November 8, 2013
Mayo Clinic in the News is a weekly highlights summary of major media coverage. If you would like to be added to the weekly distribution list, send a note to Emily Blahnik with this subject line: SUBSCRIBE to Mayo Clinic in the News.
Karl Oestreich, manager enterprise media relations
KMSP Twin Cities
OPERATION MAGIC: Magician's journey may be best trick of all
by Jeff Baillon
He got his start some 50 years ago. Peter Gloviczki traveled the world with his bag of tricks, and after all that time and all those miles, it's plain to see he still loves to be in front of a crowd…In 1981, Gloviczki said goodbye to the spotlights, packed away his magic hat and moved to Rochester, where he's lived ever since. He came to Minnesota to pursue his true passion -- he traded in his wand for a scalpel.....left the stage for the operating room at the Mayo Clinic.
Reach: Minneapolis-St.Paul is the 16th largest television market in the United States with 1.7 million TV homes. FOX 9 News (WFTC) typically has good viewership for its 9 p.m., newscast, but lags behind its competitors at 5, 6 and 10 p.m.
Context: Peter Gloviczki, M.D. is a Mayo Clinic vascular surgeon. The Mayo Clinic Gonda Vascular Center is devoted to providing state-of-the-art diagnosis and treatment in a compassionate environment for patients with vascular diseases. Mayo Clinic vascular and endovascular surgeons treat blood vessel and lymphatic system conditions (vascular diseases).
Public Affairs Contact: Sharon Theimer
Bariatric Surgery Can Keep Pounds Off For Years
by Nancy Shute
Weight-loss surgery is becoming increasingly popular because it's the only treatment that pretty much guarantees weight loss. There is very little evidence on how it will affect people's health over the long haul…Parents and doctors should think about non-medical reasons why surgery may help teenagers, according to Michael Sarr, a bariatric surgeon at the Mayo Clinic. He wrote an editorial in JAMA Pediatrics arguing that having to go through adolescence weighing 300 or 400 pounds can result in "psychosocial retardation." Additional coverage: Bariatric News
Reach: The NPR Shots Blog covers news about health and medicine. It is written and reported by NPR’s Science Desk.
Context: Michael Sarr, M.D., is a bariatric surgeon at Mayo Clinic. The Division of Gastroenterologic and General Surgery at Mayo Clinic in Rochester, Minn., has one of the largest and most experienced groups of gastroenterologic and general surgeons in the United States. The 16 staff surgeons perform more than 7000 operations annually and have a combined 172 years of experience.
Public Affairs Contact: Brian Kilen
US News & World Report
The Push to Personalize Medicine
by Laura McMullen
At the U.S. News Hospital of Tomorrow Forum, industry experts discuss how to increase the value of care through personalization…While using gene sequencing seems to be valuable for patients, their families and medical institutions, the high cost seems to be slowing down its progression to the use by everyday patients. But as Gianrico Farrugia, director of the Center for Individualized Medicine at Mayo Clinic, pointed out: “It’s happening now. The future is now, it’s just uneven. This unevenness will level out.”
Reach: US News reaches more than 10 million unique visitors to its website each month.
Context: Gianrico Farrugia, M.D. is director of the Center for Individualized Medicine at Mayo Clinic. The center seamlessly integrates the latest genomic and clinical sciences to transform health care. Mayo Clinic has a rich tradition of providing exceptional individualized and tailored medical care to its patients. The center provides another chapter in a 150-year patient care history by integrating up-to-date knowledge of genes and the human genome into personalized care for each Mayo patient.
Public Affairs Contacts: Nick Hanson, Sam Smith
Tapping Medical Marijuana’s Potential
by Jane Brody
Marijuana has been used medically, recreationally and spiritually for about 5,000 years. Known botanically as cannabis, it has been called a “crude drug”: marijuana contains more than 400 chemicals from 18 chemical families. More than 2,000 compounds are released when it is smoked, and as with tobacco, there are dangers in smoking it…Dr. J. Michael Bostwick, a psychiatrist at the Mayo Clinic in Rochester, Minn., said the classification was primarily political and ignored more than 40 years of scientific research, which has shown that cellular receptors for marijuana’s active ingredients are present throughout the body. Natural substances called cannabinoids bind to them to influence a wide range of body processes.
