healthy minds, healthy hearts · resume your outdoor ˜ tness regimen safely and e˚ ectively....

WINTER 2013

Healthy Minds, Healthy Hearts

Compliments of

Johns HopkinsUSA

Young people at risk for this cancer

Get healthy and get back in the game

Do you have facial pain?

Responding to a heart attack with the goal of renewal, not

just recovery

Insight and news from Johns Hopkins Medicine

FdJHWI1303_01_Cover.indd 1 12/28/12 9:47 AM

If you are suffering from age-related macular degeneration (AMD)—a disease that slowly destroys the eye tissue related to central vision—and

think hope is lost for clearly seeing the faces of loved ones again, there might be a chance for regaining some of your independence and quality of life. The Johns Hopkins Wilmer Eye Institute is one of the first institutions in the country to offer an implanted minia-ture telescope that replaces the eye’s natural lens and can help certain people with AMD see better.

“This device can enhance distance vision and improve clarity,” says Judith Goldstein, O.D., Wilmer’s chief of low vision and vision rehabilitation service. But she is cautious: “Careful screening of candi-dates is essential to ensure rehabilitation after surgery will maximize visual function and meet patient expectations.”

This is an alternative to external telescopes, which some people find to be cumbersome and provide only a narrow field of vision.

Better Vision in Sight for Sufferers of Age-Related Eye Disease

WIntER 2013

Quick consult

4| Facing Pain Discover what may be causing excruciating facial pain and how doctors are treating it.

5| Get Back in the Game–and stay there Physical therapists are working to keep people free from injury.

First Person

10| Match Maker A father made sure a kidney was available when his son needed a new one.

second oPinion

11| early Warning As colorectal cancer affects younger people, know what to watch for.

on tHe coVer

Healthy Minds, Healthy HeartsBe assured that the steps you take after a heart attack can lead to renewal as well as recovery.

Contents

Get the latest news on health and wellness topics important to you and

your family, all from the experts at Johns Hopkins Medicine. the Your Health e-newsletter is delivered straight to your inbox. Visit hopkinsmedicine.org/news/ e-newsletters for your free email subscription.

Sign Up for Health Information from Johns Hopkins

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For more information, appointments or consultations, call 877-546-1872.

Rather, the new implanted telescope could be life-altering.

Oliver Schein, M.D., Wilmer’s vice chair-man for quality and safety and a surgical investigator on the study that led to Food and Drug Administration approval of the device, says the implant can help many patients with facial recognition, television watching and social interactions, and allow them to track moving objects more easily than can be done with a conventional external telescope.

Ideal candidates for the implant are people ages 75 and older who have stable AMD, aren’t undergoing active injection or laser treatment, haven’t had cataract surgery in at least one eye, and experience a measured ben-efit using an external telescope. According to a long-term safety study, the implant, which Medicare covers, improves vision an average of three lines on the eye chart.

| 2 | johns hopkins health winter 2013 877-546-1872 | hopkinsmedicine.org/usa

FdJHWI1303_02-03_Insights.indd 2 12/28/12 9:47 AM

healthinsights

A new Johns Hopkins study shows that regular aerobic exercise pro-vides great fuel (and ef� ciency) for the pumping heart. This is encour-aging news for people who have type 2 diabetes, who also frequently have a high risk of heart disease.

“Diabetic people have elevated glucose and fat in the blood,” explains lead researcher Miguel Aon, Ph.D. “They can have twice as much as a healthy person.” Each of these factors contributes to heart disease.

Exercise breaks up stored fatty acids, giving the diabetic heart the extra fuel it needs to func-tion normally. “To our surprise, the heart improved performance in the presence of hyperglycemia [high blood sugar] when there was a high energy demand,” Aon says. “If a person is exercising, the heart needs more energy, and energy is provided by fat.”

In the study, research-ers gave double the normal fatty acids to type 2 dia-betic mice and then used an adrenaline-like substance to stimulate their hearts to beat faster, mimicking stress or physical activ-ity. They found the diabetic mice’s hearts improved their function to the same level as normal mice and also counteracted the negative effects of too much glucose.

This doesn’t mean you can eat whatever you want if you have diabetes, but it does mean regular biking, swimming, running or walking will improve your cardio-vascular function and reduce your risk of heart failure.

