Re: Keepsake 3D
From: art fougner, md (evsono@pipeline.com)
Mon May 24 13:58:46 2004
A nice souvenir for the folks often can rule out facial clefts so, in
that regard, it IS a diagnostic image.
art
At Mon, 24 May 2004, David Nyberg wrote:
>
>I think these are excellent guidelines Allen.
>What is clear is that keepsake imaging has hit a chord with a segment of our patient population and these commerical sites have filled a void. It is unlikely they are going away and we should help them fit into established practices and procedures.
>I also completely agree that we all do some form of patient-directed imaging. The only difference is that the primary intent of our exams is for diagnostic purposes. Keepsake imaging could also provide some diagnostic information.
>
>David
>
>On Mon, 24 May 2004, Allen Worrall wrote:
>
>> Yes, we all do that I am sure. Maybe the answer to this problem is something
>> like the following:
>>
>> 1- All Keepsake fetal imaging centers must be licensed by the appropriate
>> State agency. The State agency might require that the keepsake imaging
>> center have a medical director, a radiologist or ob/gyn physician
>> 2- The imaging must be done by sonographers registered in ob/gyn by ARDMS or
>> the appropriate Radiological organization , or by Board Certified ob/gyn
>> physicians or radiologists.
>> 3- The ultrasound examination must meet the requirements of the AIUM or
>> radiological organization for obstetrical exams.
>> 4- The patient must be given a written formal report of the examination.
>> This report must be of the same quality as would be expected from an
>> ultrasound lab at a medical facility, although it may be written by the
>> sonographer.
>>
>> Thus the main issue becomes that the patient referred herself, she was not
>> referred by an obstetrical provider. Since she is paying for the exam
>> herself, that should not be a big hurdle. The imaging center would be
>> assuming more responsibility for what they are doing. Indeed, they probably
>> would find it prudent to obtain medical liability insurance. The main thrust
>> would be to provide the patient with the CD, DVD, music, photos, etc, but
>> there would be more emphasis on examining the fetus. The cost of operating
>> such a center probably would go up, and thus the fee would go up.
>>
>> Allen
>>
>> Joseph A Worrall MD RDMS
>> OB/GYN Ultrasound at the Fairbanks Clinic
>> Fairbanks, AK 99701
>> http://www.obgynsono.com
>
>>>> ----- Original Message -----
>> From: "Dave Berck" <djberck@yahoo.com>
>> To: "Multiple recipients of list ULTRASOUND" <ultrasound@dns.obgyn.net>
>> Sent: Monday, May 24, 2004 7:06 AM
>> Subject: Re: Keepsake 3D
>>
>> > As an aside, I happen to know the sonographer who
>> > works at Peek in the Pod. She happens to be RDMS
>> > certified, and a lovely, conscientious person.
>> >
>> > PS: does anyone ever take ANY extra time at an exam to
>> > get a nice picture for the parents? If so, welcome to
>> > fetal foto because you are doing the same thing.
>> >
>> > Dave Berck, MD, MPH, RDMS
>> > Mt. Kisco, NY.
>> >
>> > --- "art fougner, md" <evsono@pipeline.com> wrote:
>> > > As a follow-up, Robert Modugno,MD posted this on
>> > > OB-Gyn-L
>> > >
>> > > May 17, 2004 By MARC SANTORA
>> > >
>> > > "I'm going to cry."
>> > >
>> > > Limor Fronimos, 25 weeks pregnant, was taking part
>> > > in one of the
>> > > stranger and more controversial outgrowths of the
>> > > ultrasound industry -
>> > > the high-resolution, artistic photography of fetuses
>> > > - and was
>> > > overwhelmed by what she was seeing on the video
>> > > monitor.
>> > >
>> > > For a few hundred dollars, expectant mothers can get
>> > > sepia-toned prints
>> > > to give to their families and friends, a CD-ROM with
>> > > the pictures so
>> > > they can be e-mailed around the world and a DVD with
>> > > a 20-minute video
>> > > of the fetus squirming in the amniotic sac.
>> > >
>> > > In an age of medical marvels, nothing would seem out
>> > > of the ordinary
>> > > about this experience, except that these ultrasounds
>> > > are not being
>> > > performed in doctors' offices or medical clinics,
>> > > but at fetal photo
>> > > studios that have been opening across the country in
>> > > recent years and
>> > > arrived in Manhattan in March.