Reach: The New York Times has a daily circulation of more than 735,000. Its website receives more than 16.2 million unique visitors each month.
Context: J. Michael Bostwick, M.D., is a Mayo Clinic psychiatrist. Dr. Bostwick wrote about medical marijuana in the Feb. 2012 issue of Mayo Clinic Proceedings.
Public Affairs Contact: Nick Hanson
Additional Mayo Clinic News Highlights This Week:
Bloomberg, Harvard Zebrafish Research Yields Possible Treatments for Muscle Diseases by John Lauerman, The Harvard experiment attacks “a major unmet need” in producing human cells that may be used to study and perhaps treat a number of muscle disorders, said Andre Terzic, director of the Mayo Clinic’s Center for Regenerative Medicine in Rochester, Minnesota. Showing that the same drugs work in cells from several species also bolsters the findings, he said.
MPR, A little baba ghanoush helps you go a long way, A new study suggests that if you base your meals on a Mediterranean diet, you might get a chance to eat many more of them — and enjoy them more… On the radio Katherine Zeratsky: Registered dietician and specialty editor for the Mayo Clinic Nutrition and Healthy Eating Guide and blogger at the Nutrition-wise Blog
Arizona Business Magazine, TGen-led Study Finds Link to Parkinson’s Disease, The absence of a protein called SMG1 could be a contributing factor in the development of Parkinson’s disease and other related neurological disorders, according to a study led by the Translational Genomics Research Institute (TGen)… TGen collaborators in this study included researchers from Banner Sun Health Institute and Mayo Clinic Scottsdale.
ABC15 Ariz, Scientists say new discovery 'miracle' in battle against aging by Katie Rami, The quest for ageless beauty – it’s a driving force in Western culture giving rise to a trillion dollar a year industry…The Mayo Clinic’s Dr. Robert Caselli is an expert in the treatment of Alzheimer’s disease. He says recent discoveries involving chromosomes in mice offer a tantalizing glimpse at a future where the aging process is slowed, or perhaps, one day, even reversed.
KTTC, DMC Reality Check: We do it all for the Mayo by Nicole Goodrich… Essentially when we talk about support of Mayo Clinic, that can really take on a lot of flavors if you will," said Rochester City Council President Randy Staver… So what responsibility does Mayo Clinic have? "$200 million is the threshold," said Staver. That's 200 million dollars not just given, but spent by either The Clinic or other private developers. "Before the state of Minnesota starts to kick their share of the 585 million," said Staver. "What that does is really proves that we're going to make this happen in Rochester, and until we show some of that proof, the dollars won't flow," said Mayo Clinic's DMC Administrator Lisa Clarke.
KTTC, DMC Reality Check: What about the local guys? By Nicole Goodrich, There are two centers of power in Downtown Rochester, and they're partners in Destination Medical Center. "I have great respect for the people at the Mayo Clinic, but they're not the ones that got elected," said Mayor Ardell Brede who also sits on the DMCC Board.
KTTC, DMC Reality Check: Making the Plans by Nicole Goodrich, After nearly six months since the Destination Medical Center legislation hit Governor Dayton's desk, Rochester is a city lying in wait. "It's the future of our city, and that makes it pretty important," said Rochester City Council Representative and DMCC Board Member Ed Hruska…"What we want to do in Rochester is not just let development just happen," said Lisa Clarke, Mayo Clinic's DMC Administrator. "We want to create a thoughtful deliberate plan so that the development really meets the needs of the DMC vision."
KTTC, DMC Reality Check: Back to Basics by Nicole Goodrich, It hit the airwaves in January, sat in the Legislature for months and reached the Governor's desk in May. Now it's here in Rochester, and it's growing…"Nobody can predict the future, said Lisa Clarke, Mayo Clinic's DMC Administrator. "Nobody knows what the economic forecast will be. But what we want to do is secure our future, secure Rochester's future in the state of Minnesota for growth and for success."
KTTC, NewsCenter Extra: Visions of Rochester - Dr. Brad Narr, You travel around the world and chances are, people will know the Mayo Clinic name. It's a history and reputation worth building on. And it's one of the reasons state lawmakers approved nearly 600-million dollars for economic support of Destination Medical Center. All this week, we're talking to visionaries about the future of our community as it relates to DMC. Recently, KTTC's Tom Overlie met with Mayo Clinic's Medical Director for DMC, Dr. Brad Narr. Where is Mayo Clinic in ten to twenty years?
