FINDING CURES FOR MANKIND

  1. Home
  2. The Dr Dean Blog
2174 Views 0 Comment

The Marriage of 3D Printing and Medicine

17th Feb 2015 Hearing, Medical News

The first 3D printer was developed over 2 decades years ago as a means of taking a concept and developing a  prototype that could easily be modified without mass production.  It was believed that 3D printing would revolutionize manufacturing in many different fields.  Now, with continued advancements in 3D printing technology, regenerative medicine, and biological sciences, this unique combination of disciplines coming together is transforming medicine.

Hundreds of thousands prototypes of medical devices and organ tissues are being printed daily.  Based on current medical news and case reports, here are some areas that 3D printing is being used:

Orthopedics– Knee replacements using 3D printing technology are already being used by orthopedists.  Using a CT scan of a knee, hip or other joint, a specific model of the patient’s anatomy is developed. This information is then combined with 3D printing technology to produce a tailored joint replacement and individualized instrumentation.  The true benefit is that patient’s receive an implant that matches with their specific anatomy and not a “mass produced” implant.  It is estimated that there are nearly 30,000 patients who have already received a 3D orthopedic implant.

A 3D printed cast has also been developed to allow for faster bone healing. The device is made of a lightweight, ventilated material (unlike traditional fiberglass casts) and is more conformable to the patient’s specific anatomy.  The manufacturer claims that it can reduce healing time by nearly 40% and improve overall healing rates.

Hearing Aids– There are estimates that there are more than 10 million 3D hearing aids already in use throughout the world.  Patients are reporting increased comfort with in-the-ear type hearing aids that are 3D produced.

Dental Implants– Crowns, caps, bridges, and veneers are being printed using 3D technology.  Current estimates of more than 750,000 3D dental implants worldwide have been used. Digital scans of the patient’s mouth are more accurate than physical molds that have been traditionally used allowing for betting fitting implants.

Prosthetics – Customized prosthetic limbs that match the symmetry and function of the natural limb are being developed.  3D printing has already made a huge impact within the prosthetics and orthotics field. In 2012, a 12 year Haitian boy received the first 3D printed robotic hand.

Spinal Surgery – Surgeons in China successfully replaced the  C2 verterbral body in a 12 year old with bone cancer body using a 3D printed artificial vertebra replacement.  The implant matched the exact shape and form of his natural anatomy which is believed to provide stronger fixation than a traditional titanium implant.

Other spinal manufacturers have developed customized interbody cages and pedicle screw placement guides using 3D printing.

Organ development – This is still in its infancy. The concept of “bioprinting” to develop living tissue structures is advancing.  Researcher’s are seeking to develop transplant-ready organs.  Using a 3D printed organ combined with the patient’s own cells, this has the potential to eliminate transplant lists and treat organs that are failing.

2133 Views 0 Comment

Craiglist and HIV: Back to Basics

12th Feb 2015 Diseases, Medical News, Viruses

With the recent study released by the University of Minnesota linking Craigslist personals with an increase in reported HIV cases, it may be a good time to review this disease that has, in a way, fallen under the radar for many individuals. What is HIV? Where does it come from? How can you protect yourself? These are all questions that everyone should know how to answer.

What is HIV?

HIV is the initialism for human immunodeficiency virus. This virus is a type of retrovirus that causes AIDS, or acquired immunodeficiency syndrome. This disease causes progressive loss of immune system function, which can result in infections and cancers.

How does HIV damage the immune system?

HIV attacks certain immune system cells and directly or indirectly causes their death. When the number of these cells gets too low the individual loses cell-mediated immunity, which is a part of the immune response that does not use antibodies.  Without cell-mediated immunity opportunistic infections can take hold.

What are the symptoms of HIV?

Many people with HIV aren’t even aware they have the virus. Symptoms generally appear about a month or two after infection, but they can be so mild that they go unnoticed. These symptoms include: fever, fatigue, diarrhea, coughing, weight loss, shortness of breath, and swollen lymph nodes. The swollen lymph nodes are often the first signs of HIV infection. Some people describe it as “the worst flu ever.”

Without treatment HIV will progress and symptoms may include shaking chills, fever, night sweats, lesions of the tongue and mouth, blurred vision, and skin rashes. Over time cancers and opportunistic infections will develop and will be the cause of death if untreated.

