peduncle

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Anyone know the salaries of a PMR pain specialist?
 

lobelsteve

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180 to 1M+
Cannot even begin to discuss the compensation issues as it is so varied and should be based on productivity. Any thing less and you are selling yourself short.
 

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lobelsteve said:
180 to 1M+
Cannot even begin to discuss the compensation issues as it is so varied and should be based on productivity. Any thing less and you are selling yourself short.

Steve....im surprised you even aswered. I can answer too....$1 to $100,000,000 or somewhere around there.

T
 
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peduncle

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haha thanks guys...

Its just that everyone seems to know a ballpark for Anesthesia Pain salaries... why not PMR pain.. or is it the same ballpark
 

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maybe $80,000 after taxes. I would stay in anesthesia.....dont do pain. It sucks.

T
 

wonthurtabit1

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peduncle said:
Anyone know the salaries of a PMR pain specialist?
What is a PMR pain specialist? If you are a self-anointed PMR pain specialist probably not a lot of money ... so be it. The bigger salaries come w/ acgme interventional physiatry or anesthesia pain fellowship training, ABA boards, etc. Lots of folks are calling themselves pain specialists just out of residency. There are also great non-acgme PMR fellowships w/ the kings/queens that you cannot shake a stick at: Slipman, Windsor, Derby/Yung Chen, April, Press, Prather, etc and probably some that I have missed.

I also think continuing education is key, run the PASSOR and ISIS series. Go hang out with the top folks and learn their tricks. Go to the ISIS, ASIPP, NASS courses. :cool:
 

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wonthurtabit1 said:
What is a PMR pain specialist? If you are a self-anointed PMR pain specialist probably not a lot of money ... so be it. The bigger salaries come w/ acgme interventional physiatry or anesthesia pain fellowship training, ABA boards, etc. Lots of folks are calling themselves pain specialists just out of residency. There are also great non-acgme PMR fellowships w/ the kings/queens that you cannot shake a stick at: Slipman, Windsor, Derby/Yung Chen, April, Press, Prather, etc and probably some that I have missed.

I also think continuing education is key, run the PASSOR and ISIS series. Go hang out with the top folks and learn their tricks. Go to the ISIS, ASIPP, NASS courses. :cool:

I'm very offended. :mad: :mad: :mad: :mad: :mad: :mad:

Emory University PMR-Pain Fellowship- Georgia Pain Physicians. Robert Windsor is the Program Director and we are ACGME accredited and our fellows are ABPMR certified in PM via the ABMS. We are the cutting edge of PM and have been since Dr. Windsor became one of the founding fathers of PMR-Pain. Our fellows average starting base salary has been close to $250,000 and there are fellows who walk into practice with a one third partnership in an ASC based practice with a fixed overhead as their threshold.
 

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I think getting a quality education is a better measure of a pain physician than whatever background they have provided they have a pmr, anesthesiology, or in some cases, a neurology background. Unfortunately, there are many family practitioners without fellowship or significant training in pain during residency that are advertising themselves as a pain specialist or as a pain clinic.
The outside-of-university programs may offer a singular perspective on pain that may be just as valid as the university programs and it is my hope the number of partnerships between pain practices outside the academic setting of a university and the university programs will expand for the betterment of the overall education in pain.
 

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lobelsteve said:
I'm very offended. :mad: :mad: :mad: :mad: :mad: :mad:

Emory University PMR-Pain Fellowship- Georgia Pain Physicians. Robert Windsor is the Program Director and we are ACGME accredited and our fellows are ABPMR certified in PM via the ABMS. We are the cutting edge of PM and have been since Dr. Windsor became one of the founding fathers of PMR-Pain. Our fellows average starting base salary has been close to $250,000 and there are fellows who walk into practice with a one third partnership in an ASC based practice with a fixed overhead as their threshold.
like I said, some that i missed: of course Windsor and the Emory pain group. geez :love:
 

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wonthurtabit1 said:
like I said, some that i missed: of course Windsor and the Emory pain group. geez :love:
One of the reasons I mention getting as many feathers in your cap as possible: fellowship, acgme, board exams, etc. is that in many urban centers there are major turfs wars and you are judged by those achievements. I think the toughest area in pain medicine today is how to come up with agreed standards of practice for folks who did not do a fellowship, but want to enter PM. How do we go about the privileging? What benchmarks do we use?
 

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I've asked around about this and it seems that the majority of hospitals (of those that do have requirements) are requiring proof of at least 10 of the advanced techniques (pumps, stims, discs, vertebroplasty). This seems reasonable, or at least better than no requirements. However, many don't have specific requirements for basic injections. Of those that do, it seems most don't require specific numbers, but do require fellowship training or documentation of proficiency (supervision by someone who is fellowship trained or already has priviledges). Oh well...it's a start.

Of course, I suppose the real problem are the masses of untrained "pain specialists" doing procedures in their offices. I think the only way to get rid of them is to get Medicare involved. This may be a whole can of worms we don't want to open, but if these people had to provide evidence of their training in order to get paid, alot of them would abandon doing procedures. I don't know...just a thought.
 

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PainDr said:
Of course, I suppose the real problem are the masses of untrained "pain specialists" doing procedures in their offices.
AKA "Feral Injectionsists." An oldie, but a goodie...


What is Feral?

Nikolai Bogduk, BSC(Med) MB BS PhD MD Dip Anat FAFRM

A feral animal is one that was previously domestic but which has been released into the wild. Examples include, pigs, goats, and cats. Each of these is a problem in Australia.

Domestic pigs that escape into the wild become feral. In the wild they uproot native vegetation and disturb the native ecosystem; they become very aggressive; and subsequent generations revert to the behavior of
wild boars; but the difference is that feral pigs grow much bigger than native boars.

Goats have survived shipwrecks and inhabit islands around Australia. There they cause the same sort of problems as feral pigs - disrupting the natural environment.

