Sept/Oct 2011 Bulletin

ESCAMBIA COUNTY MEDICAL SOCIETY

President’s Message

SEPTEMBER/OCTOBER2011 Volume 41, No. 5

POLST and New Paradigm for End-of-Life Care

by Michelle Brandhorst, MD

Upcoming Events October 11, 2011

General Membership Meeting 5:30 PM

Speaker: Daniel J. Van Durme, MD Sponsor: MAG Mutual Location: Heritage Hall

November 8, 2011

General Membership Meeting 5:30PM

Speaker: Paul McLeod, MD Sponsor: Sacred Heart Health Systems Location: Angus Restaurant

RSVP: 478-0706

ECMSinfo@bellsouth.net Founded in 1873

Ethical dilemmas in healthcare are always challenging in our advanced technological society. The initiatives encompassing Physician Orders for LifeSustaining Treatment (POLST) center around creating a replacement or substitution for the current Do Not Resuscitate (DNR) form. The termination of medical treatment has been evolving since 1976, with the case of Karen Ann Quilan vs. New Jersey. The continued evolution of palliative care in 1991 gave us the Patient Self-Determination Act, which mandates hospitals to ensure adherence to a patients rights to create a personal health care decision. In 1996, additional research found the demand for change in end-of life care, creating the POLST order through the Center for Ethics in Health Care at the Oregon Health & Science University. By 2004 POLST was fully adopted by ten states as well as being partially implemented in several others.

The issues that served as an impetus to the POLST movement can be seen on daily by physicians and nurses who care for patients with a life limiting diagnoses. First, there is the reluctance or discomfort of many physicians and some patients to discuss the reality that a patient may soon die.

Because of this, patients often receive medical treatment that they would not want, if the true severity of their illness was known to them and their family.

Second, the living will and DNR forms or either too generic or too restrictive. In spite of the best intentions, the living will form conveys little information regarding the specific treatment decisions that present in the course of treating potentially life limiting illnesses. Family members are therefore often left to make painful decisions as they try to extrapolate from the verbiage on this form to specifics such as peg tubes, tpn, or ICU drips. The DNR form is foreboding and often signed by a patient or family members in a patients last days of life. Third, documented patient wishes and instructions never seem to be there when they are needed.

The POLST form is a single page that documents a conversation between a physician and patient regarding life sustaining treatment after the diagnosis of a life limiting condition. Examples of the brightly colored POLST form as well as further in-

formation are available at www.ohsu.edu/polst/ index.htm. The form contains sections that collectivly not only cover CPR preference but Dr. Michelle Brandhorst also addresses medical interventions such as antibiotics, iv fluids, feeding tubes and preferences regarding being transported to a hospital. It is an order form and must be signed by a physician. It is therefore placed in the orders section of a chart and transferable from home/ extended care facility to hospital and back. Most importantly however the POLST form serves as a guideline for having meaningful discussions regarding care parameters and hopefully encourages this conversation.

The initiative to implement POLST is being lead

by Marshall B. Kapp, J.D., M.P.H who is the Director, Center for Innovative Collaboration in Medicine & Law at Florida State University College of Medicine.

Mr. Kapp convened a group of interested parties from around the state to forward the move forward with bring POLST to Florida. POLST has been endorsed by The Florida Medical Association, Florida Academy of Family Practice, Florida Bar Association, AARP as well other organizations. Misguided rhetoric regarding “Death Panels” continues to make progress difficult as I was reminded during a recent discussion regarding POLST I had with Dr. Frank Farmer our current Florida State Surgeon General. Previous efforts to implement POLST bogged down in details such as where to electronically store POLST documents. Acceptance of medical record repositories such as PORTAL may solve this perceived problem and we can then move forward with the more important work of adopting the POLST paradigm. I hope this article will spur your interest in learning about POLST at www.ohsu.edu/polst/index. htm. I also hope that you will support local efforts.

Without physician support this effort to improve care that is consistent with patient wishes will not succeed. The POLST paradigm is an opportunity to provide effective medical care and to preserve the patient-physician relationship.

ECMS Bulletin The Bulletin is a publication for and by the members of the Escambia County Medical Society. The Bulletin publishes six times a year: Jan/ Feb, Mar/Apr, May/Jun, Jul/Aug, Sept/Oct, Nov/Dec. We will consider for publication articles relating to medical science, photos, book reviews, memorials, medical/legal articles, and practice management.

Editors Norman Vickers, MD Erica Laxson, Executive Director

AD PLACEMENT Contact Erica Laxson at 478-0706 Ad Rates Full page: $600 • ½ page: $300 • ¼ page: $150

IN A MEDICAL MALPRACTICE CLAIM: Be ready for anything and everything.