How does someone contract HIV?

HIV can be spread through unprotected sexual intercourse (oral, anal, or vaginal), through blood transfusions (US hospitals screen for HIV to prevent this), sharing contaminated needles, and through pregnancy or breast-feeding. The virus is present in blood, semen, vaginal fluid, pre-ejaculate, and breast milk.

When does HIV become classified as AIDS?

The current standard for diagnosing AIDS is: a positive HIV test along with a CD4 cell count below 200, AND the presence of an AIDS-defining complication. This complication can be a disease like pneumocystosis, tuberculosis, toxoplasmosis, or many others.

How is HIV treated?

There is no cure for HIV or AIDS, but many drugs can be used to manage symptoms. Physicians usually prescribe multiple different types of medication to avoid developing HIV strains that are immune to single drugs. Treatment involves taking multiple pills at certain times every day for the rest of the patient’s life. These drugs can in turn cause their own side effects and if other health issues are present they may interfere with the individual’s ability to tolerate treatment.

Treatment can help a person life a normal life span, but without treatment life-expectancy is only 3 years.

How can I protect myself from HIV?

There is no vaccine available for HIV, but there are other methods you can use to protect yourself. The biggest way you can protect yourself is to use a new condom every time you have sexual intercourse (either vaginal or anal) and use a dental dam during oral sex. There is a drug called Truvada that MAY reduce the risk of sexually transmitted HIV if you are a high-risk individual (have unprotected sex, use IV drugs, are an uncircumcised male, or have another sexually transmitted disease.)

You should also use a new, clean needle every time if you are injecting drugs. There are needle-exchange programs available in many communities that you can use. Even better – seek help for your drug use.

If you are HIV-positive be sure to inform your sexual partners. If you become pregnant you need to speak to your doctor immediately about treatment to reduce the chance of passing the disease on to your baby.

1958 Views 0 Comment

Novel Antibiotic Design to Prevent Hearing Loss

10th Feb 2015 Hearing, Medical News

One of ongoing challenges that modern medicine faces is the treatment of bacterial infections. One of the most widely used class of antibiotics to treat serious infections of the upper respiratory tract, urinary tract, and septicemia are the aminoglycosides.  They are also been used in cases where other antibiotics have failed. Aminoglycosides are used primarily in infections involving aerobic, gram negative bacteria.  While this class of antibiotics offers potent antimicrobial properties, the major side effect is loss of hearing. It is estimated that 20 – 50% of those treated with aminoglycosides develop either partial or complete loss of hearing.  In simplest form, aminoglycosides cause hearing loss by inducing sensory hair cell degeneration in the cochlea (Huth ME, Ricci AJ, Chen AG.  International Journal of Otolaryngology 2011).  This can also result in damage to the vestibular system resulting in ataxia and dizziness.

In a recent study published at the beginning of January, researchers from the Stanford University School of Medicine have developed a modified version of an aminoglycoside that has just as effective antimicrobial properties,  but does not carry the major side effect of deafness. Dr. Alan Cheng and Dr. Anthony Ricci spent over 4 years of research to develop and produce a small amount of an antibiotic, now known as N1MS. This newly patented drug was derived from another aminoglycoside, sisomicin.  N1MS was used to treat a urinary tract infection in mice.  The drug successfully eliminated the infection but did not cause deafness, as other drugs in this class have.  Comparatively, treatment with sisomicin caused 75 – 85% hair cell loss and profound hearing loss in treated mice.  The mechanism of action of N1MS was designed so that it avoids entering into the inner ear cell’s ion channels where deafness is known to occur. The other benefit of this newly designed drug is that it is non-toxic to the kidneys, which is also a known major side effect of aminoglycosides.

The continual development of bacterial resistance to antibiotics and toxicities that are known among the most effective drugs, have created a platform for the development of novel therapeutic agents like N1MS.  The aminoglycosides are subject of further research in the treatment of specific human genetic diseases.

Journal Reference:

Huth ME, Han KH, Sotoudeh K, Hsieh YJ, Effertz T, Vu AA, Verhoeven S, Hsieh M, Greenhouse R, Cheng AG, and Ricci AJ. Designer aminoglycosides prevent cochlear hair cell loss and hearing loss.  Journal of Clinical Investigation. 2015 Jan 2

3411 Views 0 Comment

MOXle Study: Evaluating the drug RTA 408 in the treatment of Friedreich’s Ataxia.