Feral cats are probably the worst problem. The gentle domestic ***** becomes a fabulous survivor in the wild. They become fierce in the search of food; they become expert predators; they grow large as do their
offspring; they destroy native animals that are easy prey in a country with no more than a handful of carnivores, only the dingo (dog) being larger than a hand.

The key features of feral animals are that on the one hand, they were once domestic, in which environment they were relatively gentle, approachable, well behaved, and even trained; on the other hand, when they are released into the wild, they become aggressive survivors, and take advantage of the environment, which they disturb and destroy in their fight for survival.

I have on occasions used “feral” as a metaphor in Pain Medicine. There are practitioners that strike me as feral. They are ones who were once domestic (they went to medical school and were trained in the correct answers and correct behaviors) but once released into the wild (Pain Medicine) they become feral.

For reference, the features of feral practitioners are any of the following, alone or in combination.

§ They perform procedures without proper indications.
§ They perform procedures contrary to indications or contrary to best practice guidelines.
§ Incorrectly they call what they do by the same name as the legitimate procedure.
§ They charge the same CPT code even when they do the procedure wrongly or suboptimally.
§ They abuse the procedure by not assessing their results, i.e.
they perform diagnostic blocks but do not formulate a reliable or valid diagnosis; they perform therapeutic procedures but their outcomes are substandard or nil;
§ neither of which concerns them.
§ They misuse the literature, usually by quoting the legitimate literature to support what they do, even though what they do bears little resemblance to that literature.
§ They announce that what they do is better than what is reported in the literature, but never subject their techniques to scrutiny and evaluation.


For feral practitioners the consequences are clear - like feral animals they survive in the wild; some survive well. Some get elevated to positions of prestige, and teach courses (showing their offspring how to survive in the wild).

For others the behavior of feral practitioners can be as offensive as the behavior of feral animals. Feral medical practice gives a bad name to the procedures; it gives a bad name to responsible practitioners.

It is for this reason that I have introduced the metaphor - feral, in the context of Pain Medicine.

The objectives of ISIS are not so much to stamp out feral practice, but to represent cogent and responsible practice that stands in contrast to feral behavior. It is to lead by example.

It has been for this reason that ISIS sponsored research to provide a legitimate scientific base for the procedures that we promote. It is for this reason that the Standards Committee is nearing completion of
comprehensive descriptions of what is good behavior; that is not destructive to our environment - respected medical practice.

My own tragedies in this arena, and why I use the descriptor - feral, have arisen when I have published good work, only to have it decried by critics, not because it is scientifically unsound but because the procedure, now legitimized, will be abused by the ferals. I estimate, perhaps incorrectly, that for every good operator there are 9 feral exponents. I, and the reputation of good practice, are outnumbered by the ferals, and it is the ferals, not the good practitioners, that the critics see day to day. It is no wonder that they
are not impressed with needle procedures.

I look to ISIS for support, through its programs of research and Standards, I seek allies and growing numbers of responsible practitioners, who lead by example.

You can live comfortably with domestic pigs, domestic goats, and domestic cats; they can even be fun to live with; and even insurers might be tempted to feed the young at an animal farm. No-one wants to feed
cat food to feral cats.

In case you missed the depth of the metaphor, the innocent native animals who get eaten or have their habitat destroyed by feral animals are the patients.
 

drrinoo

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drusso said:
AKA "Feral Injectionsists." An oldie, but a goodie...


What is Feral?

Nikolai Bogduk, BSC(Med) MB BS PhD MD Dip Anat FAFRM

A feral animal is one that was previously domestic but which has been released into the wild. Examples include, pigs, goats, and cats. Each of these is a problem in Australia.

Domestic pigs that escape into the wild become feral. In the wild they uproot native vegetation and disturb the native ecosystem; they become very aggressive; and subsequent generations revert to the behavior of
wild boars; but the difference is that feral pigs grow much bigger than native boars.

Goats have survived shipwrecks and inhabit islands around Australia. There they cause the same sort of problems as feral pigs - disrupting the natural environment.

Feral cats are probably the worst problem. The gentle domestic ***** becomes a fabulous survivor in the wild. They become fierce in the search of food; they become expert predators; they grow large as do their
offspring; they destroy native animals that are easy prey in a country with no more than a handful of carnivores, only the dingo (dog) being larger than a hand.

The key features of feral animals are that on the one hand, they were once domestic, in which environment they were relatively gentle, approachable, well behaved, and even trained; on the other hand, when they are released into the wild, they become aggressive survivors, and take advantage of the environment, which they disturb and destroy in their fight for survival.

I have on occasions used “feral” as a metaphor in Pain Medicine. There are practitioners that strike me as feral. They are ones who were once domestic (they went to medical school and were trained in the correct answers and correct behaviors) but once released into the wild (Pain Medicine) they become feral.

For reference, the features of feral practitioners are any of the following, alone or in combination.

§ They perform procedures without proper indications.
§ They perform procedures contrary to indications or contrary to best practice guidelines.
§ Incorrectly they call what they do by the same name as the legitimate procedure.
§ They charge the same CPT code even when they do the procedure wrongly or suboptimally.
§ They abuse the procedure by not assessing their results, i.e.
they perform diagnostic blocks but do not formulate a reliable or valid diagnosis; they perform therapeutic procedures but their outcomes are substandard or nil;
§ neither of which concerns them.
§ They misuse the literature, usually by quoting the legitimate literature to support what they do, even though what they do bears little resemblance to that literature.
§ They announce that what they do is better than what is reported in the literature, but never subject their techniques to scrutiny and evaluation.


For feral practitioners the consequences are clear - like feral animals they survive in the wild; some survive well. Some get elevated to positions of prestige, and teach courses (showing their offspring how to survive in the wild).

For others the behavior of feral practitioners can be as offensive as the behavior of feral animals. Feral medical practice gives a bad name to the procedures; it gives a bad name to responsible practitioners.

