Re: Keepsake 3D
From: art fougner, md (evsono@pipeline.com)
Mon May 24 14:02:43 2004
When the first AIUM bioeffects safety statements were issued, who knew
this would be an issue? Then there were data confirming ultrasound as a
bonding tool. Fetal Foto Centers seem an outgrowth of that trend. In
this regard,
Fetal Foto Centers come under the aegis of Frankenstein's Law - you make
the monster - you live with the monster.
art
At Mon, 24 May 2004, Allen Worrall wrote:
>
>Yes, it is like Prohibition in the 1920s. If we try to legislate it away, it will not work, because it is something the public wants.
>
>Allen
>
>>> ----- Original Message -----
> From: David Nyberg
> To: Multiple recipients of list ULTRASOUND
> Sent: Monday, May 24, 2004 7:50 AM
> Subject: Re: Keepsake 3D
>
> 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& i=1&en½c3f0f54184cbb6
> > > >
> > > > ---------------------------------
> > > >
> > > > ---------------------------------
> > > > ---------------------------------
> > > > ---------------------------------
> > > > 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
> > > >>>---------------------------------------------------------------
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> > > > >>>To: Multiple recipients of list ULTRASOUND
> > > >>>---------------------------------------------------------------
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> > > >>>---------------------------------------------------------------
> > > > >>>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
