layer of filtration- the piece that goes across the face at the anti microbial hypoallergenic piece of cotton. This gives you a decent feel to the face- and the finishing piece on the mask.

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Credit: NIOSH/CDC  - Counterfeit Respirators
Misrepresentation of NIOSH-Approval
(Click to enlarge)
BOOTLEGGERS FREE-FOR-ALL AND HOW TO IDENTIFY THEM
According to Fortune Business Insights, Personal Protective Equipment (PPE) Market Size will Hit USD 85.72 Billion by 2026.  (Presswire link)  This market spike is greatly due to the current health Pandemic of 2020. Meanwhile, as with any booming industry, millions in counterfeit masks and other PPE arises from China and other foreign countries, taking full advantage of its high global demand.

According to the CDC and NIOSH (The National Institute for Occupational Safety and Health), Counterfeit respirators are products that are falsely marketed and sold as being NIOSH-approved and may not be capable of providing appropriate respiratory protection to workers. When NIOSH becomes aware of counterfeit respirators or those misrepresenting NIOSH approval on the market, they are posted on the CDC/NIOSH website to alert users, purchasers, and manufacturers.

How to identify a NIOSH-approved respirator:  NIOSH-approved respirators have an approval label on or within the packaging of the respirator (i.e. on the box itself and/or within the users’ instructions). Additionally, an abbreviated approval is on the FFR itself. You can verify the approval number on the NIOSH Certified Equipment List (CEL) or the NIOSH Trusted-Source page to determine if the respirator has been approved by NIOSH. NIOSH-approved FFRs will always have one the following designations: N95, N99, N100, R95, R99, R100, P95, P99, P100.

For the complete coverage on Counterfeit PPE, please visit the CDC/NIOSH website: 
https://www.cdc.gov/niosh/npptl/usernotices/counterfeitResp.html


Addtl references: BusinessInsider.com
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The Humbling of 3M: New Industry Boom by the Pandemic
The recent explosion of today's PPE market is greatly influenced by the Coronavirus pandemic- for better and for the worse.   On one hand, the major demand has sparked a global wave of new manufacturers of all sizes. Meanwhile, there is a rampant loss of $$ from private buyers and distributors' due to delayed or lost orders as shipments from foreign countries are often seized or even destroyed.  This is either due to the major wave of bootlegging or political issues at the border.  In addition, new tarriffs, price wars, gouging and travel bans have all added to the import restrictions and challenged access to these PPE.  This opened up a floodgate of other countries now getting involved in product sourcing.  Countries like Germany have Bosch (the spark plug manufacturer) who is now manufacturing great masks.

New standards in protective gear for EMS professionals
in all New York fire departments (Elizabeth Banchitta)
Where 3M once 'ruled the game', the War Powers Resolution Act pushed every major company to get involved in producing ventilators and PPE.  This brought out the Ford's and the GM's who once paid 3M millions of dollars for masks and  are now learning to make them in house for public distribution as well as for their own protective uses. Now, if they know how to make them in house, 3M just lost that client making it hard for 3M to recover from that loss.   Due to this massive new demand escalating new price points, so many small manufacturers can finally afford to pay an American employee and earn a reason to get up and running.  Many small mom and pops throughout the country are going to get a little bit of booming. And the 3D printing industry right now has also become a huge factor because people at home can make PPE for relatives or loved ones or anything because you can put it in the program.



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COMMUNITY FOOD DRIVES:
CARING BOOTS ON THE GROUND

The definition of a "First Responder" is one who takes on the task of coming to the aid of any emergency or crisis in the community. In our current pandemic, firehouses are 'stepping up to the plate' by collecting food and staple supplies for the many lives affected by the Coronavirus issue. 

April, 2020- The King's Park Volunteer Firehouse collected over 4500 pounds of food on a one-day drive to replenish the various empty Food Pantries in their immediate area- including ones in King's Park, Bayshore and St. Joseph's church. This is just one of their many charitable initiatives on their calendar where the firehouse is poised as the central drop-off and distribution area.

"We swore an oath to take care of the people and patients in our community to support the safety and the well-being of all our neighbors. That's always instilled in you from the beginning. But the real thanks go to all the food donors in our area!" says EMT Elizabeth Banchitta (second generation first responder and daughter of Ret. FDNY FF. Sal Banchitta - see CousinSal.org).  "There are many types of FIRES to put out, and many ways to HELP... working with the fire dept. puts us at the front lines of these 'fires' to address them accordingly. This pandemic really puts our whole country upside down economically-- and getting food to those who need is one of our major challenges..."  