It is for this reason that I have introduced the metaphor - feral, in the context of Pain Medicine.

The objectives of ISIS are not so much to stamp out feral practice, but to represent cogent and responsible practice that stands in contrast to feral behavior. It is to lead by example.

It has been for this reason that ISIS sponsored research to provide a legitimate scientific base for the procedures that we promote. It is for this reason that the Standards Committee is nearing completion of
comprehensive descriptions of what is good behavior; that is not destructive to our environment - respected medical practice.

My own tragedies in this arena, and why I use the descriptor - feral, have arisen when I have published good work, only to have it decried by critics, not because it is scientifically unsound but because the procedure, now legitimized, will be abused by the ferals. I estimate, perhaps incorrectly, that for every good operator there are 9 feral exponents. I, and the reputation of good practice, are outnumbered by the ferals, and it is the ferals, not the good practitioners, that the critics see day to day. It is no wonder that they
are not impressed with needle procedures.

I look to ISIS for support, through its programs of research and Standards, I seek allies and growing numbers of responsible practitioners, who lead by example.

You can live comfortably with domestic pigs, domestic goats, and domestic cats; they can even be fun to live with; and even insurers might be tempted to feed the young at an animal farm. No-one wants to feed
cat food to feral cats.

In case you missed the depth of the metaphor, the innocent native animals who get eaten or have their habitat destroyed by feral animals are the patients.
There is no doubt that he is advocating for patient welfare and the correct practice of medicine. However, now that ISIS's second 'I' stands for intervention and not injection, perhaps Dr. Bogduk go after 'feral' big game. He could use his talents to reduce 'feral' spine surgery and the 'feral' use of spine imaging. Based on conservative estimates spine surgery costs society approximately 10-14 fold compared to spinal injections. I wish I knew how much advanced spine imaging costs society.
 
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drrinoo

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drusso said:
AKA "Feral Injectionsists." An oldie, but a goodie...


What is Feral?

Nikolai Bogduk, BSC(Med) MB BS PhD MD Dip Anat FAFRM

A feral animal is one that was previously domestic but which has been released into the wild. Examples include, pigs, goats, and cats. Each of these is a problem in Australia.

Domestic pigs that escape into the wild become feral. In the wild they uproot native vegetation and disturb the native ecosystem; they become very aggressive; and subsequent generations revert to the behavior of
wild boars; but the difference is that feral pigs grow much bigger than native boars.

Goats have survived shipwrecks and inhabit islands around Australia. There they cause the same sort of problems as feral pigs - disrupting the natural environment.

Feral cats are probably the worst problem. The gentle domestic ***** becomes a fabulous survivor in the wild. They become fierce in the search of food; they become expert predators; they grow large as do their
offspring; they destroy native animals that are easy prey in a country with no more than a handful of carnivores, only the dingo (dog) being larger than a hand.

The key features of feral animals are that on the one hand, they were once domestic, in which environment they were relatively gentle, approachable, well behaved, and even trained; on the other hand, when they are released into the wild, they become aggressive survivors, and take advantage of the environment, which they disturb and destroy in their fight for survival.

I have on occasions used “feral” as a metaphor in Pain Medicine. There are practitioners that strike me as feral. They are ones who were once domestic (they went to medical school and were trained in the correct answers and correct behaviors) but once released into the wild (Pain Medicine) they become feral.

For reference, the features of feral practitioners are any of the following, alone or in combination.

§ They perform procedures without proper indications.
§ They perform procedures contrary to indications or contrary to best practice guidelines.
§ Incorrectly they call what they do by the same name as the legitimate procedure.
§ They charge the same CPT code even when they do the procedure wrongly or suboptimally.
§ They abuse the procedure by not assessing their results, i.e.
they perform diagnostic blocks but do not formulate a reliable or valid diagnosis; they perform therapeutic procedures but their outcomes are substandard or nil;
§ neither of which concerns them.
§ They misuse the literature, usually by quoting the legitimate literature to support what they do, even though what they do bears little resemblance to that literature.
§ They announce that what they do is better than what is reported in the literature, but never subject their techniques to scrutiny and evaluation.


For feral practitioners the consequences are clear - like feral animals they survive in the wild; some survive well. Some get elevated to positions of prestige, and teach courses (showing their offspring how to survive in the wild).

For others the behavior of feral practitioners can be as offensive as the behavior of feral animals. Feral medical practice gives a bad name to the procedures; it gives a bad name to responsible practitioners.

It is for this reason that I have introduced the metaphor - feral, in the context of Pain Medicine.

The objectives of ISIS are not so much to stamp out feral practice, but to represent cogent and responsible practice that stands in contrast to feral behavior. It is to lead by example.

It has been for this reason that ISIS sponsored research to provide a legitimate scientific base for the procedures that we promote. It is for this reason that the Standards Committee is nearing completion of
comprehensive descriptions of what is good behavior; that is not destructive to our environment - respected medical practice.

My own tragedies in this arena, and why I use the descriptor - feral, have arisen when I have published good work, only to have it decried by critics, not because it is scientifically unsound but because the procedure, now legitimized, will be abused by the ferals. I estimate, perhaps incorrectly, that for every good operator there are 9 feral exponents. I, and the reputation of good practice, are outnumbered by the ferals, and it is the ferals, not the good practitioners, that the critics see day to day. It is no wonder that they
are not impressed with needle procedures.

I look to ISIS for support, through its programs of research and Standards, I seek allies and growing numbers of responsible practitioners, who lead by example.

You can live comfortably with domestic pigs, domestic goats, and domestic cats; they can even be fun to live with; and even insurers might be tempted to feed the young at an animal farm. No-one wants to feed
cat food to feral cats.