05th Feb 2015 Diseases, Friedreich's Ataxia, Medical News

A clinical trial for a novel medication to treat Friedreich’s Ataxia was announced this past week. Reata Pharmaceuticals, a privately held biopharmaceutical company based out of Texas, announced the beginning of enrollments for a phase 2 and 3 clinical study titled “MOXle – RTA 408 Capsules in Patients with Friedreich’s Ataxia.” The study aims to further evaluate the safety, efficacy and pharmacodynamics of the treatment medication. A randomized, double blind, study to evaluate the maximum tolerated dose will be part one of the study. Part two will consist of splinting participants into two groups and giving two different dose levels of RTA 408. The second part will also be a randomized, placebo-controlled, double blinded study. This will be a multi-center study in which 52 patients are being sought.

Two clinical interests of the study will be peak workload during exercise as well as the modified Friedreich’s ataxia rating scale (FARS). The latter is a measurement tool which monitors proficiency of patients during activities. Additional biochemical endpoints will also be evaluated. Treatment with the study medication or placebo will be given to patient’s once daily for twelve weeks.

Nrf2 or Nuclear Factor 2, is a protein that regulates the expression of antioxidant proteins that protect against oxidative damage. Friedreich’s Ataxia is caused by defects in the gene for frataxin which is involved in the regulation of iron levels in the mitochondria. In pre-clinical studies, lower expressions of Nrf2 were correlated with frataxin deficiency and lower mitochondrial function. It is believed that RTA 408 can activate the Nrf2 pathways and improve mitochondrial function. Taken from animal models, RTA 408 showed the ability to improve overall cellular metabolism.

The study is expected to achieve final outcome measures by the spring of 2015 and study completion closer to June 2016.

http://www.marketwatch.com/story/reata-enrolls-first-patient-in-the-moxie-study-a-phase-23-study-examining-rta-408-in-friedreichs-ataxia-patients-2015-01-29

http://clinicaltrials.pharmaceutical-business-review.com/news/reata-enrolls-first-patient-in-phase-iiiii-moxie-study-of-rta-408-in-friedreichs-ataxia-patients-300115-4500885

1929 Views 0 Comment

Hospital-acquired Infections

03rd Feb 2015 Diseases, News and Events, Viruses

Hospital-acquired infections have once again found a place in the news. Thirty-two individuals are reported to have been infected by a number of different drug-resistant strains of bacteria through contaminated endoscopes.  Eleven of these patients have died, but due to their prior severe illnesses it is unclear whether or not the new infections played any role. The endoscopes in question are called duodenoscopes and are used to treat liver and pancreas illnesses. They are professionally sterilized to high standards between patients, which has unfortunately turned out to no longer be adequate.

The disinfection procedures that the manufacturers recommended were approved by the U.S. Food and Drug Administration (FDA), but after the hospital was able to identify the sterilized scopes as the source of infection they had to switch to a method that exceeded the national standards. The FDA is working with the endoscope suppliers and medical centers to develop new solutions, but this is not the first time scopes have been identified as a source of nosocomial infections. Pittsburgh in 2012 and Chicago in 2014 both saw hospital-acquired infections due to contaminated endoscopes, but luckily there were no fatalities.

The most well-known hospital-acquired infection is Methicillin-resistant Staphylococcus aureus, or MRSA. MRSA originated in the hospital setting, but has expanded to locker rooms, livestock, prisons, military barracks, and homeless shelters. Since many of the individuals infected have weakened immune systems they are already at a greater risk of nosocomial infections. In addition, MRSA’s resistance to certain antibiotics (like penicillins and cephalosporins) make it very difficult to treat.

One of the drug resistant strains of bacteria responsible for the infections in Seattle include Carbapenem-resistant enterobacteriaceae (CRE). Two examples of CRE include Klebsiella species and Escherichia coli (E. coli). While these are normal human gut bacteria, they can cause infection in those undergoing invasive treatments due to illness (like the endoscopes) or those that are taking long courses of antibiotics. Many strains of CRE have become resistant to most of the available antibiotics, making them especially deadly.