Post-Bulletin, Surrounding area eyes Mayo Clinic expansion plan by Jeff Hansel, Medical expansions will change Rochester's look during the next 20 years. But how will that impact surrounding communities? Today, the Post-Bulletin highlights Destination Medical Center thoughts from regions outside Rochester that DMC will affect.
Minneapolis / St. Paul Business Journal, Mayo Clinic's Destination Medical Center is just getting started by Sam Black, While developers scramble to buy land and build awareness of their projects, there’s no formal way for them to apply to have infrastructure costs offset as part of the broader Destination Medical Center plan, and there won’t be for several months. The DMC is moving along “expediciously” to set up its process and respond to all the activity, said Dr. Patricia Simmons, a Mayo Clinic administrator who is heading up the new DMC Economic Development Agency.
ELLE, She’s All That by Laurie Abraham, Brittney Griner is a slam-dunking, gender-bending, girl-loving phenom who's changing the world of sports—make that changing the world…While the IOC has defended its policy, the medical community basically agrees that there is no testosterone cutoff that makes a person definitely male or female. Moreover, many argue, why single out testosterone from the other physical advantages elite athletes tend to possess? “Having big hands, being tall, having lax joints, having high oxygen-carrying capacities”—these aren’t disqualifying factors, says J. Michael Bostwick, a Mayo Clinic psychiatrist who has studied the issue.
KABC Los Angeles, Playing harmonica can help patients with lung problems by Denise Dador, Playing a musical instrument can be fun, but for people with lung problems, it can also offer them a big health benefit. Music has always been a huge part of Larry Rawdon's life…Rawdon told his doctor about what he observed on his lung tests."I knew I could not just ignore what he was saying because this guy knows what he's talking about," said Dr. Cesar Keller with the Mayo Clinic Florida.
HealthNewsDigest, Mayo Study Customizing Treatments for Deadly Prostate Cancer with Tumor Genomics, A new study at Mayo Clinic is using genomic sequencing to develop customized treatments for men with castration-resistant prostate cancer, a progressive and incurable stage of prostate cancer, which no longer responds to hormone therapies that stop or slow testosterone production. "Men with castration-resistant prostate cancer have abysmal survival rates, typically living an average of two years once hormone therapies fail," says Manish Kohli, M.D., a Mayo Clinic oncologist and principal investigator of the Prostate Cancer Medically Optimized Genome-Enhanced Therapy (PROMOTE) study.
Medscape, Fewer Cases of Glaucoma Now Progressing to Blindness by Larry Hand, The probability of glaucoma leading to blindness in at least 1 eye fell almost 50% for patients in Olmsted County, Minnesota, who were diagnosed during 1981 to 2000 compared with patients diagnosed during 1965 to 1980, according to an article published online October 28 in Ophthalmology…Mehrdad Malihi, MD, from the Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, and colleagues analyzed medical records of open-angle glaucoma (OAG) incidences of patients in the most recent group through the end of 2009.
Inforum Fargo-Moorhead, Truck drivers considered last of rolling cowboys by John Lundy, Truck driving is one of the least healthy of careers, according to medical experts and those in the profession. The U.S. Bureau of Labor Statistics supports that claim, calling trucking one of the highest-risk occupations in the U.S. in a 2007 study. While the risk obviously includes the danger posed by highway accidents, unhealthy lifestyles also play a part, said Dr. Clayton Cowl, who practices occupational medicine at the Mayo Clinic in Rochester.
MedPage Today, New HCV Drugs Offer Hope After Transplant by Michael Smith, The advent of new all-oral regimens for hepatitis C (HCV) offers hope to patients who have undergone liver transplant and had the disease recur, a researcher said here. Patients with hepatitis C who get a new liver universally have a recurrence of the disease in the new organ, according to Michael Charlton, MD, of the Mayo Clinic in Rochester.