>> > >
>> > > Mrs. Fronimos, 29, was a client at A Peek in the
>> > > Pod, just off Madison
>> > > Avenue on the Upper East Side, in a neighborhood of
>> > > trendy maternity and
>> > > children's stores. The top-of-the-line ultrasound
>> > > package at the
>> > > studio, including prints, CD-ROM and DVD, costs
>> > > $295.
>> > >
>> > > But along with keepsake pictures, the new studios
>> > > have generated a good
>> > > deal of concern. They are not subject to
>> > > regulation, and anyone with an
>> > > ultrasound machine - the best cost upwards of
>> > > $150,000 - can open up
>> > > shop.
>> > >
>> > > The Food and Drug Administration in Washington has
>> > > issued a blanket
>> > > warning against what it calls "entertainment"
>> > > ultrasound photos, and
>> > > there is a move in Albany, led by the deputy
>> > > majority leader of the
>> > > State Senate, Dean G. Skelos, a Republican from
>> > > Long Island, to try to
>> > > ban the practice.
>> > >
>> > > "This is high-powered equipment, and every step must
>> > > be taken to ensure
>> > > that mothers and their unborn children are protected
>> > > from unforeseen
>> > > harm," Mr. Skelos said about his legislation to ban
>> > > stores like A Peek
>> > > in the Pod. "This legislation will guarantee that
>> > > ultrasounds are
>> > > limited to medically necessary treatments."
>> > >
>> > > Prenatal ultrasound works by sending energy into the
>> > > mother's womb in
>> > > the form of sound waves, which bounce off the fetus
>> > > and are converted
>> > > into images. When the practice first began more
>> > > than two decades ago,
>> > > the images were so cloudy and blurred that to all
>> > > but the most expert
>> > > eye they seemed more like Rorschach blots than
>> > > portraits.
>> > >
>> > > However, in the past few years, there have been
>> > > tremendous strides in
>> > > the technology, which has moved from two-dimensional
>> > > black-and-white
>> > > images to three-dimensional color stills to videos.
>> > > About a year ago,
>> > > General Electric ran a series of national
>> > > advertisements about the
>> > > technology and its results. Industry officials said
>> > > the response from
>> > > mothers was overwhelming. They wanted to see the
>> > > kinds of pictures
>> > > featured in the ads.
>> > >
>> > > "The advances in technology that we have seen have
>> > > created pictures that
>> > > are much more lifelike," said Dr. Daniel Schultz,
>> > > the acting director
>> > > for the Food and Drug Administration's Center for
>> > > Devices and
>> > > Radiological Health.
>> > >
>> > > Dr. Schultz said that over the years ultrasound
>> > > technology has proved
>> > > safe, but that when the agency first learned of the
>> > > artistic ultrasound
>> > > photos in 1994 in Texas, it recommended against the
>> > > technology's use for
>> > > any purpose other than medical. The fear was that
>> > > an irresponsible
>> > > practitioner could subject a woman to a dangerously
>> > > long exposure to
>> > > ultrasound. As more shops have opened in the past
>> > > year, Dr. Schultz
>> > > said, the food and drug agency thought it should
>> > > issue the warning
>> > > again. "From the sense we are getting, we are
>> > > dealing with a growing
>> > > issue," he said.
>> > >
>> > > The F.D.A. governs only the advertising and selling
>> > > of the equipment
>> > > and does not police how it is used. Still, Dr.
>> > > Schultz said: "It makes
>> > > us nervous. The message that we would like to get
>> > > out is that women
>> > > should not engage in this activity or any other
>> > > activity that could
>> > > possibly have a harmful effect on their child."
>> > >
>> > > Rocky McClintock, the owner of A Peek in the Pod,
>> > > agrees that it would
>> > > be wise to establish a set of guidelines. In the
>> > > absence of a standard,
>> > > she has set her own rules.
>> > >
>> > > She has hired a sonographer, Narda L. Johnson, to
>> > > perform the
>> > > ultrasounds. She also requires that clients have
>> > > prenatal care and
>> > > consult with their doctors before coming in for
>> > > sessions. The studio
>> > > recommends that women who have the keepsake
>> > > sonograms be from 22 to 32
>> > > weeks pregnant, that the length of one ultrasound
>> > > session be no more
>> > > than 20 minutes, and that no client undergo more
>> > > than three sessions,
>> > > each on different days. Ms. McClintock said that
>> > > of about 60 clients
>> > > who have come to her seeking ultrasounds since the
>> > > store opened in
>> > > March, only 2 had doctors who opposed the idea, and
>> > > those women did not
>> > > proceed with the sessions.