In case you missed the depth of the metaphor, the innocent native animals who get eaten or have their habitat destroyed by feral animals are the patients.
There is no doubt that he is advocating for patient welfare and the correct practice of medicine. However, now that ISIS's second 'I' stands for intervention and not injection, perhaps Dr. Bogduk could go after 'feral' big game. He could use his talents to reduce 'feral' spine surgery and the 'feral' use of spine imaging. Based on conservative estimates spine surgery costs society approximately 10-14 fold compared to spinal injections. I wish I knew how much advanced spine imaging costs society.
 

algosdoc

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Wow...good point! Perhaps Dr B can aim his guns with a broader swath. It was fascinating seeing Dr Bogduk and Dr Racz on the same stage together with their academic jousting. Both are respected leaders of the field and both had valid points. I think it is that type of interaction that benefits us mere mortals the most.
 

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algosdoc said:
Wow...good point! Perhaps Dr B can aim his guns with a broader swath. It was fascinating seeing Dr Bogduk and Dr Racz on the same stage together with their academic jousting. Both are respected leaders of the field and both had valid points. I think it is that type of interaction that benefits us mere mortals the most.
Maybe it was just my innate ISIS bias, but to me Dr. Racz came off as a doddering old man, shilling for ASIPP and Epimed, while Drs. Bogduk and Aprill stood their ground and did not let him ramble off touting the virtues of blunt needles without a shred of evidence.
 

md2k

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paz5559 said:
Maybe it was just my innate ISIS bias, but to me Dr. Racz came off as a doddering old man, shilling for ASIPP and Epimed, while Drs. Bogduk and Aprill stood their ground and did not let him ramble off touting the virtues of blunt needles without a shred of evidence.
Yes, it was your ISIS bias. And yes there is some evidence that Pauza conveniatly forgot to mention or he just didn't do his homework. Look up the Atkins paper in 89, bergers paper and heavners paper in relation to artery punctures. No one ever said you cant puncture veins!!!!
Personally I have used them hundreds of times and have yet to get an arterial puncture.
 

drusso

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paz5559 said:
Maybe it was just my innate ISIS bias, but to me Dr. Racz came off as a doddering old man, shilling for ASIPP and Epimed, while Drs. Bogduk and Aprill stood their ground and did not let him ramble off touting the virtues of blunt needles without a shred of evidence.
For those of us who didn't have the opportunity to attend, can you please elaborate...paint a picture if you will? What was the setting and what were the major points??
 

wonthurtabit1

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paz5559 said:
Maybe it was just my innate ISIS bias, but to me Dr. Racz came off as a doddering old man, shilling for ASIPP and Epimed, while Drs. Bogduk and Aprill stood their ground and did not let him ramble off touting the virtues of blunt needles without a shred of evidence.
We should all hope to have achieved all that "doddering"... give the guy a break. How many of us will be invited to the big table in 40 years? show some respect for the forefathers

nuff said
 

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md2k said:
Yes, it was your ISIS bias. And yes there is some evidence that Pauza conveniatly forgot to mention or he just didn't do his homework. Look up the Atkins paper in 89, bergers paper and heavners paper in relation to artery punctures. No one ever said you cant puncture veins!!!!
Personally I have used them hundreds of times and have yet to get an arterial puncture.
Care to give us any citations so we can look these articles up (or perhaps even post the abstracts so they can be discussed in this forum?)
 

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paz5559 said:
Care to give us any citations so we can look these articles up (or perhaps even post the abstracts so they can be discussed in this forum?)
You are making me work too hard. :)
 

md2k

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wonthurtabit1 said:
We should all hope to have achieved all that "doddering"... give the guy a break. How many of us will be invited to the big table in 40 years? show some respect for the forefathers

nuff said
Ditto, respect papa racz :thumbup:
 

md2k

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paz5559 said:
Care to give us any citations so we can look these articles up (or perhaps even post the abstracts so they can be discussed in this forum?)

ORIGINAL ARTICLE
Sharp Versus Blunt Needle: A Comparative Study of Penetration of Internal Structures and Bleeding in Dogs
James E. Heavner, DVM, PhD1,2; Gabor B. Racz, MD1; Bharat Jenigiri, MBBS1; Travis Lehman1; Miles R. Day, MD

Abstract:

Background and Objectives: Complications associated with interventional pain procedures have raised questions regarding the relative safety of sharp vs. blunt needles. It has been speculated that the incidence of hemorrhage, intraneural and/or intravascular injections may be reduced by the use of blunt needles. In this study we compared penetration and bleeding associated with sharp vs. blunt needle punctures.

Methods: Attempts were made to insert blunt and sharp needles (18-, 20-, 22-, and 25-gauge) directly or percutaneously into kidney, liver, renal artery, intestine or spinal nerve/nerve root of anesthetized dogs. Penetration and bleeding were ascertained by direct vision through a surgical wound.

Results: All attempts to directly puncture the kidney and liver with sharp needles were successful. All but one attempt to puncture a spinal nerve/nerve root with 20-, 22-, and 25-gauge sharp needles were successful but half or less attempts to puncture the intestines were successful. All attempts to puncture the renal artery with sharp needles were successful. Blunt needles never punctured the renal artery, spinal nerve/nerve root and intestines and rarely penetrated the kidney (22- and 25-gauge one time each). All attempts to puncture the liver with blunt needles were successful. Bleeding scores for kidney punctures were generally higher for larger sharp needles than for smaller ones. Bleeding scores for blunt needle punctures of the liver were generally smaller than for sharp needle puncture.

Conclusion: Blunt needles are less likely than sharp ones to enter vital structures and/or produce hemorrhage. Thus, blunt needles may be preferable to sharp ones for performing interventional pain procedures.
 
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paz5559 said:
Care to give us any citations so we can look these articles up (or perhaps even post the abstracts so they can be discussed in this forum?)

The Blunt Needle: A New Percutaneous Access Device
E. William Akins,1 Irvin F. Hawkins, Jr., Christopher Mladinich, Richard Tupler, Roy J. Siragusa, and Richard Pry
All previously reported methods of gaining percutaneous access for interventional radiologic procedures have used needles with sharp tips. Surgeons have used blunt-tipped devices to avoid inadvertent penetration of arteries or adjacent vital structures [1 , 2]. This report documents our development and clinical testing of a new blunt access needle that applies this surgical technique to interventional radiology.