Bloomberg, Mechanical Hearts Beat Death for Transplant List Patients by Michelle Fay Cortez, Scott Morgan wrote off the pain on his left side as an old sports injury, never imagining it was a sign his heart was failing. When he finally went to the hospital last year, he was shocked to learn he needed a transplant. With fewer than 2,500 donated hearts that become available each year in the U.S. for transplant, Morgan’s doctors offered him another option. He got a mechanical pump placed inside his chest to keep him alive…The benefits of the pump are clear, said John Stulak, a cardiovascular surgeon at the Mayo Clinic in Rochester, Minnesota, who studies and implants the devices. Every trial comparing them with the best drug therapy, often the only treatment available, shows they lengthen and improve lives, he said.
ABC News, Early Puberty Tops List of Surprising Obesity Effects by Liz Neporent…Dr. Donald Hensrud, a nutritionist and preventive medicine expert in the department of endocrinology, diabetes, metabolism and nutrition at the Mayo Clinic, said one of the most immediate health dangers for many obese people is sleep apnea, a condition in which a person gasps or stops breathing momentarily while asleep.
Downtown Devil Ariz., Mayo Clinic journal editor discusses misleading medical coverage by Kristy Westgard, The editor of Mayo Clinic Proceedings spoke about the impact medical journalism has on the public to a group of about 15 students and medical professionals Tuesday at the Walter Cronkite School. William Lanier spoke about the process of producing a top medical journal and navigating the field of medical journalism.
Chicago Tribune, Mayo Clinic Medical Edge: Criteria can help determine if patient is good candidate for gastric bypass by Michael Sarr, M.D., Mayo Clinic, DEAR MAYO CLINIC: I have been overweight most of my life. I've tried for years to shed the extra pounds, but nothing works. I'm now 45 and about 100 pounds beyond my ideal weight. I have high blood pressure, and my doctor says I'm at risk for diabetes. I'm considering gastric bypass. Could this surgery work for someone like me?
Chicago Tribune, Mayo Clinic Medical Edge: For those with osteoarthritis, exercise can ease stiffness and increase mobility, by Shreyasee Amin, M.D, Rheumatology, DEAR MAYO CLINIC: I've been diagnosed with osteoarthritis, and my doctor says I need to start exercising.
Chicago Tribune, Mayo Clinic Medical Edge: MRI not intended to be used in place of a mammogram, DEAR MAYO CLINIC: Why is a mammogram the standard screening tool used to look for breast cancer? Wouldn't MRI catch the disease earlier? By Stephanie Hines, M.D., Breast Clinic, Mayo Clinic, Jacksonville, Fla.
ASU News, Mayo Clinic partners with ASU to help solve Latino health issues, A recent article in Hispanically Speaking News highlighted Mayo Clinic’s collaboration with Arizona State University and Mountain Park Health Center to create the Sangre por Salud Biobank, which will support studies in areas of special concern to the Latino population, such as obesity, metabolism and diabetes.
La Salud, Artritis reumatoide y enfermedad cardiac…En uno de los estudios, los científicos de Mayo Clinic descubrieron que los pacientes con artritis reumatoide más grave son más proclives a padecer problemas cardíacos. Esto ocurre poco después del ataque de la artritis reumatoide, lo que hace todavía más importante el tratamiento temprano de esta afección, comenta uno de los autores, el Dr. Eric Matteson, director de reumatología en Mayo Clinic de Rochester, Minnesota.
Chicago Tribune Innovations target risk of lymphedema by Nara Schoenberg, In the past few years, surgeons have made strides in preventing lymphedema, a potential side effect of breast cancer surgery in which a blockage in the lymphatic system causes fluid buildup and swelling in the arm…."There are a lot of people working on different things," said Dr. Sarah McLaughlin, a breast surgeon at the Mayo Clinic in Jacksonville, Fla. But as much as researchers would like to see advances in this area, she said, it's important to wait until new approaches are backed up by reliable data. Additional coverage: Fresno Bee, Hamilton Spectator, Bellingham Herald, Merced Sun Star Calif., Tri-City Herald
MedPage Today, Tell, Don't Ask When It Comes to Vaccinating Kids by Chris Kaiser, Pediatricians who told parents their child needed a vaccination rather than asked if they wanted one met less parental resistance, researchers found…"There is a lot of information out there and it can be really confusing to parents who mean well, but not all sources are credible," Jay Homme, MD, a pediatrician at the Mayo Clinic in Rochester, Minn., who was not involved with the study, told MedPage Today. "I feel like we have to build on a trust relationship. I've seen their children since they were infants. I've seen other children of theirs and really work on developing a trusting relationship," he said.