2011 ECMS Officers President Michelle Brandhorst, MD President-Elect George Smith, MD Vice President Wendy Osban, DO Secretary /Treasurer Susan Laenger, MD

Decades of experience, true financial stability, and a tough-as-nails defense team make First Professionals a well-rounded — and yes, affordable — choice when it comes to protecting your medical reputation and career. No other Florida medical malpractice provider knows the industry quite like we do, nor do they defend our doctors with as much tenacity. We’re committed to protecting you and everything you’ve got, with everything we’ve got.

Page 4 An Exciting New Journey Page 6 Electronic Death Registration System (EDRS)

YOU SAVE LIVES. WE SAVE LIVELIHOODS.

Page 8 2011 Women in Medicine Brunch Pages 10-12 Vendors of Choice

www.firstprofessionals.com

Vision for the Bulletin: -Appeal to the family of medicine in Escambia and Santa Rosa County and to the world beyond.

- Collaborate with the Alliance to bring together Escambia and Santa Rosa County medical families. To know the needs of the community and promote the healthcare needs.

- A powerful instrument to attract and induct members to organized medicine.

Views and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the directors, staff or advertisers.

For more information, contact Shelly Hakes, Director of Society Relations at (800) 741-3742, Ext. 3294.

Endorsed by

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Membership Welcome New Members!

James Adams, MD

Michael Harris, MD

Radiation Oncology Medical School: Univ. of Alabama School of Medicine, Birmingham, AL Residency: SUNY Health Sciences Center, Syracuse, NY Board Certified: American College of Radiology 1717 North E Street, Ste 134 Pensacola, FL 32501 Phone: (850) 469-2200 Fax: (850) 469-2202

Interventional Physical Medicine and Rehabilitation Medical School: Tulane University School of Medicine, New Orleans, LA Residency: University of Michigan, Ann Arbor, MI Board Certified: American Board of Physical Medicine and Rehabilitation 1040 Gulf Breeze Parkway Gulf Breeze, FL 32561 Phone: (850) 916-3700

Donald Mason, MD

Erika Schneider, MD

Family Practice Medical School: Uniformed Service University, Bethesda, MD Residency: Naval Hospital, Pensacola, FL Board Certified: American Board of Family Medicine 6715 Hwy 98W Pensacola, FL 32506 Phone: (850) 453-6737 Fax: (850) 453-1196

Obstetrics and Gynecology Medical School: Univ. of Florida College of Medicine, Gainesville, FL Residency: Shands University of Florida, Gainesville, FL Board Certified: American College of Obstetrics and Gynecology 3417 North 12th Ave Gulf Breeze, FL 32503 Phone: (850) 432-7310 Fax: (850) 432-7320

Medical Students

Corrections to July/August 2011 Bulletin

Naomi Salz FSU College of Medicine

Jessica Jackson, MD

Laura Davis

FSU Sacred Heart OB/GYN Residency

FSU College of Medicine

We are currently accepting new applications for 2012 members and please don’t forget that membership dues for 2012 are due by January. We look forward to another great year at the Escambia County Medical Society.

Benefits of Membership 2012 9 Dinner Meetings in 2012: Opportunities to receive Free Florida Mandated Courses.

Representation in Legislature: ECMS has members actively participating in the FMA and AMA. Such topics include: Managed care legislation, PRN sovereign Immunity, Mandatory malpractice, tort reform, and grass roots efforts. ECMS gives our physicians’ updates through our newsletters, email, and faxes.

Malpractice Insurance Discount: FPIC gives ECMS members a 5% discount. In addition, FPIC’s claim-free program currently allows for the following discounts: 25% claims-free 15= years; 20% claims feree10-14 years; 10% claims-free 5-9 years.

20% Discount on Pensacola Opera Tickets DocBookMD: ECMS providers are now listed on the ECMS iPhone and Android application.

Workers’ Compensation Insurance: Members can receive up to 24.8% return on insurance premiums with OptaComp.

CME: ECMS offers free CMEs to our members at many of our meetings.

Directory and Website: ECMS website and Member directory, which includes you office information and picture, as well as allows you to control the information and register for ECMS events. We also work with physicians to create and manage their own internet site.

Patient Referral: ECMS refers patients to our physicians daily.

Physician Information Service: ECMS has connections in Pensacola. The Society is pleased to research, ask, and retrieve information for you or your office personnel.

Vested Vendor Resource Guide: This is a guide offered to all members.