Methods
The standard 18-gauge splenic needle (Cook, Bloomington, IN) has a sharp stylet within the blunt cannula. Our blunt needle was made by filing down the sharp inner stylet (Fig. 1). The commercially available versions(Cook, Bloomington, IN; National Standard, Gainesville, FL) feature an extremely smooth blunt tip and a Iockin9 hub. The 18-gauge needle was chosen because we thought that this size would truly behave as a blunt instrument, whereas a fine blunt needle theoretically could enter arteries because its tiny tip may not be “discriminating.” The 18-gauge needle also permits insertion of large guidewires or aspiration, and it has enough strength that the position
of the tip can be changed after insertion to provide a better angle of entry into the target. Studies were performed in 12 mongrel dogs as follows. Blunt and sharp needle punctures were performed with direct inspection of
resultant bleeding in five dogs (open model); percutaneous renal and
hepatic puncture was performed in three dogs; and percutaneous, directed puncture of the renal artery opacified with barium was done in four dogs.
The blunt needle was used for 52 interventional procedures in 46 patients (1 8 nephrolithotomies, eight nephrostomies, 12 biliary drainages, 12 abscess drainages, and two coaxial biopsies). Informed consent was obtained. After a skin nick was made, the blunt needle was advanced to the target in a routine manner by using fluoroscopic, sonographic, or CT guidance as needed. When the blunt needle was advanced within 2 mm of the target, sharp needles were used coaxially for all biliary drainages and nephrolithotomies.

Results
In the open model, 20 sharp needle punctures of the kidney resulted in seven instances (35%) of brisk arterial bleeding as well as slow capsular bleeding when the needle was removed. The blunt needle caused a similar amount of capsular bleeding but no brisk arterial bleeding after 50 direct renal punctures.
The blunt needle displaced loops of bowel without laceration or entry into the intestines. When a percutaneous technique was used in three dogs, the blunt needle was directed through the deep fascia down to the kidney and, in most passes, through the renal parenchyma. When a glancing needle pass was not perpendicular to the kidney, the blunt needle bounced off the renal capsule.
Parenchymal entry in this circumstance required a jabbing action at the capsule. After 20 transrenal passages, aspiration through the blunt needle, as it was slowly withdrawn, revealed no arterial bleeding and only one instance of venous bleeding (5%). Using identical access routes, we verified fluoroscopically and arteriographically that the sharp needle entered arteries in 3 (38%) of 8; venous entry occurred in two other cases (25%). In four dogs, we could not force the blunt needle to enter a barium-filled renal artery despite at least 1 00 direct forceful attempts. The blunt needle deformed the renal pedicle without arterial damage; the artery moved out of the needle path. The sharp needle entered the renal artery on the first or second
attempt and caused massive extravasation in all instances. We used the blunt needle to perform 52 procedures on 46 patients. The overall success rate was 98%. Six patients had minor complications. With moderate pressure, the blunt
needle was capable of traversing organ parenchyma. Some resistance was often noted at fascial planes, but this was overcome by using a controlled jabbing motion of the needle at the entry site. The blunt needle failed to enter one kidney with dense capsular fibrosis, but it served as a coaxial trocar,
allowing direction of the 22-gauge needle guide into the appropriate calix.
None of the 1 8 patients in whom the blunt needle was used for access in 18 endourologic procedures required transfusion for bleeding. In one case, nephroscopy revealed a thrombus but no active bleeding. In one other case, we achieved excellent initial access using the blunt needle, but the nephrolithotomy was aborted because of a pelvic tear caused by the tract dilator. In 1 6 other percutaneous nephroscopic procedures performed with the blunt needle, bleeding was minimal even when the tract was dilated to 36 French for rigid nephroscopy and stone removal. Eight simple nephrostomies
were easily performed with the blunt needle. Either the blunt needle can be advanced into calices directly, or final access can be gained with a coaxial 22-gauge needle. The blunt needle was used successfully for 12 percutaneous
biliary drainage procedures in 1 1 patients. In these cases, the biliary system was first opacified with contrast material. The blunt needle was used to gain access down to the duct. Because the blunt tip impressed the duct and did
not enter, we placed a 22-gauge needle guide through the wall, taking care to make a single wall puncture. A guidewire was then advanced into the duct to allow catheter placement. Patients tolerated this procedure as well as other patients had tolerated similar procedures with sharp needles. The blunt needle was used for percutaneous abscess drainage when vascular structures or bowel was present in the pathway to be used for needle placement. Viscous pus was aspirated through the 1 8-gauge cannula in more instances than would be possible through 22-gauge needles. Using the blunt needle as a coaxial trocar for insertion of a 22-gauge biopsy needle, we successfully performed two aspiration biopsies.

Discussion
Initial access for drainage procedures in radiology previously has been accomplished with a variety of entry needles, all with sharp tips that cut a tract through tissue and do not discriminate between vascular and nonvascular tissues. Less bleeding occurs when 22-gauge needles are used [3] because the smaller needle tract allows spontaneous hemostasis after
inadvertent arterial puncture. However, if transarterial placement of the skinny needle occurs during the pass when the target is entered, arterial hemorrhage may occur if a large catheter is advanced through this tract. Percutaneous biliary drainage has been complicated by fatal hemorrhage [4], and hemorrhage requiring transfusion therapy also has occurred in 1 0-43% of percutaneous nephrolithotomies [5, 6]. Modem surgeons avoid sharp dissection, preferring to perform blunt or manual dissection of tissue planes because it is safer and generally adequate for exposure or definitive drainage.
Transcerebral ventriculostomy [1] has been done with blunt drainage tubes. Periorbitai anesthesia [2] has been done with blunt-tipped needles, and significant procedural hemorrhage is rare. The Cuatico needle (Becton-Dickinson, Rutherford, NJ), which has a blunt stylet, has been used for Pantopaque myelography. Our results support our hypothesis [7] that the blunt needle is able to puncture abdominal viscera and fluid collections
safely and without arterial damage because of the resilience of the arterial wall. Although these results are encouraging, further studies will be required to prove whether percutaneous nephrolithotomy performed with blunt needles causes less bleeding than a procedure done with sharp needles. Use of the blunt needle, based on the surgical premise of blunt dissection, can be applied to a wide variety of interventional radiologic procedures and is particularly applicable when inadvertent arterial or intestinal puncture is possible. :smuggrin:
 