Wednesday, May 13, 2020

Covid-19 Effects on the Lungs + Chest Ultrasound (v)

Written and presented by: Dr. Stephen Chagares
Edited by: Dr. Robert L. Bard & Lennard Gettz (of NYCRA HealthScan News)
The Coronavirus has been shown to be very lethal to a subset of patients. What happens is that the virus is ingested into the mouth or nose, going down into the back of the throat (called the hypopharynx and the larynx) and then is breathed into the lungs themselves. The lungs are made of millions of little air SACS called alveoli, and the virus gets into these little layer sacks and adheres to the inner lining. That lining is what allows the interface between the blood and the air and the CO2 from the blood is given out. The oxygen from the air is given into the blood. That's how we breathe in oxygen and blow out CO2.

When the virus gets in there and coats that surface, everyone creates some kind of reaction. One is an antibiotic body reaction- which is an immune response. The other thing that happens is a physical inflammatory response where the immune system automatically goes into defense mode and wants to go in and kill the virus. It senses it's there and sends in "defender" cells, and to most people, it can send the proper amount of little soldiers to do the job. But in a small percentage of patients, the body's internal reaction causes too much inflammation causing a large body of fluid to fill up in the alveoli (air sacs) in the lungs. This stops the ability for oxygen to fuse through those air sacks to get oxygen into the entire body, include vital organs like the heart, the brain, the liver etc.  Without oxygen, this could result serious problems like heart and liver failure (and other such symptoms).

To visually identify this problem, existing technologies have to be tuned to track and monitor cardio-pulmonary performance. Chest x-rays or CT/catscans are available and are widely used now- but carry a number of key issues when it comes to regular chest monitoring. Often normal chest X rays are going to miss this because radiation itself will go through the lung tissue and the fluid and it may not show anything too specific. And then a cat scan may show something totally different where you can see how both lungs are all inflamed and have fluid in them.

The newest thought is the "LUNGSCAN" paradigm through the  use of ultrasound technology- as published by Dr. Robert Bard and a number of European experts in this field. The system of checking the lungs for covid-related issues is applied in tandem with (and not instead of) replacing other radiologic testing.  The concept of INTEGRATIVE solutions is about making as many solutions available to the public as you can to support patient treatment. So although chest X rays and cat scans are often used, there's a lot of radiation to them- and that's a major discrepancy to regular testing.

THE COMPLEX PROCESS OF CT IMAGING
If you're in the ICU, taking a "field trip" down to a radiology center is no fun at all.  It's probably the most dangerous part of a patient's day. Just getting switched from everything on the wall to everything portable and then getting them down and transferring them first from their bed to the stretcher, and then another stretcher into the cat scan table- can be quite harrowing. And then everyone has to get out and leave the patient there. And all the tubes still have to work. And as they come through to make sure nothing pops off and then they have to get transferred back onto the stretcher, up into the elevator, back into the ICU, back into their bed, and then hook everything back up again. So yes, cat scans work great, but there's a lot to it.

PORTABLE IS "IN"
Though we still have the high-powered center units the size of a washing machine, today's ultrasound technology design has been streamlined to offer PORTABLE versions to respond to its many field applications and demands. An "all-in-one" touch screen with detachable probes can be used at the bedside or in any kind of radiologic facility. It is also used in triage units, battlefields, ocean liners, helivacs/ambulances and even the space station.

You can expect to see "LUNGSCAN STATIONS" open up everywhere for outpatients to get quick lung scans (about a 5-minute experience) in urgent care centers per se.  The accuracy, speed and low prep combination of ultrasound alongside our new TeleMedicine trend makes for a SAFER alternative to imaging.



Ultrasound for Critical Care and Regular Covid Monitoring of Respiratory Pathogens

Adding to the arsenal of diagnostic solutions for the Covid-19 respiratory pathogen, the LUNG (or CHEST) ULTRASOUND is making great strides in triage facilities and bedside monitoring.  A growing community of European health specialists are joining a procedural movement to "replace" the dependency on stethoscopes with portable ultrasound use to check a patient's immediate cardiopulmonary condition. For Covid-positive patients, today's ultrasound excels in getting immediate answers safely without radiation - allowing for screening and repeated monitoring. Such is the case in this test sample.