These vendors are financially and personally invested in the success of the practice of medicine. They support our CME events, dinners, special events and our Bulletin newsletter. Please make sure to call a supporter of ECMS. The Florida Healthcare Law Firm: At no charge members of the Escambia County Medical Society may call the hotline 561-306-5699 with questions regarding specific legal issues.

Membership An Exciting New Journey

By Erica Laxson, ECMS Executive Director was offered the Graduate Assistant position with the University of West Florida Athletics Department in Compliance. During the next two years I obtained my Masters in Leadership Health Communication and studied health care ethics. I continued to not only participate in community events but plan them as well. A week before graduation I received a phone call with a job offer to co-manage David’s Bridal in Pensacola. A year in retail management with long hours, feisty brides, and managing 15 associates taught me more than will fit in this segment. Enduring these various journeys has brought me to where I am now.

My journey from over- achieving student athlete, dedicated graduate assistant, and multi-tasking retail manager has ultimately brought me to earning the title of Executive Director. I have learned a lot about myself and what passions I have developed along the way and believe I have found my niche with the Escambia County Medical Society. I believe you will find that my journey thus far has taught me the leadership skills and intangibles it takes to be a successful Executive Director. While I am a self-proclaimed leader, only time will allow me to prove my abilities.

I appreciate the opportunity to serve as your Executive Director. I look forward to our opportunities in the future with the Escambia County Medical Society.

As cliché as it sounds, a wise man once said “everything happens for a reason”.

Therefore I never question life and its processes.

My name is Erica Laxson and I am your Photograph by Hara, Documented Photography new Executive Director for the Escambia County Medical Society. Seven years ago I came to the Pensacola area on a full scholarship for both academics and athletics. When I started school I didn’t know exactly what path I would choose to study (as most freshman don’t), but I knew I wanted to be someone who made a positive impact in others’ lives. I have always considered myself to be a caring and compassionate person. I receive fulfillment from making an impact in people’s lives both professionally and personally.

During my four years of undergraduate studies at the University of West Florida I realized how much passion I had for volunteering within our community and serving others. There is something to be said about planning an event and seeing the return on your investment. I continued to participate in community events throughout my undergraduate studies while donating my resources and time.

Upon the completion of my undergraduate degree in Advertising, I

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Medical/Legal Case Study: Liability Attributed to Physician Extender By the Risk Management Experts at First Professionals Insurance Company Editor’s Note: This case study analysis reflects an actual FPIC case.

Case Analysis

A 53-year-old female underwent laparoscopic cholecystectomy without incident. The surgeon saw the patient three days post-op, noting she was doing well and without complaints other than the expected incisional pain. The patient was next seen five days post-op by the surgeon’s physician assistant (PA) who noted an infection at the umbilical surgical wound.

A culture was obtained (which later proved to be Klebsiella) and patient was started on the antibiotic Levaquin. The patient returned four days later and was re-evaluated by the surgeon who noted that the wound still looked infected with the presence of drainage. Cellulitis was diagnosed and instructions given to continue the Levaquin and return if needed. A week later the patient returned and was seen by the PA. She complained of nausea, vomiting, diarrhea and a temperature of 103. Although the PA noted that the wound still appeared infected, because the abdomen was non-tender and no masses were felt, he diagnosed “superficial wound infection” and “gastroenteritis”. The PA instructed the patient to continue the Levaquin and prescribed Phenergan for nausea and vomiting. Three days later the patient was admitted through the ER with an acute abdomen. She underwent exploratory surgery, was diagnosed with an intrahepatic abscess and developed disseminated intravascular coagulation (DIC). The patient continued to deteriorate until her expiration several days later.

Suit was filed against the surgeon, the PA and the medical practice alleging failure to diagnose and treat the intrahepatic abscess. Defense experts could not support the PA’s failure to properly assess the patient when she presented with obvious clinical signs of infection. The PA was criticized for failing to consult with the physician. The surgeon, having signed off on the PA’s medical management, was held vicariously liable for the acts of the PA and directly liable for his inadequate supervision of the PA. Settlement of the case was necessitated for the surgeon’s direct negligence and his vicarious liability for the PA, for the practice, for the negligence of the PA, and for the PA. Risk Management Discussion Frequently, claims involving post-operative complications involve known risks. Early recognition and appropriate case management are key factors in reducing a physician’s exposure in these situations. Consider the following loss prevention measures in order to help reduce errors and deter lawsuits and preserve defenses necessary to defeat the unavoidable claims: • • • • • •

Utilize informed consent Re-evaluate post-op patients prior to discharge Obtain all outstanding labs and diagnostic studies prior to discharge Document the absence of clinical indications of complications Schedule prompt follow-up appointments Document no-shows or cancellations

• Provide written post-op instructions, outlining the expected side

effects and the unanticipated signs and symptoms that should be reported • Give high priority to post-op patient complaints.