For more health news, research and events from Johns Hopkins Medicine, follow @HopkinsMedicine on Twitter.

Mouth Swabs May Be as Effective as Blood Draws

Before You Assume ADHD, Check Your Child’s Hearing

WANT TO REDUCE THE EFFECTS OF DIABETES? GET MOVING

I T ’ S N O F U N getting stuck with a needle at the doctor’s of� ce, but drawing blood is often the only way to detect illness, test the effectiveness of medicines and evaluate organ function. That may be changing, however, thanks to the research of Johns Hopkins University professor Doug Granger, Ph.D., who has spent the past 20 years looking at how to use a saliva swab as an alternative for blood collection.

“In the early ’90s, when I was working with children who had to give blood samples,” Granger says, “I found the parents and kids just didn’t want to do it if blood had to be drawn.”

Johns Hopkins researchers began a quest to discover

that saliva, with its mix of proteins, hormones, enzymes and DNA, can be used in some instances for disease diagnoses and data col-lection. And it’s already making things easier for patients. Women receiving in vitro fer-

tilization, for example, now can get their daily estrogen hormone lev-els tested with saliva as opposed to a blood sam-ple, and a home saliva

test kit for detecting HIV was approved by the Food

and Drug Administration in 2012.“The diagnostic world has never

thought of saliva as something that could help them very much,” Granger

says. “We’ve just scratched the surface of the potential here.”

When a child exhibits behavior problems in school or doesn’t progress academically in line with peers, some parents might think of a developmental disability or attention de� cit hyperactivity disorder (ADHD). First, says Margaret Skinner, M.D., consider getting the child’s hearing checked, especially if he or she has suffered

repeated ear infections.“During an ear infection, there is � uid in the middle ear,” says Skinner, a Johns Hopkins pediatric

otolaryngologist (ear, nose and throat surgeon). “The infection can resolve but � uid may remain. That � uid is associated with mild but typically reversible hearing loss.”

Permanent hearing loss from a common infection is extremely rare. But, she says, “children who have chronic � uid in their ears can experience impacts on language and behavior development.”

Skinner recommends all children with hearing loss be evaluated by a pediatric otolaryngologist to help determine the best inter-vention, before going to a psychiatrist to evaluate behavior problems or developmental issues.

If hearing loss is a concern, parents can get children preferential seating in classrooms, ask for written instruc-tions from teachers, or have the children � tted with hear-ing aids. Surgery is also an option in certain circumstances, Skinner says.

NOW HEAR THIS!Discover more about children’s hearing problems from Emily Boss, M.D., Johns Hopkins pedi-atric otolaryngologist, in the video “The ABCs of Pediatric ENT.” Visit bit.ly/ABCsofPedsENT.

hopkinsmedicine.org/usa | 877-546-1872 winter 2013 johns hopkins health | 3 |

FdJHWI1303_02-03_Insights.indd 3 12/28/12 9:47 AM

Facing Pain

quickconsult

Do You ExpEriEncE Facial pain?Watch a video of Michael lim, M.D., Johns Hopkins neurosurgeon, to learn more about the symptoms, causes and treatment options for trigeminal neuralgia. Visit bit.ly/facingpain. For more information, appointments or consultations, call 877-546-1872.

Intermittent yet excruciating pain in your face could be a sign of a nerve disorder. Michael Lim, M.D., a neurosurgeon at Johns Hopkins, explains the condition and the treatments that can bring relief

How can I find relief?

The first line of treatment is usually medication. A majority of people respond well and their pain is well-controlled. If medica-tion doesn’t work, there are three surgical options. Be sure to seek out a treatment center, like the Johns Hopkins Trigeminal Neuralgia Center, that has extensive experience and handles a high volume of cases.

What causes trigeminal neuralgia?

No one is exactly sure, but many people believe the cause is an artery that rubs on the nerve near the brain-stem. As people age, the insulation on the nerve wears down, much like wires in a home that cause electrical shocks when exposed.

Can you tell me about the surgical treatments?

The first is called microvascular decompression. It’s an open sur-gery involving a small incision to lift the artery off the trouble-some nerve and insert a cushion to eliminate rubbing. Although a short hospital stay is required, about 90 percent of people are completely cured. The second is called a rhizotomy, where a needle is used to insert medicine or apply other treatments to stop the pain. It’s an outpatient procedure, but the pain typi-cally returns within a few years. For the third option, doctors deliver focused beams of radiation to the nerve. People return to work the same day, but the procedure doesn’t take effect right away and the pain can return a few years later. n

Recently I started experiencing sharp facial pain. What is going on?