CBS News, New test may predict preeclampsia odds in pregnant women by Ryan Jaslow, Preeclampsia is a potentially dangerous complication facing pregnant women, but new research suggests an experimental test may be able to get ahead of the illness. Researchers at Kings College London say they've developed a new test that can predict which women will have the condition. Their findings were published Nov. 4 in the American Heart Association's journal, Circulation…When left untreated, it can lead to potentially fatal complications for both mom and baby, according to the Mayo Clinic.
NY Times Women’s Flexibility Is a Liability (in Yoga) by William Broad, From my own practice and research, I know that yoga is generally a good thing. The bending, stretching and deep breathing can renew, calm, heal, strengthen, lift moods, lower the risk of heart disease, increase flexibility and balance, counter aging and improve sex. In short, the benefits are many and commonplace while the serious dangers tend to be few and comparatively rare… Michael J. Taunton, an orthopedic surgeon at the Mayo Clinic, told me that he first learned of the danger a half decade ago and now annually performs 10 to 15 hip replacements on people who do yoga. About 90 percent, he added, are women.
Post-Bulletin Mayo Clinic researcher elected to Institute of Medicine, Dr. Clifford Jack Jr., radiologist and noted Alzheimer's disease researcher at Mayo Clinic, has been elected to the Institute of Medicine, part of the national academies. Election is considered one of the top honors in medicine.
WRTV (Ind)., Researchers identify 'red flag' breast cancer genes to predict disease chances by Anne Kelly… Researchers at the Mayo Clinic figured out a way to measure by percentage points how likely a woman is to develop the disease…It's what many doctors tell women when they discover the breast cancer gene runs in their family. But having the breast cancer gene doesn't necessarily mean someone is going to get cancer. Every woman is made up of so many other genes, and every single one of them also plays a role in determining whether or not a person develops cancer. Researchers at the Mayo Clinic, led by Dr. Fergus Couch, are studying those genes.
Lansing State Journal, Sparrow-Mayo partnership pays off by Lindsay VanHulle, Over a year into a partnership with the world-renowned Mayo Clinic, Sparrow Health System officials are touting the benefits, and both healthcare providers say the pact will offer better medical care as the effects of health care reform become apparent… The affiliation with Mayo — which also has clinics in Arizona and Florida — has allowed Sparrow to market itself using Mayo’s name and draw on Mayo’s expertise in so-called “best practices” and medical research. “As health care reform is underway, you see a lot of groups being acquired or merging and we really wanted to work with groups that wanted to stay independent, that are locally based,” said Shirley Weis, Mayo’s vice president and chief administrative officer.
Post-Bulletin, Historic CT scanner on display at Mayo Clinic by Jeff Hansel, Mayo Clinic is extending a historical exhibit to showcase its 40-year-old CT scanner — the first one ever used in the United States. "It is such a historical part of medicine," said Cynthia McCollough, professor of medical physics and biomedical engineering and director of the Mayo CT Clinical Innovation Center.
Houston Chronicle, Telehealth program aimed at NH stroke patients, Two New Hampshire hospitals are working together to provider better access to specialists for stroke patients. Dartmouth-Hitchcock has created a "telestroke" program so that patients have access to a specialist at any hour. Catholic Medical Center in Manchester will be the first site in the region to offer the service, which will connect its patients to vascular neurologists not only from Dartmouth-Hitchcock but from the Mayo Clinic. Additional coverage: Kansas City Star
Pharmacy Practice News, Open Access to Genomics May Spur Myeloma Therapy by Ben Guarino, A Boost for Personalized Medicine As the database grows, the MMRF’s goal in collecting this information will be to improve personalized medicine. “It’s knowing the genomic profile of an individual patient and tailoring therapy to meet this patient’s needs” that is such a compelling aspect of the initiative, said Keith Stewart, MB, ChB, a professor at Mayo Clinic in Phoenix, during the MMRF conference. “It’s using the right drug, for the right patient, at the right time.”