>> > >
>> > > The room where the ultrasound is performed looks
>> > > more like a New Age spa
>> > > than a sterile hospital room. The bed is soft, the
>> > > lights are chilled,
>> > > and in the corner, for children, there is a
>> > > PlayStation.
>> > >
>> > > The music playing gently in the background also
>> > > serves as the soundtrack
>> > > for the DVD the clients receive. It was composed by
>> > > a client's husband,
>> > > Marc Bazermat, who was so taken by the experience he
>> > > had with his wife
>> > > that he created what they call in the office "The
>> > > Ultrasound Song."
>> > >
>> > > "Clients can also bring in their own music," Ms.
>> > > McClintock said. So
>> > > an unborn baby can groove to the Beatles or Busta
>> > > Rhymes, depending on
>> > > what the parents think their offspring's tastes may
>> > > be.
>> > >
>> > > Mrs. Fronimos's tiny daughter seemed to favor
>> > > chocolate.
>> > >
>> > > When the baby would not cooperate, choosing instead
>> > > to shield herself
>> > > with tiny hands from the prenatal equivalent of
>> > > paparazzi, Ms. Johnson
>> > > turned to a trick she picked up during the 20 years
>> > > she has performed
>> > > ultrasounds in doctors' offices.
>> > >
>> > > She gave the mother chocolate.
>> > >
>> > > "It goes straight to the baby," Ms. Johnson said.
>> > > "It's a sugar rush."
>> > >
>> > > Sure enough, the image on the screen soon became
>> > > clearer, and a big
>> > > smile could be discerned.
>> > >
>> >
>> http://www.nytimes.com/2004/05/17/nyregion/17fetus.html?ex=1085802642&ei=1&en=bdc3f0f54184cbb6
>> > >
>> > > ---------------------------------
>> > >
>> > > ---------------------------------
>> > > ---------------------------------
>> > > ---------------------------------
>> > > art
>> > > ---------------------------------
>> > >
>> > > ---------------------------------
>> > > At Sun, 16 May 2004, art fougner, md wrote:
>> > > ---------------------------------
>> > > >
>> > > >SKELOS INTRODUCES LEGISLATION BANNING "KEEPSAKE"
>> > > ULTRASOUNDS
>> > > >
>> > > >Bill Follows Opening of First Prenatal Photography
>> > > Studio in New York
>> > > >
>> > > >Thursday, May 6, 2004
>> > > >
>> > > >New York State Senate Deputy Majority Leader Dean
>> > > G. Skelos (R-C,
>> > > >Rockville Centre) today announced the introduction
>> > > of legislation
>> > > >prohibiting non-medical ultrasounds used solely for
>> > > entertainment
>> > > >purposes. Although private prenatal "photography"
>> > > shops have appeared
>> > > >in shopping malls around the country, New York's
>> > > first private
>> > > >ultrasound studio recently appeared in Manhattan.
>> > > >
>> > > >"The FDA has concluded that these unregulated
>> > > ultrasounds 'put a mother
>> > > >and her unborn baby at risk,'" said Senator Skelos.
>> > > "This is
>> > > >high-powered, equipment and every step must be
>> > > taken to ensure that
>> > > >mothers and their unborn children are protected
>> > > from unforeseen harm.
>> > > >This legislation will guarantee that ultrasounds
>> > > are limited to
>> > > >medically-necessary treatments and administered by
>> > > trained
>> > > >professionals."
>> > > >
>> > > >Generally, ultrasound equipment produces a
>> > > high-frequency sound wave to
>> > > >generate diagnostic images of developing babies.
>> > > Since the 1960s,
>> > > >ultrasounds have offered an invaluable tool for
>> > > diagnosing pregnancy and
>> > > >any potential abnormalities and determining the
>> > > proper course of medical
>> > > >care. When correctly administered by trained
>> > > professionals, such as
>> > > >sonographers, radiologists and obstetricians,
>> > > low-power ultrasounds are
>> > > >generally considered a safe means of gaining
>> > > information about a
>> > > >pregnancy.
>> > > >
>> > > >Utilizing state-of-the-art 4D technology, the most
>> > > advanced ultrasound
>> > > >machines can provide much clearer pictures than
>> > > older
>> > > >equipment-including facial contours, muscle
>> > > definition and hair-and
>> > > >combine these images into short videos. However,
>> > > this modern ultrasound
>> > > >equipment is capable of producing intensities eight
>> > > times higher than
>> > > >the machines commonly used by medical
>> > > professionals.