There are many causes of facial pain. One of them, trigeminal neuralgia, is characterized by episodic stab-bing pain over the forehead and eyes or near the cheek, nose or jaw. Some people describe a sensation of electric shocks or ice picks. The pain, usually on one side of the face, can be triggered by eating, drinking, talking or feeling a slight wind or breeze.


FdJHWI1303_04_Consult.indd 4 12/28/12 9:47 AM

W I T H S P R I N G fast approaching, you might be eager to get back out on the golf course or the

running trail. Make sure you’re ready to resume your outdoor � tness regimen safely and e� ectively.

“� e majority of sports injuries are due to training errors, improper tech-nique or a biomechanical imbalance,” says Dorianne Feldman, M.D., MSPT, a physiatrist with Johns Hopkins Medicine and Rehabilitation. “Lack of conditioning is another factor, especially for people who don’t play a sport year-round.”

Perfecting the right form and technique for your pastime can reduce the risk of injury. Or if you’ve been sidelined, combin-ing skill re� nement with rehabilitation can help prevent future problems.

� at’s the idea behind a series of Johns Hopkins programs designed to help people of all activity levels perform at their best while learning to prevent or recover from injuries.

“We place highly trained clinicians in direct oversight of each area based on their skills and personal experience,” says Ken Johnson, P.T., clinical manager of the Johns Hopkins Rehabilitation � erapy Services Clinic. “For example, we have therapists who are runners working with our

running rehab program and therapists with a professional background in ballet working in our dance rehab service.”

Using high-tech equipment that cap-tures detailed body movements in real time, therapists analyze each patient’s form and technique. For instance, they measure the mechanics of a golfer’s swing at three points: address, top of backswing and impact.

“What we’re doing is identifying the particular joints or muscles that may be causing pain or performance issues,” says Terrence G. McGee, P.T., a fellowship-trained clinical specialist at the Rehabilitation � erapy Services Clinic. “� rough manual therapy techniques and corrective exercises, we improve the biomechanics at particular joints that help them build muscle memory and improve the consistency of their performance.”

If a runner tends to be a hard heel striker, for example, therapists can help prevent or reduce heel pain through coaching, injury prevention tips, strengthening or rehabilita-tion, based on each person’s needs.

“When you think about it, the body’s like a machine,” Johnson says. “We study the machine for mechanical failures and weak links, and then we apply our therapy knowl-edge and experience to improve the function of that machine.” �

TRAINING TIPSPut these simple steps into your routine to keep pulls and strains at bay:

� Check with your doctor. Even if you’ve worked out in the past but stopped for a signi� cant amount of time, it’s a great idea to make sure you’re still good to go.

� Start smart. Don’t overestimate your abilities. Whatever you think you can do, take it down a notch in the beginning.

� Warm up 15 minutes before starting an activity. This routine prepares the body by elevating the core tem-perature, loosening the muscles and raising the heart rate.

� Stretch, but only after a short cardio-vascular activity, when muscles have had a chance to warm up.

� Drink plenty of water—before, dur-ing and after exercise—to prevent dehydration and fatigue.

� Increase the pace and intensity of your workout over time. Consider a 10 percent boost per week.

� Rest. It’s critical to help your body recover from the strain of exertion.

� Call in the pros. If you are having aches and pains that won’t go away, schedule time with a physiatrist or a sports medicine physician, who can refer you to a physical therapist as needed.


Get Back in the Game–and Stay There� erapy programs help people of all activity levels perform at their peak

FREE ONLINE SEMINAR

MASTER YOUR GOLF SWING BY IMPROVING YOUR

MOVEMENT MECHANICSTuesday, March 5, 7–8 p.m. EST

Do you want to improve your golf game? Join Terrence G. McGee, P.T., Johns Hopkins clinical specialist and certi� ed golf � tness and medical professional, to learn how you can

improve your body motion to better your swing and prevent injuries. To register, visit

hopkinsmedicine.org/healthseminars.