If a complication develops, consider the following steps: • • • •

Inform the patient – express empathy Document your medical rationale Increase communication Seek legal or risk management guidance

This information does not establish a standard of care, nor is it a substitute for legal advice. The information and suggestions contained here are generalized and may not apply to all practice situations. First Professionals recommends you obtain legal advice from a qualified attorney for a more specific application to your practice. This information should be used as a reference guide only.

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Practice Management Electronic Death Registration System (EDRS) The Florida Department of Health, Bureau of Vital Statistics is implementing an Electronic Death Registration System (EDRS) for filing Florida death records. The system is currently being piloted in Northeast Florida, in Medical Examiner District 4, with statewide implementation by medical examiner district to follow. Physicians within this district are among the first to use the electronic system.

EDRS is the method by which Florida death records are registered through a secure Internet site. EDRS provides the user direct access to the state database for entry of death record information. EDRS increases accuracy and timeliness while improving statistics for state and national surveillance systems.

Some of the benefits of EDRS for the physician are: • Remote Fax Attestation of medical certification of death, or online access, depending on the number of death records normally signed; • No hard copy death certificate • No funeral directors or their staff waiting in your office • Accurate and timely cause of death data • Certifications available to families much sooner • Easily re-directs records sent to wrong physician • Automatic reminder if physician has had the record beyond 72 hours

Remote Fax Attestation (sample on next page) • What is it? Remote fax attestation replaces the handwritten medical information on the death certificate, including the physician’s signature.

The physician can review and certify the death certificate from any location accessible by fax. This process eliminates the need for a hard copy of a death certificate to be hand carried or mailed by the funeral director to the physician and back again.

• How does Remote Fax Attestation work? m Funeral director generates via EDRS, a copy of the death certificate, known as the Fax Attestation, to the physician, which includes the demographic information on the decedent; m Physician completes medical information, signs and faxes to EDRS; m Funeral director enters data as provided by the physician; m Record status changes to “Awaiting State Confirmation.” m Medical Review and Coding staff at the state office will review for accuracy; m Any discrepancies are addressed by the state office until the record is Registered/Completed.

Continued on next page

Department of Health, Bureau of Vital Statistics Physicians’ Online Tutorial for Completing Cause of Death on the Florida Death Record

The Department of Health Bureau of Vital Statistics, in cooperation with the Florida Medical Association and the Florida Association of Medical Examiners, has an online tutorial for physicians. This complimentary tutorial, which is worth one CME credit, takes about one hour to complete and can be accessed at: http://floridavitalstatisticsonline.com.

The tutorial is constructed for physicians, providing an overview of the death registration process in Florida and how to go about properly completing the medical information on the death record. It provides sample case histories; an explanation of the physician’s, the medical examiner’s, and the funeral director’s responsibilities in getting death records filed; how mortality data is used and why the death record is so important to families. =====

Electronic Death Registration System Launched in Florida

Vital Statistics has moved to electronic filing of Florida Death records. This means the record is filed online, via a secure Internet site, using the Electronic Death Registration System (EDRS). The user has direct access to the state database for entry of death record information. EDRS increases accuracy and timeliness while improving statistics for state and national surveillance systems.

Funeral directors are online users and complete the demographic/personal information on the decedent. The EDRS record is then sent electronically to the physician for certifying the medical information.

The certifying physician can be an online user and complete the medical certification electronically, using EDRS; OR can be an offline user and complete the medical certification via Fax Attestation. The fax is system generated and looks much like the medical portion of the paper death record.

Questions? 904-359-6900, ext. 9020 • Quality Assurance • Bureau of Vital Statistics P.O. Box 210 • Jacksonville, Florida 32231-0042

Practice Management Online Physician • Funeral director enters the demographic information; • System emails the physician that a record is awaiting medical certification; • Physician enters the medical information and the record goes to Registered/Completed; • Automatic email sent to the funeral director notifying that record is complete and certified copies can be obtained.

In order to have a better understanding of our project, please visit our website and review what we have posted regarding EDRS: http://floridavitalstatisticsonline.com/ Scroll down the left column until you see Electronic Death Registration and click on that link. At the top of the page are several links to EDRS information.

An informational brochure is available (pictured left). If you have questions or would like to learn more about EDRS, contact Kenny Higginbotham, ken_higginbotham@doh.state.fl.us, 904-359-6900, ext. 1171; or Sharon Dover, sharon_dover@doh.state.fl.us, 904-359-6951.