>> > > >
>> > > >As introduced by Senator Skelos, S.6776-A would
>> > > restrict the
>> > > >administration of any ultrasound on a pregnant
>> > > woman to those performed
>> > > >pursuant to an order or referral by a licensed
>> > > physician, nurse
>> > > >practitioner or licensed midwife. In addition, the
>> > > legislation
>> > > >prohibits the dispensation of ultrasounds for
>> > > entertainment purposes or
>> > > >those not warranted by the condition of the
>> > > patient. If enacted, a
>> > > >violation of this new law would be a Class A
>> > > misdemeanor, with a maximum
>> > > >prison sentence of one year.
>> > > >
>> > > >"Ultrasounds on pregnant women are used for medical
>> > > purposes, to obtain
>> > > >information about the pregnancy," said William B.
>> > > Rosenblatt, M.D.,
>> > > >President Medical Society of the State of New York.
>> > > "The practice of
>> > > >performing ultrasounds on pregnant women without a
>> > > medical reason and an
>> > > >order from a physician, nurse practitioner or nurse
>> > > midwife should not
>> > > >be done. The Medical Society of the State of New
>> > > York supports this
>> > > >bill as an effort to end this unnecessary and
>> > > extremely costly
>> > > >practice."
>> > > >
>> > > >A U.S. Food and Drug Administration (FDA)
>> > > investigation concluded that
>> > > >non-medical, entertainment ultrasounds are often
>> > > performed without a
>> > > >doctor's supervision. Moreover, the FDA warned
>> > > that "[u]ltrasound is a
>> > > >form of energy, and even at low levels, laboratory
>> > > studies have shown it
>> > > >can produce physical effects in tissue, such as
>> > > jarring vibrations and a
>> > > >rise in temperature." As such, the FDA concluded
>> > > that "prenatal
>> > > >ultrasounds can't be considered completely
>> > > innocuous." Further, the FDA
>> > > >noted that many of these companies use the
>> > > ultrasound machines at higher
>> > > >energy levels and for as long as one hour to secure
>> > > clear pictures
>> > > >and/or videos for their customers.
>> > > >
>> > > >The FDA first became aware of the "keepsake"
>> > > ultrasound industry in 1994
>> > > >(Texas) and informed these providers that anyone
>> > > promoting, selling or
>> > > >leasing ultrasound equipment for the making of
>> > > "keepsake" fetal videos
>> > > >could be breaking the law. Although the ultrasound
>> > > devices are
>> > > >regulated by the FDA and, as such, the FDA can take
>> > > action against the
>> > > >"keepsake" video industry for using a prescription
>> > > device without a
>> > > >prescription from a medical professional, the
>> > > qualifications and
>> > > >behavior of technicians and physicians is regulated
>> > > by the states.
>> > > >
>> > > >"In the new Manhattan studio's first month, more
>> > > than 40 mothers-to-be
>> > > >have paid $300 each for a procedure that could have
>> > > dire consequences,"
>> > > >said Senator Skelos. "Even General Electric, the
>> > > leading seller of 4D
>> > > >ultrasound machines, has joined the Medical
>> > > Society, the American
>> > > >Institute of Ultrasound in Medicine, American
>> > > College of Obstetricians
>> > > >and Gynecologists and the New York State
>> > > Radiological Society to express
>> > > >its opposition to the use this equipment for
>> > > nonmedical purposes. Until
>> > > >all the risks associated with this new technology
>> > > are completely known,
>> > > >we must make every effort to err on the side of
>> > > public safety."
>> > > >
>> > >
>> > >http://www.senatordeanskelos.org/press_archive_story.asp?id=8664
>> > > >
>> > > >art
>> > > >
>> > > >At Fri, 14 May 2004, art fougner, md wrote:
>> > > >>
>> > > >>Terry
>> > > >>
>> > > >>In the US as you well know, every afternoon you
>> > > can channel surf and
>> > > >>find a court show. Americans are afflicted with
>> > > lawsuit mania. If
>> > > >>something bad happens, even if they don't feel
>> > > that way, someone in the
>> > > >>family or a neighbor encourages them to sue. And
>> > > that is how those
>> > > >>cases will go to litigation. Not necessarily
>> > > because we agree with the
>> > > >>principle but because that's the American way.