According to radiologist Dr. Robert Bard, indication of the presence of Covid-19 will show in the form of B-LINES (or the 2 vertical rays). "B-Lines specifically mean that the lung tissue adjacent to the coating of the lung is abnormal- and that's what generates these lines. Normal lung tissue should never have B-lines. If you don't have B-Lines, you don't have Covid in the lungs..."

ULTRASOUND ACCESS TO THE "NEW WORLD" OF MEDICINE
The evolution of the portable ultrasound is now being viewed by many as a diagnostic game-changer for patient care in the field. From an interview with professional technical instructor Michael Thury of Terason Ultrasound, he states "the industry just exploded from 30 years ago with the ability and the confidence that ultrasound can give you. The technology enables the physician to really do a much better job diagnosing the patient. As a clinical trainer with clients worldwide, the boom of telemedicine adds to the success of teaching clinicians how to get the most out of remote ultrasound, but also to have fast and easy access to the physician to read and diagnose the patient from any location!"

...............................................................................................................................................................

Seeing your doctor (during the coronavirus pandemic) can be more systematic these days. Just come right to an exam room, get the ultrasound examination, go home, and then review those results with your physician via Video chat.  This third imaging option helps augment radiologic testing for Coronavirus effects in the chest area.

I also see the "bedside ultrasound" in the ICU carry huge benefits use. Being able to bring in a portable unit to a patient's room has a major safety element. Ultrasound can see fluid levels and in densities very nicely and with a small amount of training, you are able to use ultrasound to distinguish the density of the fluid in the areas where there is most fluid. This kind of imaging innovation really helped to support the understanding of A.R.D.S. (Acute Respiratory Distress Syndrome) in association with SIRS (Systemic Inflammatory Response Syndrome) where the lungs are majorly affected by these types of illnesses, filling them with fluid.

For regular monitoring of the lungs, ultrasound is a safe (non radiation) bet.  To identify symptoms in the lungs where the fluid can fill up is priceless data as part of early detection. Failure to breathe happens next, where ventilators come in to increase the oxygen level and be able to push through that fluid all caused by this simple little virus that just goes in and wreaks havoc on a small number of patients.

Percentage wise (not small total number), over 60,000 patients had that high reaction and it loops right back to "how do we keep an eye on that"?  Let's say you had grown a virus and then you're discharged. The lung reaction afterwards can be weeks or months until all the inflammation has gone. Some people less, some people more. And if chest X rays don't really see that type of level of fluid and and infiltration of the lungs with water and if cat scans or a lot of radiation, then these outpatient ultrasound sites could provide a literal progression from the discharge date all the way out until it looks like a normal lung again.

To me, that's a sensible protocol for early detection.


..............................................................................................................................................................

ABOUT THE AUTHOR


STEPHEN CHAGARES, MD, FACS - CANCER SURGEON
Dr. Chagares is a board certified general, laparoscopic, robotic and breast surgeon in Monmouth County, NJ.  He obtained specialty training in breast surgery at Memorial Sloan Kettering Cancer Center. In addition to breast surgery, Dr. Chagares regularly performs hernia repairs of all types, including open, laparoscopic and robotic repairs. He was the first surgeon in his region to perform a robotic hernia repair and remains on the cutting edge of all advanced surgical techniques.  He routinely performs multiple other abdominal procedures, including laparoscopic gallbladder removal.  Dr. Chagares has received numerous awards for excellence and academic teaching, Top Doctors Awards and Patients’ Choice Awards. His philosophy is to provide quality care with a personal touch. He respects the art of surgery and feels honored to treat patients every day. visit his website- drchagares.com


EDITOR / CO-PUBLISHER


ROBERT L. BARD, MD, PC, DABR, FASLMS  - RADIOLOGIST
Dr. Bard is recognized for his specialized work in advanced cancer diagnostic imaging. He co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital imaging technology and has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered sonograms, Power Doppler Histogram, sonofluoroscopy, 3D/4D image reconstruction and the Power Doppler Histogram  are safe, noninvasive, and do not use ionizing radiation. It is used as a complement to find anomalies and help diagnose the causes of pain, swelling and infection in the body’s internal organs while allowing the diagnostician the ability to zoom and ‘travel’ deep into the body for maximum exploration.


Special thanks to: Alice Chiang and Michael Thury of Terason Ultrasound (https://www.terason.com/) and LonShine Technologies Inc.