md2k

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paz5559 said:
Care to give us any citations so we can look these articles up (or perhaps even post the abstracts so they can be discussed in this forum?)
paz
I found you two of the articles. Hopefully this helps you understand blunt needles and the concept behind them my freindly biased ISIS member. :love:
 

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md2k said:
*******************
I found you two of the articles. Hopefully this helps you understand blunt needles and the concept behind them my freindly biased ISIS member. :love:

Spoken like a fellow in Racz's program....

Puncturing dog kidneys is not analogous to arterial puncture.

Bias from Racz's article cannot be ignored.

The debate rolls on.
 

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lobelsteve said:
Spoken like a fellow in Racz's program....

Puncturing dog kidneys is not analogous to arterial puncture.

Bias from Racz's article cannot be ignored.

The debate rolls on.
You obviously did not read the articles are are just speaking out of your ass. Read them first and learn. :laugh:
 

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md2k said:
You obviously did not read the articles are are just speaking out of your ass. Read them first and learn. :laugh:
Ad hominim attacks attest to your character.

"Results: All attempts to directly puncture the kidney and liver with sharp needles were successful. All but one attempt to puncture a spinal nerve/nerve root with 20-, 22-, and 25-gauge sharp needles were successful but half or less attempts to puncture the intestines were successful. All attempts to puncture the renal artery with sharp needles were successful. Blunt needles never punctured the renal artery, spinal nerve/nerve root and intestines and rarely penetrated the kidney (22- and 25-gauge one time each). All attempts to puncture the liver with blunt needles were successful. Bleeding scores for kidney punctures were generally higher for larger sharp needles than for smaller ones. Bleeding scores for blunt needle punctures of the liver were generally smaller than for sharp needle puncture.

Conclusion: Blunt needles are less likely than sharp ones to enter vital structures and/or produce hemorrhage. Thus, blunt needles may be preferable to sharp ones for performing interventional pain procedures."

So explain how this translates to spinal procedures in humans. Really, please.
Get some real data or better yet just look at Pauza's data. Blunt over sharp makes intuitive sense and in PM that is close enough for most folks. The added cost without known added benefit makes the debate plausible but not worth wasting time over.

Your attitude is unprofessional at best and does nothing to support your stance onm the issue. A little decorum if not respect even in this forum is still appropriate.
 

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lobelsteve said:
Ad hominim attacks attest to your character.

"Results: All attempts to directly puncture the kidney and liver with sharp needles were successful. All but one attempt to puncture a spinal nerve/nerve root with 20-, 22-, and 25-gauge sharp needles were successful but half or less attempts to puncture the intestines were successful. All attempts to puncture the renal artery with sharp needles were successful. Blunt needles never punctured the renal artery, spinal nerve/nerve root and intestines and rarely penetrated the kidney (22- and 25-gauge one time each). All attempts to puncture the liver with blunt needles were successful. Bleeding scores for kidney punctures were generally higher for larger sharp needles than for smaller ones. Bleeding scores for blunt needle punctures of the liver were generally smaller than for sharp needle puncture.

Conclusion: Blunt needles are less likely than sharp ones to enter vital structures and/or produce hemorrhage. Thus, blunt needles may be preferable to sharp ones for performing interventional pain procedures."

So explain how this translates to spinal procedures in humans. Really, please.
Get some real data or better yet just look at Pauza's data. Blunt over sharp makes intuitive sense and in PM that is close enough for most folks. The added cost without known added benefit makes the debate plausible but not worth wasting time over.

Your attitude is unprofessional at best and does nothing to support your stance onm the issue. A little decorum if not respect even in this forum is still appropriate.
Heavner study: All attempts to puncture the renal artery with sharp needles were successful. Blunt needles never punctured the renal artery, spinal nerve/nerve root and intestines and rarely penetrated the kidney (22- and 25-gauge one time each).

Akins study:In four dogs, we could not force the blunt needle to enter a barium-filled renal artery despite at least 100 direct forceful attempts.

Yes they are dog studies. However, they did show that they couldn't penetrate the renal arteries with blunts and with sharps they could. What else do you want?? So it wasn't done in the spine. Do you want a study where you attempt to inject in the vertebral artery, or the artery of adamkewicz? Pauza's study?? All he showed is that you can get in a vein. Big deal, thats not a complication. He has no data regarding arterial puncture. As you said, Blunt over sharp makes intuitive sense.
I agree, the needles cost much, much more. Probably 3 to 5 times more and thats unfortunate.

This was not an attack Ad hominim. I am not trying to kill the messenger. I was merely replying to your comment and was not trying to affend you. In the future I will atone my responses in respect to you :love:
 

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md2k said:
Ditto, respect papa racz :thumbup:
guys in "bowties" have hit the apex.... bowties are the province of chancellors of ivy league universities or precocious neurologists :laugh:
 

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md2k said:
Heavner study: All attempts to puncture the renal artery with sharp needles were successful. Blunt needles never punctured the renal artery, spinal nerve/nerve root and intestines and rarely penetrated the kidney (22- and 25-gauge one time each).

Akins study:In four dogs, we could not force the blunt needle to enter a barium-filled renal artery despite at least 100 direct forceful attempts.