How can you protect yourself from hospital-acquired infections, like MRSA and CRE? Most of the prevention is done by the hospital – sterilizing equipment, using appropriate isolation procedures, washing hands, wearing gloves, sanitizing surfaces, wearing aprons while treating patients, and even using antimicrobial surfaces like copper bedrails. For patients that want to protect themselves there is a list of questions you can ask your healthcare provider that is provided by the Centers for Disease Control and Prevention: http://www.patientcarelink.org/uploadDocs/1/Massachusetts-Consumer-HAI-Basics.pdf

2320 Views 0 Comment

Chikungunya in Florida

15th Dec 2014 Uncategorized

Chikungunya is a viral disease that is transmitted from the bite of an infected mosquito. To date, two specific species have been identified, which include Aedes aegypti and Aedes albopictus. Chikungunya is classified as an alpha virus with positive single-stranded RNA genome. The disease was first described by M. Robinson and W.H.R. Lumsden following an outbreak that occurred in Tanzania in 1952. Since that time, outbreaks have continued to occur in Africa, Europe, parts of Asia, and more recently in the Caribbean. The Pan American Health Organization has reported over 900,000 suspected cases in 40 countries over the last 11 months. From a clinical perspective, Chikungunya has an incubation period of two to twelve days, with the majority of cases occurring between 3 and 7 days after being bitten by an infected mosquito. A fever of 102 degrees (F) and joint pain are the characteristic symptoms. Rash, fatigue, joint stiffness, headache, and nausea/vomiting may also occur. While a majority of patients do feel significantly better within a week of onset, joint pain (arthralgia) may persist for several years following infection. Schilte C. et al (2013) followed 180 patients in 2006 from an outbreak on La Reunion Island and concluded that over 60% continued to experience symptoms of arthralgia 3 years after infection. Young children, elderly adults, pregnant women, and those with pre-existing disease are at greatest risk. The disease has caused mortality in a relatively small number of cases so far.

The disease has been reported in the US since 2006, stemming from travellers who had been to countries where the virus is common. The disease has spread rapidly throughout the Caribbean and parts of Central America. In late June 2014, the first two locally acquired cases were identified in south Florida. Neither infected patient had travelled outside of the U.S. The virus is not airborne or able to be transmitted from person to person. Mosquitos are the primary vector and transmit the disease by biting a healthy person. Following infection, immunity is incurred as protective antibodies have been developed. Unfortunately, the spread of the disease can occur rapidly as it is a new virus to the continental U.S. leaving most of the population susceptible. To date, 11 locally acquired cases have been reported in Florida. Counties affected include Miami-Dade, Broward, Palm Beach, and St. Lucie (http://www.cdc.gov/chikungunya).

Primary diagnosis is made based off of clinical symptoms, travel history, place of residence, and exposures. Confirmation of disease by laboratory testing through serum or plasma can occur with detection of virus, viral RNA or viral antibodies. The CDC and some state health departments perform viral testing.

At present, there are no vaccines or specific anti-viral treatments for Chikungunya infection. Treatment focuses around supportive care including rest, hydration therapy, and non-steroidal anti-inflammatories (NSAIDs) to relieve pain and fever.

There is concern that Chikungunya could affect more than 10,000 people in Florida alone. This projection, from the Florida Medical Entomology Laboratory, is based off statistics from other outbreaks.

4470 Views 0 Comment

The ‘Kissing Bug’ Disease: What You Need To Know

17th Nov 2014 Diseases, Medical News

Chagas disease, also known as the ‘kissing bug’ disease, is an infection that is affecting more and more Americans every year. Since this disease has primarily been found in places like Mexico as well as South and Central America, many people in the United States, including physicians, are unfamiliar with it. However, the last few years have seen cases turning up in the United States. Most people are believed to have been infected abroad, but recently more of these infections have been contracted locally.

The kissing bug (also known as the triatomine bug, reduviid bug, assassin bug, cone-nosed bug, or blood sucker) includes many different species that can all carry the parasite Trypanosoma cruzi that causes Chagas disease. These insects can be found both indoors and outdoors, particularly in the cracks and holes found in substandard housing. They are found across the southern two-thirds of the United States, but the parasite is generally found in the triatomine bugs from Latin America. There are other bugs that resemble this insect (like the assassin bug or the wheel bug), so if one is found it can be taken to an entomologist for positive identification.