Disclaimer & Copyright Notice: The materials provided on this website are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.


Thursday, May 7, 2020

Covid-19 Effects on the Lungs + Chest Ultrasound

Written and presented by: Dr. Stephen Chagares
Edited by: Dr. Robert L. Bard & Lennard Gettz (of NYCRA HealthScan News)

 The Coronavirus has been shown to be very lethal to a subset of patients. What happens is that the virus is ingested into the mouth or nose, going down into the back of the throat (called the hypopharynx and the larynx) and then is breathed into the lungs themselves. The lungs are made of millions of little air SACS called alveoli, and the virus gets into these little layer sacks and adheres to the inner lining. That lining is what allows the interface between the blood and the air and the CO2 from the blood is given out. The oxygen from the air is given into the blood. That's how we breathe in oxygen and blow out CO2.

When the virus gets in there and coats that surface, everyone creates some kind of reaction. One is an antibiotic body reaction- which is an immune response. The other thing that happens is a physical inflammatory response where the immune system automatically goes into defense mode and wants to go in and kill the virus. It senses it's there and sends in "defender" cells, and to most people, it can send the proper amount of little soldiers to do the job. But in a small percentage of patients, the body's internal reaction causes too much inflammation causing a large body of fluid to fill up in the alveoli (air sacs) in the lungs. This stops the ability for oxygen to fuse through those air sacks to get oxygen into the entire body, include vital organs like the heart, the brain, the liver etc.  Without oxygen, this could result serious problems like heart and liver failure (and other such symptoms).

To visually identify this problem, existing technologies have to be tuned to track and monitor cardio-pulmonary performance. Chest x-rays or CT/catscans are available and are widely used now- but carry a number of key issues when it comes to regular chest monitoring. Often normal chest X rays are going to miss this because radiation itself will go through the lung tissue and the fluid and it may not show anything too specific. And then a cat scan may show something totally different where you can see how both lungs are all inflamed and have fluid in them.

The newest thought is the "LUNGSCAN" paradigm through the  use of ultrasound technology- as published by Dr. Robert Bard and a number of European experts in this field. The system of checking the lungs for covid-related issues is applied in tandem with (and not instead of) replacing other radiologic testing.  The concept of INTEGRATIVE solutions is about making as many solutions available to the public as you can to support patient treatment. So although chest X rays and cat scans are often used, there's a lot of radiation to them- and that's a major discrepancy to regular testing.

THE COMPLEX PROCESS OF CT IMAGING
If you're in the ICU, taking a "field trip" down to a radiology center is no fun at all.  It's probably the most dangerous part of a patient's day. Just getting switched from everything on the wall to everything portable and then getting them down and transferring them first from their bed to the stretcher, and then another stretcher into the cat scan table- can be quite harrowing. And then everyone has to get out and leave the patient there. And all the tubes still have to work. And as they come through to make sure nothing pops off and then they have to get transferred back onto the stretcher, up into the elevator, back into the ICU, back into their bed, and then hook everything back up again. So yes, cat scans work great, but there's a lot to it.

PORTABLE IS "IN"
Though we still have the high-powered center units the size of a washing machine, today's ultrasound technology design has been streamlined to offer PORTABLE versions to respond to its many field applications and demands. An "all-in-one" touch screen with detachable probes can be used at the bedside or in any kind of radiologic facility. It is also used in triage units, battlefields, ocean liners, helivacs/ambulances and even the space station.

You can expect to see "LUNGSCAN STATIONS" open up everywhere for outpatients to get quick lung scans (about a 5-minute experience) in urgent care centers per se.  The accuracy, speed and low prep combination of ultrasound alongside our new TeleMedicine trend makes for a SAFER alternative to imaging.



Ultrasound for Critical Care and Regular Covid Monitoring of Respiratory Pathogens

Adding to the arsenal of diagnostic solutions for the Covid-19 respiratory pathogen, the LUNG (or CHEST) ULTRASOUND is making great strides in triage facilities and bedside monitoring.  A growing community of European health specialists are joining a procedural movement to "replace" the dependency on stethoscopes with portable ultrasound use to check a patient's immediate cardiopulmonary condition. For Covid-positive patients, today's ultrasound excels in getting immediate answers safely without radiation - allowing for screening and repeated monitoring. Such is the case in this test sample.