FdJHWI1303_05_Sports.indd 5 12/28/12 9:47 AM


FdJHWI1303_06-09_Heart.indd 6 12/28/12 9:48 AM

HealtHyMinds,

HealtHyHearts

ew things in life are as scary as a heart attack. And then, after surviving one, a person must take many steps to resume a normal life and, in most cases, a more healthy lifestyle. What can be just as surprising as the heart attack itself are the unexpected, nonphysical effects, which are equally threatening to one’s quality of life. Although these effects might make the road to full recovery somewhat bumpy, experts at Johns Hopkins are proving that life after a heart attack not only goes on, but it can get better.

facing Down challenges“A heart attack is a major life change. All of a sudden, someone has a wake-up call and it’s as if, ‘I’m not healthy anymore,’ ” says Shellee E. Nolan, M.D., a Johns Hopkins cardiologist. “Patients perceive themselves as being ill, and so they start to think about their future and how long their life is going to be. Many feel depressed, defeated, weakened.”

Though some people develop depression, for most it’s anxiety that dominates their lives, largely in the form of worries about behaviors they believe might trigger another cardiac event, such as climbing stairs, having sex or drinking a glass of wine. >

Responding to a heart attack with the goal of renewal, not just recovery



So while they recover from an attack—attending rehabilitation and working to establish healthy habits—they struggle with the possibility of future heart problems.

Rehabilitation, too, is challenging. It can take several weeks to several months or more, and peo-ple’s day-to-day lives change so much as to be barely recognizable. Some cannot resume work right away, especially if they have physically demanding jobs or their employers insist on an extended leave. And strain on relationships with spouses and caregivers,

who themselves frequently have questions and fears, may also hinder recovery.

For many individuals, however, time is of the utmost importance,

as people learn about their health through the course of their recovery. Nolan calls this cardiac awareness.

“You don’t know whether the symptom you’re having is signi� cant versus really nothing at

all,” she says. “But with time, you learn what is a

real concern or not a concern, and a lot of worries pass.”

Success Begets Success� ough it is said that time heals all wounds, what can people recovering from a cardiac event do to fast-track their success?

“To some extent, part of [recovery] comes just from asking your doctor about the di� er-ent issues you’re facing, but this is where cardiac rehabilitation can also truly be bene� cial,” says Stuart Russell, M.D., chief of heart failure and transplantation at the Johns Hopkins Heart and Vascular Institute. “You’re with people who are going through the same thing as what you’re going through, which is probably by far the best therapy.”

If heart health were for sale, cardiac rehabilita-tion would be considered one-stop shopping. It is designed primarily to help restore physical func-tioning by means of supervised exercise training. And the bene� ts don’t end there.

“It helps people cope with their illness in terms of dealing with stress and depression and improv-ing quality of life,” says Kerry J. Stewart, Ed.D., director of clinical and research exercise physiology at Johns Hopkins Bayview Medical Center. “It also educates them about what lifestyle changes they may need to make, as people who have had some type of cardiac event are certainly at a high risk for having another one.”

Cardiac rehabilitation is considered a standard of care after heart attack, coronary artery bypass surgery and angioplasty (blood vessel repair), and both of Johns Hopkins’ cardiac rehabilita-tion programs, at Bayview Medical Center and at Green Spring Station, are certi� ed by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). But just as important, research at Johns Hopkins has helped the AACVPR set the bar for excellence.

“We were involved in the � rst studies demon-strating that the use of resistance exercise is not only safe but also e� ective in people with heart problems; that has now become part of the stan-dard of care,” Stewart explains. “We have also been a member of the American Heart Association’s writing committees that created the standards for cardiac rehabilitation.”

Along with exercise, cardiac rehabilitation at Johns Hopkins includes nutritional counseling, smoking cessation, stress reduction and basic edu-cation about topics such as medication adherence. And even when people don’t elect to pursue all options, Stewart observes, “by performing exercise where they are monitored and get feedback that says ‘you’re OK,’ people regain a level of con� dence about their ability to do things, which in turn leads to them doing more when not in the program.”

Bill Fusting, one of Nolan’s patients, experienced a heart attack in January 2012 and, after placement of a stent (a mesh tube that will keep his artery

fears, may also hinder recovery.For many individuals, however, time is of the utmost importance,

as people learn about their health through the course

all,” she says. “But with time, you learn what is a

real concern or not a concern, and a lot of worries pass.”