Fortunately, contracting Chagas disease from kissing bugs is rather difficult – an individual needs to contact the insect’s feces through a wound (like the bite wound that the insect makes, often on the face) or a mucous membrane (like the mouth or the eyes.) Some people are allergic to the insect’s saliva, but this does not mean that they have contracted the disease. Signs of an allergic reaction include redness, itching, swelling, and welts or hives. In rarer cases this reaction can cause anaphylactic shock.

In the event that someone does contract Chagas disease there may be a mild swelling at the site where the parasite entered the body – this is known as a chagoma. Romaña’s sign is swelling around the eye if the eye was the parasite’s inoculation point. The chagoma or Romaña’s sign both last longer than an allergic reaction and are not nearly as itchy. Other than the potential swelling and fever, there are very few early signs for Chagas disease. In rare cases there may be severe inflammation around the heart muscle, brain, and lining of the brain.

If a person remains untreated they can enter a chronic phase of disease where very few or no parasites are found in their blood, making diagnosis difficult. Many people will remain symptom free and never know they have the disease, but 20-30% can develop symptoms. These symptoms include heart rhythm abnormalities that can cause sudden death, a dilated heart that doesn’t pump well, and a dilated esophagus or colon that makes it difficult to eat or to pass stool.

Chagas disease can be spread through blood transfusions, organ transplants, and congenitally from mother to child. Many people have been notified that they test positive for the parasite after donating blood, despite not being aware that they had it. Two drugs can be used to treat the disease if it is caught early enough – nifurtimox and benznidazole. Due to the more “exotic” nature of this disease many physicians aren’t familiar with it. If you are concerned that you may have been exposed to or contracted Chagas disease you can talk to your physician or seek one familiar with the disease here: http://www.astmh.org/source/ClinicalDirectory/

 

2225 Views 0 Comment

Dr. Susan Perlman and Stephanie Magness on American Health Journal Nov 7

11th Nov 2014 Diseases, Friedreich's Ataxia, Hearing, Medical News

Dr. Susan Perlman appeared on American Health Journal this Friday to discuss Friedreich’s Ataxia (FA) along with one of her patients, Stephanie Magness. They educated viewers on the clinical aspects of the disease as well as daily life and clinical studies.

Dr. Perlman is a professor in the Department of Neurology at the David Geffen School of Medicine at UCLA and physician specializing in ataxia, Huntington’s Disease, and neurogenetics. She is the Director of the Ataxia and Neurogenetics Program and the Post-Polio Program at UCLA and has been a primary investigator for many Friedreich’s Ataxia trials over the years.

In this program, Dr. Perlman reviews some of the basic facts of the disease – it is a recessive neurogenetic disorder caused by mutations in both copies of the gene that controls the production of frataxin, it is a disease of childhood, and the symptoms start with balance and coordination difficulties. It begins in the legs and progresses to the hands, speech, vision, and even hearing. The patients may also develop cardiac symptoms, which include hypertrophic cardiomyopathy, heart rhythm problems, and even heart failure. Diabetes is another potential symptom and can cause affected individuals to require insulin.

Stephanie Magness is currently one of Dr. Perlman’s patients and, like all too many people with FA, she was not diagnosed correctly for the first few years of her symptoms. Friedreich’s Ataxia is often misdiagnosed as another recessive childhood neurogenetic disease like Charcot-Marie-Tooth disease, cerebral palsy, and idiopathic peripheral neuropathy. She was eventually diagnosed correctly via gene testing and is now able to manage her symptoms accordingly. Stephanie has also taken part in a natural history study as well as a clinical drug trial – possibly the first approved drug for FA.

According to Stephanie one of the most difficult aspects of the disease is its progressive nature. Even if a patient is able to handle their symptoms well currently they know that it may all change. Her advice was to focus on what you can do instead of things that you obviously cannot and find new things to do that you can excel in.

Now that drug companies have begun to take an interest in Friedreich’s Ataxia and to see it as an important area scientifically there is hope that a drug will be approved to treat FA in the not-too-distant future. Watch the program on Vimeo here: http://vimeo.com/110841193 (the section about Friedreich’s Ataxia starts at 15:39)

 

2237 Views 0 Comment

Hearing Loss and Veterans

05th Nov 2014 Hearing, Medical News

One of the most common injuries to war veterans is hearing damage. 60% of soldiers returning from warzones experience some version of hearing damage – either hearing loss, tinnitus, or both. This accounts for around 414,000 US veterans from Iraq and Afghanistan to date. Most people are concerned with loss of limbs, post-traumatic stress disorder, and brain injuries while less attention is brought to hearing loss. Despite its prevalence, hearing damage is often overlooked since it is generally does not cause loss of life.