According to radiologist Dr. Robert Bard, indication of the presence of Covid-19 will show in the form of B-LINES (or the 2 vertical rays). "B-Lines specifically mean that the lung tissue adjacent to the coating of the lung is abnormal- and that's what generates these lines. Normal lung tissue should never have B-lines. If you don't have B-Lines, you don't have Covid in the lungs..."

ULTRASOUND ACCESS TO THE "NEW WORLD" OF MEDICINE
The evolution of the portable ultrasound is now being viewed by many as a diagnostic game-changer for patient care in the field. From an interview with professional technical instructor Michael Thury of Terason Ultrasound, he states "the industry just exploded from 30 years ago with the ability and the confidence that ultrasound can give you. The technology enables the physician to really do a much better job diagnosing the patient. As a clinical trainer with clients worldwide, the boom of telemedicine adds to the success of teaching clinicians how to get the most out of remote ultrasound, but also to have fast and easy access to the physician to read and diagnose the patient from any location!"

...............................................................................................................................................................

Seeing your doctor (during the coronavirus pandemic) can be more systematic these days. Just come right to an exam room, get the ultrasound examination, go home, and then review those results with your physician via Video chat.  This third imaging option helps augment radiologic testing for Coronavirus effects in the chest area.

I also see the "bedside ultrasound" in the ICU carry huge benefits use. Being able to bring in a portable unit to a patient's room has a major safety element. Ultrasound can see fluid levels and in densities very nicely and with a small amount of training, you are able to use ultrasound to distinguish the density of the fluid in the areas where there is most fluid. This kind of imaging innovation really helped to support the understanding of A.R.D.S. (Acute Respiratory Distress Syndrome) in association with SIRS (Systemic Inflammatory Response Syndrome) where the lungs are majorly affected by these types of illnesses, filling them with fluid.

For regular monitoring of the lungs, ultrasound is a safe (non radiation) bet.  To identify symptoms in the lungs where the fluid can fill up is priceless data as part of early detection. Failure to breathe happens next, where ventilators come in to increase the oxygen level and be able to push through that fluid all caused by this simple little virus that just goes in and wreaks havoc on a small number of patients.

Percentage wise (not small total number), over 60,000 patients had that high reaction and it loops right back to "how do we keep an eye on that"?  Let's say you had grown a virus and then you're discharged. The lung reaction afterwards can be weeks or months until all the inflammation has gone. Some people less, some people more. And if chest X rays don't really see that type of level of fluid and and infiltration of the lungs with water and if cat scans or a lot of radiation, then these outpatient ultrasound sites could provide a literal progression from the discharge date all the way out until it looks like a normal lung again.

To me, that's a sensible protocol for early detection.


..............................................................................................................................................................

ABOUT THE AUTHOR


STEPHEN CHAGARES, MD, FACS - CANCER SURGEON
Dr. Chagares is a board certified general, laparoscopic, robotic and breast surgeon in Monmouth County, NJ.  He obtained specialty training in breast surgery at Memorial Sloan Kettering Cancer Center. In addition to breast surgery, Dr. Chagares regularly performs hernia repairs of all types, including open, laparoscopic and robotic repairs. He was the first surgeon in his region to perform a robotic hernia repair and remains on the cutting edge of all advanced surgical techniques.  He routinely performs multiple other abdominal procedures, including laparoscopic gallbladder removal.  Dr. Chagares has received numerous awards for excellence and academic teaching, Top Doctors Awards and Patients’ Choice Awards. His philosophy is to provide quality care with a personal touch. He respects the art of surgery and feels honored to treat patients every day. visit his website- drchagares.com


EDITOR / CO-PUBLISHER


ROBERT L. BARD, MD, PC, DABR, FASLMS  - RADIOLOGIST
Dr. Bard is recognized for his specialized work in advanced cancer diagnostic imaging. He co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital imaging technology and has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered sonograms, Power Doppler Histogram, sonofluoroscopy, 3D/4D image reconstruction and the Power Doppler Histogram  are safe, noninvasive, and do not use ionizing radiation. It is used as a complement to find anomalies and help diagnose the causes of pain, swelling and infection in the body’s internal organs while allowing the diagnostician the ability to zoom and ‘travel’ deep into the body for maximum exploration.


Special thanks to: Alice Chiang and Michael Thury of Terason Ultrasound (https://www.terason.com/) and LonShine Technologies Inc.

Disclaimer & Copyright Notice: The materials provided on this website are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.

©Copyright Intermedia Worx Inc./Prevention 101. All Rights Reserved.