Success Begets Success

RECOVER AND RENEW!

Watch and listen to Johns Hopkins physicians discuss the invaluable bene� ts of cardiac rehabilitation.

Visit bit.ly/recoverandrenew. For more information,

appointments or consultations, call 877-546-1872.



levels, weight and mood shortly after starting the program. “Even now, sometimes I don’t want to go, but when I finish, I just feel so good,” he says. “It absolutely builds your confidence and clears your mind, which keeps you from worrying. And when you feel good, you can do more in life.”

Knowing Is Half the BattleJust as exercise strengthens the mind as well as the body, education plays an important role in nonphysi-cal healing. Optimal recovery from a heart attack is more likely when people understand why the event occurred and the nature and purpose of the treat-ment. Nolan says it’s more than just sharing facts; people also must be taught how to return to healthier lifestyles and avoid the habits that likely contributed to their problems in the first place. This is yet another way in which cardiac rehabilitation is beneficial, providing a form of self-care, as in Fusting’s case.

“He had this heart attack, but now he has embraced a new life, fully and happily,” Nolan says. “He has incorporated this new diet and this new exercise, and is just as robust now as before his heart attack—but just doing it differently.

“A lot of people end up embracing their situa-tion with such vigor; it’s really quite amazing,” she adds. “People who were couch potatoes before and never paid much attention to their diet, and who maybe had this belief that they were invincible, they come out of this with a new appreciation for life and embrace the knowledge about how to keep themselves healthy.” n

open) and a brief hospitalization, was immediately referred to cardiac rehabilitation. Fusting was somewhat skeptical about how three days of exer-cise each week could make such a difference, but he trusted Nolan’s recommendation.

“She introduced me to the fine people at cardiac rehab, and I’m glad she did,” says Fusting, who saw improvements in his blood pressure, cholesterol

or decades, men were tHougHt

to suffer from heart disease and heart attacks more so than women. But, sadly, women have narrowed the gap, and cardiovascular disease is now the No. 1 killer of both genders. Hormonal and anatomical disparities between the sexes, however, mean some differences do exist. For instance, women generally report higher rates of depression after a heart attack than men—an unfortunate finding because depression increases the risk of mortality in heart disease and heart attacks. Whether this is attributable to women’s unique physiology is unclear, but Marlene Williams, M.D., director of the cardiac care unit at Johns Hopkins Bayview Medical Center, is trying to unravel the mystery, which could prove useful for preventing and treating depression in all heart attack patients.

Williams is looking to an increasingly popular area of cardiovascular research: blood platelets, and a particular protein stored within and used by platelets called brain-derived neurotrophic factor (BDNF). People who have depression also have

lower levels of BDNF, and given that depression has a clear linkage to heart functioning, Williams is considering whether the protein is a potential culprit.

“If a depressed patient’s platelets can’t uptake and use BDNF, it circulates in their arteries, where it can contribute to plaque instability and rupture,” she says. “Maybe

that is why there is an increased inci-dence of heart attacks in people who are depressed. But what we want to see now is whether there is a difference in the amount of platelet BDNF in men and women.”

Having recently received funding associated with the Marianne J. Legato Research Scholar Award in Gender-Specific Medicine, Williams and her colleagues will examine differences in platelet function and depression among men and women with and without heart disease.

With government research funding on the decline, studies in gender medicine have similarly shrunk, making this investigation all the more valuable for patients as well as for the field as a whole.

For more information on the study, including possible enrollment, call 410-550-5128.

tHe GeNDeR CoNuNDRuM



firstperson

John Cosby couldn’t donate a kidney to his son. But, with the help of Johns Hopkins, he made a donation possible

Match Maker

The Johns Hopkins Comprehensive Transplant Center has one of the largest, most well-established kidney transplant programs in the coun-try. About half of its 225 yearly kidney transplants are from live donors, and a program for living liver donors is rapidly expanding.

Live kidney donations are optimal for the recipients, and much easier on the donors than they used to be, thanks to minimally invasive surgi-cal procedures.

To find out whether you are a match to a particular recipient, you’ll start with an evaluation that includes blood and tissue tests. If the results are positive, you’ll meet with a transplant physician to discuss the surgery and risks. Donors are given the same care and considerations as recipients.