Yes they are dog studies. However, they did show that they couldn't penetrate the renal arteries with blunts and with sharps they could. What else do you want?? So it wasn't done in the spine. Do you want a study where you attempt to inject in the vertebral artery, or the artery of adamkewicz? Pauza's study?? All he showed is that you can get in a vein. Big deal, thats not a complication. He has no data regarding arterial puncture. As you said, Blunt over sharp makes intuitive sense.
I agree, the needles cost much, much more. Probably 3 to 5 times more and thats unfortunate.

This was not an attack Ad hominim. I am not trying to kill the messenger. I was merely replying to your comment and was not trying to affend you. In the future I will atone my responses in respect to you :love:
hey guys,
i was tempted to ask pauza if he curved the needle tip or not? bogduk seemed to favor a straight, sharp needle accurately placed; in other words, if you execute good technique, there should not be a problem. i find that i have to curve my needle to get into the tight spots. If am going to re-adjust position however, esp near the foramen, i won't just propeller it. i pull it back spinning it slowly up and then spin down a new track.

who was it that questioned bogduk's safe triangle. i was impressed by all the medullary arteries found in the supposed safe triangle. this is making me think about DSA for all procedures in the L-spine.... as well as switching to depomedrol for all procedures. comments from the posse on pain-way?

april also had an interesting pearl to share, if i remember correctly w/ cervicals he will inject 1 cc lido 2% and wait for 1-2 minutes to see if he gets a sz before he injects a tfesi.
 

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drusso said:
For those of us who didn't have the opportunity to attend, can you please elaborate...paint a picture if you will? What was the setting and what were the major points??
I believe Dr. Racz was supposed to talk about epidural lysis of adhesions. From what I remember much of his intro involved going on about how important it was to be on Capitol Hill.

Funny, in Dr. Endres' opening address, he stated how fortunate he felt to be part of an organization that did not focus its budget on "buying congressmen".

Then, there was also Dr. Racz during his lecture flashing up a picture from Fenton of the ISIS "Safe Triangle", wanting to know "Who is responsible for this?".
 

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wonthurtabit1 said:
What is a PMR pain specialist? If you are a self-anointed PMR pain specialist probably not a lot of money ... so be it. The bigger salaries come w/ acgme interventional physiatry or anesthesia pain fellowship training, ABA boards, etc. Lots of folks are calling themselves pain specialists just out of residency. There are also great non-acgme PMR fellowships w/ the kings/queens that you cannot shake a stick at: Slipman, Windsor, Derby/Yung Chen, April, Press, Prather, etc and probably some that I have missed.

I also think continuing education is key, run the PASSOR and ISIS series. Go hang out with the top folks and learn their tricks. Go to the ISIS, ASIPP, NASS courses. :cool:
What does the quality of your training have to do with billing?

I would argue that better training makes one more knowledgeable and conservative, therefore making less money.

Secondly, some of the fellowships you listed are "Musculoskeletal" or "Spine/Sports Medicine" fellowships. I wouldn't even call them "pain" fellowships. Not that they do not offer great training, because they do, but they lead someone down a different type of practice entirely.

I think when we stop trying to call anyone who cares for the spine or musculoskeletal system a "pain" doctor, perhaps there can be more uniform standards for those who wish to practice comprehensive pain medicine.
 

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Disciple said:
What does the quality of your training have to do with billing?

I would argue that better training makes one more knowledgeable and conservative, therefore making less money.

Secondly, some of the fellowships you listed are "Musculoskeletal" or "Spine/Sports Medicine" fellowships. I wouldn't even call them "pain" fellowships. Not that they do not offer great training, because they do, but they lead someone down a different type of practice entirely.

I think when we stop trying to call anyone who cares for the spine or musculoskeletal system a "pain" doctor, perhaps there can be more uniform standards for those who wish to practice comprehensive pain medicine.
Bingo. I think Rathmell and the boys have all that sorted out and the ACGME will implement the changes next year. There will be great change in PM&R Pain programs or they will go away from trying for ACGME accred. I'm revieing the PIF right now and it looks doable, buth the gas bias the boys put on it is overpowering. If you look at the edits- only the anes section did not get a full rewrite.

Does qanybody have the list of the PMR docs that went to the table with Rathmell? I need to discuss this....
 

paz5559

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Disciple said:
Secondly, some of the fellowships you listed are "Musculoskeletal" or "Spine/Sports Medicine" fellowships. I wouldn't even call them "pain" fellowships. Not that they do not offer great training, because they do, but they lead someone down a different type of practice entirely.

I think when we stop trying to call anyone who cares for the spine or musculoskeletal system a "pain" doctor, perhaps there can be more uniform standards for those who wish to practice comprehensive pain medicine.
Semantics, but in this case, with a core of misunderstanding beneath mere verbiage

I agree that some fellowships are non-interventional. But to suggest that preeminent ones like those run by Drs Press and Prather do not address pain demonstrates a fundamental disconnect in our field.

Injections are not, nor were they ever designed to, be the silver bullet that solves patients' symptomatology. Those with that belief are doomed to have the revolving door practice that makes a good deal more money, but ultimately doesn’t get patients better long term.

Injections and other spinal interventions are a means to an end. They enable patients to experience a pain-free window pf opportunity. What we encourage them to DO during that period is the key. Drs. Press, Weinstein, Herring, and Prather view injections as the START of the therapeutic mélange, but then take a more active role in the specifics of the physical therapy that follows.

To draw a bright line distinction between fellowships is a mistake. Clearly, some do more injections than others. Clearly some do no cervical interventions at all. But to say I am different from those trained by some of our thought leaders, and to distinguish their training as a different subset altogether misses the point - we all treat pain. Pain is a dirty word, cause at it's root, it implies we treat it with narcotics, and thus no one wants to be a pain doctor anymore. But in this forum, where narcotics are not our focus, whether we treat with injections, therapy, or both, we are ultimately treating the same entity.
 