>> > > Just as a woman can
>> > > >>place a cup of hot coffee between her thighs and
>> > > get burned and then sue
>> > > >>McDonald's, just as folks who could read a pack of
>> > > cigarettes but smoke
>> > > >>anyway could sue, just as folks who get fat and
>> > > bloated by subjecting
>> > > >>themselves to supersized whoopers could sue, that
>> > > is how folks will sue
>> > > >>the Fetal Fotomats. And the disclaimer about we
>> > > don't do medical will
>> > > >>hold up about as well as the "Not Responsible"
>> > > disclaimer in the parking
>> > > >>lot will hold up. It will sooner or later be up
>> > > to a jury to decide.
>> > > >>And once that happens, the game is afoot.
>> > > >>
>> > > >>Terry, I agree with you in principle but there is
>> > > a dearth of FDA
>> > > >>inspectors for Ultrasound labs so the Fotomats
>> > > can, as Monty Python
>> > > >>exclaimed, "Fart in their general direction."
>> > > Caveat emptor will prevail
>> > > >>here - for better or for worse. Therefore, it is
>> > > up to us to provide
>> > > >>for our patients our best efforts and let the
>> > > chips fall where they may.
>> > > >>We can only hope that Karma prevails. And it
>> > > usually does. Again, the
>> > > >>pity is that the same folks who unhesitatingly
>> > > fork over a wad of cash
>> > > >>money for their Foto-op are the same folks who
>> > > fight tooth and nail to
>> > > >>forgo the meager copay at your lab when you
>> > > participate with their
>> > > >>insurance plan. To quote Yacov Smirnoff - "
>> > > America - What a Country!"
>> > > >>
>> > > >>At Fri, 14 May 2004, DuBose, Terry wrote:
>> > > >>>
>> > > >>>Art, will an uneducated, unskilled, & unwashed
>> > > person who doesn't have a
>> > > >>>clue as to the difference between a uterine
>> > > synechia vs. an amniotic
>> > > >>>band, and won't care because it isn't a "medical"
>> > > exam, be held to the
>> > > >>>same standard as a registered sonographer or MD?
>> > > This, I fear is the
>> > > >>>fallacy in the legal solution to this problem.
>> > > >>>
>> > > >>>Given enough time the "unwashed" will develop the
>> > > psychomotor skills to
>> > > >>>acquire pretty pictures of faces, but won't have
>> > > a clue about VSDs, etc.
>> > > >>>and won't care. In time the public will come to
>> > > view these folks as
>> > > >>>the real face of sonography because that is the
>> > > "fun" part; and the real
>> > > >>>sonographers will become the gnomes in the bowels
>> > > of the hospital,
>> > > >>>giving out the bad news. We will be held to a
>> > > higher standard because
>> > > >>>of our experience, while the uneducated will be
>> > > able to throw up their
>> > > >>>hands and exclaim "gastroschisis, what is that?
>> > > Who knew?"
>> > > >>>
>> > > >>>Unless the FDA actually enforces their own
>> > > regulations on non-medical
>> > > >>>uses, then the legal system will not treat all by
>> > > the same standards.
>> > > >>>The FDA needs to either enforce their own regs or
>> > > release us all to
>> > > >>>compete in the "free market", and then we can
>> > > beat the unwashed at their
>> > > >>>own game. I include registered sonographers in
>> > > this issue of the "free
>> > > >>>market".
>> > > >>>
>> > > >>>"Just my opinion, I could be wrong."