LIfe-CHAngIng experTIse

To watch a video of John Cosby telling his story, visit hopkinsmedicine.org/mystory. For more information, appointments or consultations, call 877-546-1872.

When we found out our 19-year-old son, Sam, was in end-stage kidney failure, my wife and I felt as if we’d been hit by a truck. We didn’t want our son’s life to be limited by being on dialysis for the rest of his life.

When physicians at Johns Hopkins told us a kidney transplant was an option, I said right away I’d be a donor. I went through all the blood tests and everything and was devastated to learn I wasn’t the right match for my son.

Then they told us about their paired donation program. It’s for people like me who are willing to donate a kidney but aren’t a match for a par-ticular recipient. I agreed to donate a kidney to someone I was a match for, and someone else agreed to donate a kidney to Sam.

I’ll never forget walking into Sam’s hospital room after his transplant and seeing him with this big smile on his face. He was already doing bet-ter, and he’s been in great shape ever since. He’s now an active 22-year-old who is back to doing what he loves: snowboarding.

I donated my kidney later, when it was needed for someone else. The operation wasn’t that big of a deal for me. I went into the hospital on a Tuesday and was back at work the following Monday.

Most parents would do anything to help one of their kids. I do have a certain sense of pride knowing that Sam is thriving because Johns Hopkins enabled a stranger and me to give my son the kidney he needed. n

photo by scott suchman


FdJHWI1303_10_FirstPerson.indd 10 12/28/12 9:48 AM

T he rise of poor eating and exer-cise habits permeates the news these days and, as a result, many illnesses traditionally a� ecting

older people are now appearing in the young. One startling example is colorectal cancer; doctors are seeing an increase in cases among people younger than 50, which is the typical age to begin screening.

“Nobody knows for sure why,” says Sandy Fang, M.D., a colorectal surgeon at Johns Hopkins, “but it’s probably a com-bination of things.” Fang points to many culprits as possible risk factors: a family history of colorectal cancer, in� ammatory bowel disease, and lifestyle patterns such as low-� ber diet, excessive intake of red meat, obesity and lack of exercise.

Colorectal cancer rates have been declin-ing in older populations, but the disease is on the rise in people ages 18 to 49, with rates having gone up more than 2 per-cent between 1998 and 2007, according

to the National Cancer Institute. Fang says younger people are often misdiag-nosed because the symptoms of colorectal cancer—rectal bleeding, abdominal pain and change in bowel habits to name a few—can point to many other disorders, and doctors don’t always consider colorectal cancer because of the patients’ age.

When the disease is diagnosed it is usually advanced, because the younger person hasn’t sought care quickly or because symptoms might not have been recognized or acknowledged. � us, the treatments are more exten-sive and costly.

Fang urges people who have signs of colorectal cancer, regardless of their age, to be proactive with their care. When she sees symptoms in people who have a family history of the disease, Fang says she tends to do colonoscopies sooner rather than later. �

MINIMIZINGYOUR RISKJohns Hopkins recommends that most men and women get their � rst colonoscopy screening for colorectal cancer at age 50. There are, how-ever, certain factors that can place younger people at higher risk and necessitate earlier screening:

� Rectal bleeding, abdominal pain, diarrhea, changes in bowel movements, or anemia. Talk to your doctor about when to start screenings.

� A family history of colorectal cancer. Start screening 10 years before the diagnosis of the young-est affected family member.

� Lynch syndrome. If you are at risk for this hereditary cancer of the digestive tract, start colonoscopies at age 21 and continue every one to three years.

� Familial adenomatous polyposis. This disease is characterized by benign growths that will likely develop into cancer. Get a colonos-copy every one to two years, start-ing as early as the teen years.


FREE ONLINE SEMINAR

COLON CANCER: KNOW YOUR RISK

Thursday, March 21, 7–8 p.m. EDTAwareness of symptoms and risk factors are important in detecting colon cancer early.

Join Johns Hopkins colorectal cancer experts, gastroenterologist Francis Giardiello, M.D.,

and colorectal surgeon Susan Gearhart, M.D., as they discuss risk factors, symptoms, the importance of early screenings and current

treatment options. To register, visit hopkinsmedicine.org/healthseminars.

secondopinion

Early WarningDespite its reputation as an older person’s disease, colorectal cancer is increasing among young people


FdJHWI1303_11_2ndOpinion.indd 11 1/2/13 7:18 AM

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