The two main reasons for hearing damage from war are short-term exposure from high-intensity noise and long-term exposure to loud ambient noise. This can involve everything from loud trucks and helicopters to machine guns, artillery fire, and blasts from explosives. The prevalence and intensity of damaging wartime noises has increased over time, particularly with the use of improvised explosive devices (IEDs), which has resulted in more hearing damage for soldiers than in the past. Hearing protection is provided by the military, but many soldiers will forgo using it in order to listen carefully for signs of danger. In addition – if soldiers find themselves in a combat situation suddenly, there is no time or good way for them to grab hearing protection.

One of the problems with diagnosing hearing loss is that many veterans don’t seek medical attention when they first start to notice problems. Military culture can be partially to blame since hearing loss is so prevalent. Hearing loss has often been seen as a necessary evil or even an honorable sign that a soldier has seen action. However, this delay in treatment is not unique to veterans. Many individuals try to live with their hearing loss, despite the fact that damage to hearing cannot be reversed. On average it takes 7 years for someone to talk to a doctor after they first start noticing changes in their hearing.

Hearing loss is costly for the U.S. Department of Veterans Affairs with around $2 billion in benefits dispersed annually. The VA purchases one in every five hearing aids sold in the United States and 25-30% of all VA disability claims involve hearing. There is a push to get more funding for research in hopes that they can achieve the same innovations that the prosthetic limb field has seen. All veterans are encouraged to have their hearing evaluated upon discharge and medical attention should be sought as soon as hearing loss is noticed.

1947 Views 0 Comment

Saint Louis Encephalitis

31st Oct 2014 Diseases, Medical News, Viruses

Over the summer there have been mentions of Saint Louis encephalitis virus (SLEV) in regards to Pinellas County. This virus is a flavivirus – a group that includes West Nile – and has the potential to cause severe illness or death in older adults. The name of this disease comes from a particularly extensive outbreak that occurred in St. Louis, Missouri and the surrounding St. Louis County in 1933. Due to the high number of cases NIH was able to investigate and isolate this previously unknown virus. It is thought to have originated in northern Mexico and have been carried north by birds. Pinellas County Mosquito Control uses sentinel chickens to monitor for Saint Louis encephalitis and other arboviruses, since birds are usually the source of infection for mosquitos. Blood is drawn from the chickens weekly and tested for antibodies to the viruses of concern. Fortunately for the chickens they do not develop any symptoms, although once they test positive they have to be removed from the program since they will always carry the antibodies. Sentinel chickens from Pinellas County have tested positive for Saint Louis encephalitis in late July as well as August and into September. Regions with confirmed SLEV include Cross Bayou, Walsingham Park, Sawgrass Lake Park, and Lake Maggiore. While it is more common during hot and humid months, Saint Louis encephalitis can occur year round. Most individuals that are infected have no symptoms, but in rare cases it can manifest with such signs as fever, headache, nausea, vomiting, and fatigue. Severe infections can result in high fever, neck stiffness, disorientation, confusion, tremors, coma, and sometimes convulsion, spastic paralysis, and death. Older adults are at a greater risk for fatal disease. Since there is no cure for Saint Louis encephalitis the only treatment available is supportive care. If you or anyone you know shows symptoms of this disease be sure to talk to your health care provider for proper diagnosis. Since this virus is spread by mosquitos you should take the appropriate precautions. Wear insect repellent and protective clothing and be sure to avoid areas with high mosquito populations. Drain standing water, change pets’ water dishes and birdbaths regularly, and maintain your pool’s water balance to prevent mosquitos from breeding. If you use rain barrels be sure to cover them with fine mesh. Ornamental ponds can be stocked with fish that eat the mosquito larvae and any ornamental bromeliads should be flushed with fresh water regularly and treated with a larvicide. Mosquito Control field technicians can respond to concerns by use of the Mosquito Control Request form found on the Pinellas County website. http://www.pinellascounty.org/forms/mosquito_form.htm

CONNECT WITH DR. DEAN
© Dr. Robert Dean © 2014 | Built By enTangle media