>> > > >>>
>> > > >>>Terry J. DuBose, M.S., RDMS, FSDMS, FAIUM
>> > > >>>
>> > > >>>Assistant Professor & Director
>> > > >>>Diagnostic Medical Sonography Program
>> > > >>>University of Arkansas for Medical Sciences, CHRP
>> > > >>>4301 West Markham St. Mail Slot #563
>> > > >>>Little Rock, Arkansas, 72205 USA
>> > > >>>501-686-6510
>> > > >>>DuBoseTerryJ@UAMS.edu
>> > > >>>http://www.io.com/~dubose/
>> > > >>>http://www.uams.edu/chrp/dms/default.asp
>> > > >>>http://www.obgyn.net/us/panel/panel.htm
>> > >
>> > >>>---------------------------------------------------------------
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>> > > >>>-----Original Message-----
>> > >
>> > >>>---------------------------------------------------------------
>> > > >>>From: ultrasound@obgyn.net
>> > >>>---------------------------------------------------------------
>> > >>>---------------------------------------------------------------
>> > >>>---------------------------------------------------------------
>> > > [mailto:ultrasound@obgyn.net] On Behalf Of
>> > >>>---------------------------------------------------------------
>> > >
>> > >>>---------------------------------------------------------------
>> > >>>---------------------------------------------------------------
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>> > > >>>art fougner, md
>> > >
>> > >>>---------------------------------------------------------------
>> > > >>>Sent: Friday, May 14, 2004 11:04 AM
>> > >>>---------------------------------------------------------------
>> > >>>---------------------------------------------------------------
>> > >>>---------------------------------------------------------------
>> > >
>> > >>>---------------------------------------------------------------
>> > >>>---------------------------------------------------------------
>> > >>>---------------------------------------------------------------
>> > > >>>To: Multiple recipients of list ULTRASOUND
>> > >>>---------------------------------------------------------------
>> > >>>---------------------------------------------------------------
>> > >
>> > >>>---------------------------------------------------------------
>> > >>>---------------------------------------------------------------
>> > > >>>Subject: Re: Keepsake 3D
>> > >>>---------------------------------------------------------------
>> > > >>>
>> > >>>---------------------------------------------------------------
>> > > >>>i'm equally sure that there are anomalies missed
>> > >>>---------------------------------------------------------------
>> > > at non-3D sites as
>> > > >>>well. the glass house has many rooms. yogi had
>> > > it right - "it ain't
>> > > >>>over til it's over."
>> > > >>>
>> > > >>>however, the missed anomalies will come back to
>> > > haunt the Keepsake
>> > > >>>Centers as it already has haunted us all - if you
>> > > perform an ultrasound
>> > > >>>for whatever reason, my feeling is that you
>> > > should and will be held to
>> > > >>>the published standards.
>> > > >>>
>> > > >>>art
>> > > >>>
>> > > >>>At Thu, 13 May 2004, David Nyberg wrote:
>> > > >>>>
>> > > >>>>Larry
>> > > >>>>
>> > > >>>>I know of a case here in Phoenix where a
>> > > reputable group missed a cleft
>> > > >>>lip/palate that was then picked up by a
>> > > commericial 3D site 2 weeks
>> > > >>>later. I know that's not what you're looking
>> > > for, but it could work
>> > > >>>both ways. Of course a 3D site may be more
>> > > likely to pick up facial
>> > > >>>abnormalities since that's where their focus is.
>> > > I'm sure there are
>> > > >>>plenty of nonfacial abnormalities missed by 3D
>> > > sites.
>> > > >>>>
>> > > >>>>Dave
>> > > >>>>
>> > > >>>>On Thu, 13 May 2004 LDPLATT@aol.com wrote:
>> > > >>>>
>> > > >>>>> Does anyone have or kno a patientw of had a
>> > > keepsake video done in
>> > > >>>one of the
>> > > >>>>> "commercial"centers who subsequently had a
>> > > major fetal abnormality
>> > > >>>??? If
>> > > >>>>> so would they be willing to talk about the
>> > > experience? Thanks
>> > > >>>>>
>> > > >>>>> Larry Platt
>> > > ldplatt@aol.com
>> > > >>>>>
>> > > >>>>--
>> > > >>>>David Nyberg, MD
>> > > >>>>10401 E McDowell Mtn Ranch Rd
>> > > >>>>#2-372
>> > > >>>>Scottsdale, AZ 85255
>> > > >>>>ph cell 480-797-0993
>> > > >>>>fax 480-512-8737
>> > > >>>>work 480-512-3850
>> > > >>>>
>> > > >>>--
>> > > >>>art fougner, md
>> > > >>>ich bin ein New Yorker
>> > > >>>
>> > > >>--
>> > > >>art fougner, md
>> > > >>ich bin ein New Yorker
>> > > >>
>> > > >--
>> > > >art fougner, md
>> > > >ich bin ein New Yorker
>> > > >
>> > >
>> > > --
>> > > art fougner, md
>> > > ich bin ein New Yorker
>> >
>> > =====
>> > David J. Berck, MD, MPH
>>
>--
>David Nyberg, MD
>10401 E McDowell Mtn Ranch Rd
>#2-372
>Scottsdale, AZ 85255
>ph cell 480-797-0993
>fax 480-512-8737
>work 480-512-3850
>
--
art fougner, md
ich bin ein New Yorker