Albert Lea Tribune, Mayo Clinic Health System trying bold approach by Jason Schoonover, When Dr. Greg Angstman started with Mayo in 1990, he worked alone in an office about 40 feet from his nurse. Today at Mayo Clinic Health System in Austin, Angstman sits at one end of a bustling workspace, side-by-side with Dr. Timothy Rietz and a team: a registered nurse who handles form work, messages, medicine refills and patient education; multiple clinical nurses; nurse practitioners; a medical assistant; a care manager who helps with the most complicated patients; and a doctor of pharmacy.
Healio Rheumatology, RA patients with severe disease, early menopause at greater risk for cardiovascular disease, Patients with very severe rheumatoid arthritis had a higher risk for cardiovascular disease, according to research presented at the American College of Rheumatology annual meeting. Eric L. Matteson, MD, MPH, professor of medicine and chair of the department of rheumatology, Mayo Clinic, Rochester, Minn., presented highlights of four studies that focused on patients with rheumatoid arthritis (RA) and their risks for cardiovascular disease.
Arthritis Today, Arthritis Pain Limits Activities for Millions of Americans by Linda Rath…In fact, the opposite is the case, says Shreysaee Amin, MD, a rheumatologist at Mayo Clinic in Rochester, Minn., noting that activity actually reduces pain, makes joints healthier and helps manage other chronic health problems. Plus, she adds, "being less active leads to weight gain, which adds further stress to joints."
Medscape Knee Brace Reduces Damage, Pain in Osteoarthritis by Alice Goodman, For the first time, a scientific study has shown that a simple slip-on knee brace reduces bone marrow lesions and pain associated with osteoarthritis…"You could call this a ground-breaking study," said session moderator Eric Matteson, MD, from the Mayo Clinic in Rochester, New York. "The researchers used a simple technology and assessed it in a scientific way. No one has done that before. The biological effects of the brace and pain reduction were significant," he said.
New Yorker, Do Our Bones Influence Our Minds? By Amanda Schaffer…Karsenty’s vision of the skeleton as central to energy usage, reproduction, and memory has persuasive evidence in mice. If one of these studies “had come in isolation, I think I would have more skepticism toward it,” Sundeep Khosla, of the Mayo Clinic, said. But they’re “part of a whole series showing that bone helps regulate other tissues, and the findings in mice are well done and compelling.” (Much of the earlier work has also been corroborated by other labs, also using mouse models.)
MedPage Today, NFL Incident Shines Light on Bullying at Work by John Gever, Reports of disharmony on the Miami Dolphins football team have reminded many Americans not only that bullying extends beyond school playgrounds, but also that victims come in all sizes...Max Trenerry, PhD, a Mayo Clinic psychologist in Rochester, Minn., said that changes in effort level at work and interest in activities both at and away from work may signal something wrong in the workplace.
Modern Healthcare, At the Heart of Quality, by Maureen McKinney, Now in its 15th year, Truven's list of top cardiovascular hospitals recognizes 50 high-performing hospitals from a field of more than 1,000, based on performance across measures of cardiovascular safety, quality and efficiency, including mortality, 30-day readmission rates and whether hospitals followed evidence-based practices, such as providing instructions at discharge. 2014 The 50 top-performing hospitals listed in alphabetical order by category Years Hospital Location on list Teaching hospitals with cardiovascular residency programs… Mayo Clinic-St. Marys Hospital, Rochester, Minn.; Mayo Clinic Hospital, Phoenix.
US News & World Report, How to Prevent and Treat Cold Sores by Laura McMullen, A red, oozing – crusty, even! – cold sore ought to do it. Suffer a cold sore outbreak, and you're not only avoiding mirrors (and maybe people), but you're likely dealing with pain and itchiness, too. And while most cold sores retreat within a few weeks, why not prevent them from happening in the first place? Check out these cold sore prevention tips below from Clark Otley, the chair of the Department of Dermatology at the Mayo Clinic in Rochester, Minn., and from the Mayo Clinic website.
HealthNewsDigest, Dialysis for the Elderly: New Evidence from Mayo Clinic to Guide Shared Decision-Making, New research from Mayo Clinic finds that half of elderly patients who start dialysis after age 75 will die within one year. The findings are being presented this week at the American Society of Nephrology's Kidney Week 2013 in Atlanta."Many elderly patients and their families feel that they have no choice but to start dialysis, with several expressing regret from having initiated therapy," says primary care physician Bjorg Thorsteinsdottir, M.D., lead study author and a health care delivery scholar with the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.
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