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paz5559 said:
Semantics, but in this case, with a core of misunderstanding beneath mere verbiage

I agree that some fellowships are non-interventional. But to suggest that preeminent ones like those run by Drs Press and Prather do not address pain demonstrates a fundamental disconnect in our field.

Injections are not, nor were they ever designed to, be the silver bullet that solves patients' symptomatology. Those with that belief are doomed to have the revolving door practice that makes a good deal more money, but ultimately doesn’t get patients better long term.

Injections and other spinal interventions are a means to an end. They enable patients to experience a pain-free window pf opportunity. What we encourage them to DO during that period is the key. Drs. Press, Weinstein, Herring, and Prather view injections as the START of the therapeutic mélange, but then take a more active role in the specifics of the physical therapy that follows.

To draw a bright line distinction between fellowships is a mistake. Clearly, some do more injections than others. Clearly some do no cervical interventions at all. But to say I am different from those trained by some of our thought leaders, and to distinguish their training as a different subset altogether misses the point - we all treat pain. Pain is a dirty word, cause at it's root, it implies we treat it with narcotics, and thus no one wants to be a pain doctor anymore. But in this forum, where narcotics are not our focus, whether we treat with injections, therapy, or both, we are ultimately treating the same entity.
WTF? THere is nothing here we cannot all agree on. No argument presented or incited. PAZ is getting soft. I do not see it as all that difficult to get any of the current accredited programs up to ACGME specs. It would take a swap of 1 month with the Gas side at Emory to get everybody their acute and cancer patient numbers as well as their Gas procedure numbers (ET and IV). IN return we could take their fellow for a month and teach them SCS, PNS, disco, adhesiolysis, PDD, and whatever they don't get enough of.

Food for thought. I have yet to run it up the chain of command in my office nor has any contact been made to the Anes dept.

It would be great to also combine lectures and have some open discussion with our Gas brethren bimonthly. (Our didactics are THurs evenings ffrom 6-9)

Hope continues.
 

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lobelsteve said:
Bingo. I think Rathmell and the boys have all that sorted out and the ACGME will implement the changes next year. There will be great change in PM&R Pain programs or they will go away from trying for ACGME accred. I'm revieing the PIF right now and it looks doable, buth the gas bias the boys put on it is overpowering. If you look at the edits- only the anes section did not get a full rewrite.

Does qanybody have the list of the PMR docs that went to the table with Rathmell? I need to discuss this....
Personally, I don't think there will be anymore newly accredited PM&R pain programs.

If I remember correctly, Barry Smith MD was one of the Physiatrists at the table. Perhaps we should have had the PM&R pain/spine guys doing the negotiating.

Maybe it's too late.
 

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Disciple said:
Personally, I don't think there will be anymore newly accredited PM&R pain programs.

If I remember correctly, Barry Smith MD was one of the Physiatrists at the table. Perhaps we should have had the PM&R pain/spine guys doing the negotiating.

Maybe it's too late.

Sorry for my comment above to PAZ. If not already known he is a fellow and I am a teaching attending over him. PAZ has a strong command over the literature and is a point man for contacting anybody and everybody in the academic pain world.

I wish Windsor and Slipman sat at the table and made their voices heard. THere is really something to be said for Windsor- a genius in many spheres and able to bench press over 550 pounds. Not like he would use his mixed martial arts ability to change the face of academics running Pain. If I had what he did- I would.
 

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paz5559 said:
Semantics, but in this case, with a core of misunderstanding beneath mere verbiage

I agree that some fellowships are non-interventional. But to suggest that preeminent ones like those run by Drs Press and Prather do not address pain demonstrates a fundamental disconnect in our field.

Injections are not, nor were they ever designed to, be the silver bullet that solves patients' symptomatology. Those with that belief are doomed to have the revolving door practice that makes a good deal more money, but ultimately doesn’t get patients better long term.

Injections and other spinal interventions are a means to an end. They enable patients to experience a pain-free window pf opportunity. What we encourage them to DO during that period is the key. Drs. Press, Weinstein, Herring, and Prather view injections as the START of the therapeutic mélange, but then take a more active role in the specifics of the physical therapy that follows.

To draw a bright line distinction between fellowships is a mistake. Clearly, some do more injections than others. Clearly some do no cervical interventions at all. But to say I am different from those trained by some of our thought leaders, and to distinguish their training as a different subset altogether misses the point - we all treat pain. Pain is a dirty word, cause at it's root, it implies we treat it with narcotics, and thus no one wants to be a pain doctor anymore. But in this forum, where narcotics are not our focus, whether we treat with injections, therapy, or both, we are ultimately treating the same entity.
Many physicians effectively treat pain including PCPs, Othropaedic Spine Surgeons, Neurosurgeons and Palliative Care Physicians. However, we generally don't label them all as "pain doctors". To lump everybody into the same boat holds everyone to the same standard.

Some of the fellowships listed above perform limited interventions and shy away from Narcotics, but provide superior training in segmental structural diagnosis and rehabilitation. If anything, I would say they are closer to non-surgical Orthopaedics than a subset of pain medicine. If we lump everyone into the same group, then most of these practicioners are rightfully subject to the criticism that they do not practice comprehensive pain medicine and that they provide substandard care.

The conscientious, knowledgeable, evidence based Spine or Musculoskeletal Specialist becomes subject to the same criticisms as the needle jockey/block jock, and in the eyes of many detractors, they are equivalent.

Standardization of knowledge and skill set is a step in the right direction for pain medicine, but lets not force everyone under the pain umbrella soley to invalidate their areas of expertise.
 

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peduncle said:
Anyone know the salaries of a PMR pain specialist?
We have one larger pain clinic in this area. More than one of the PMRs have told me they have over 22,000 patients. Most are pretty much pressured into ESI and blocks of one sort or another. I was a pt there for awhile and I can attest to that. With 11 anesthesiologists, the math should be pretty healthy.

health and sunshine to all,

The A guy
 
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