Physician's EDRS Quick Reference

You may have heard about or recently been contacted by a funeral director regarding the change in the way Florida processes death records - Florida is going from a manual process to filing electronically. The new process that has the most impact on the physician is the Fax Attestation, which resembles the former paper death certificate and it is what the physician will now sign instead of the paper record.

To assist you in fully completing the medical information on the Fax Attestation, we have circled the data items that come under your jurisdiction and must be completed on the fax. All other items must be completed if applicable to your patient.

There is more information on the reverse of this flyer.

REMEMBER TO SIGN AND DATE

John Jones, M.D.

1/5/2011

Board of Medicine Introduces the Mailman System

One of the Board of Medicine’s missions is to disseminate appropriate information to consumers and practitioners. In an effort to reach out to more applicants, licensees and the public to provide information, the Board has established a “Mailman” system. Each time the Board of Medicine posts new items in Mailman, subscribers receive an email including that information.

Examples of the types of updates provided by the Mailman system includes changes in the law and board rules, reminders about legal requirements and updates that impact physicians and patients in Florida.

Subscribers’ email addresses are not publicly displayed and are not posted onto the Board’s website or onto public practitioner profiles. You are encouraged to subscribe and instructions for how to sign up follows:

Instructions for Joining the Board of Medicine’s Mailman System Step 1:

Go to

http://www.doh.state.fl.us/mqa/medical/index.html

Step 2: Select Interested Parties (Mailman) from the left side of the screen Step 3:

Enter your email address where indicated

Step 4: Click on Subscribe

You will receive a confirmation of subscription.

When the Board of Medicine posts information, you will receive an email with the posted information.

In the Community 2011 Florida Medical Association Conference (left-right) Christopher Burton, MD, Holly Strickland, George Smith, MD, John Lanza, MD, Michelle Brandhorst, MD, Eduardo Puente, MD, Wendy Osban, DO, Jill Prafke, MD

2011 Women in Medicine Brunch

(BACK ROW left-right) Abeer Abutaleb, MD, Stephanie Salas, MD, Nell Potter, MD, Kris Edwards, Cynthia Worrell-White, MD, Angeli Saith, MD, Jill Prafke, MD, Michelle Brandhorst, MD, Adelaida Torres, MD, Susan Laenger, MD, (FRONT ROW left-right) Elise Gordon, MD, Fawn Lewis, MD, Grace Torres-Hodges, MD, Shannon Scott (3rd year medical student), Naomi Salz (3rd year medical student)

2011 Women in Medicine Brunch

(left-right) Abeer Abutaleb, MD, Adelaida Torres, MD, Paula Montgomery, MD, Fawn Lewis, MD, Cynthia Worrell-White, MD, Jill Prafke, MD, Susan Laenger, MD

InThe Community Hospital News Baptist Healthcare BHC Celebrates 60 Years of Patient Care, Invites Community to Cel-

as a for-profit hospital under the terms of the proposed joint venture, which

ebrate

would provide funding for Bay Medical to eliminate its debt and gain the

financial and clinical resources of two larger healthcare organizations.

Join BHC in celebrating its 60th anniversary this year. As the area’s

only community-owned health care system, BHC was founded on philanthropy, led by physicians and funded by the community Baptist Hospital

Sacred Heart Medical Staff Annual Meeting Oct. 27 Features Patient-

opened its doors in 1951. To celebrate this momentous occasion, BHC

Safety Expert

welcomes physicians, staff and community members to attend a celebra-

tion on Thursday, October 27th from 4:30 p.m. to 6:30 p.m. on Baptist

safety, will be the keynote speaker at the Sacred Heart Hospital Pensacola

Hospital’s campus 1000 W. Moreno Street. Visit eBaptistHealthCare.org to

Medical Staff Annual Meeting on Thursday, Oct. 27, at 5:30 p.m. at the Hil-

learn more.

ton Pensacola Beach Gulf Front. Dr. McDonald will share his seven-pillars

Timothy McDonald, MD, JD, a nationally known expert in patient

approach to prevent adverse safety events and improve patient safety. This Baptist Health Care Celebrates 1,000 Robotic Surgeries

presentation will qualify for two Florida CME credits in medical errors for

physicians. For more information, please call Medical Staff Services at (850)

In September Baptist Health Care celebrated its 1,000th da Vinci® S

HD Surgical System milestone, making Baptist the most experienced and

416-2260.

best equipped robotic surgical program in northwest Florida. Four years ago, BHC was the first health care system in the region to offer da Vinci robotics’ unique and powerful technology to significantly improve patient care. Today BHC continues to be the region’s leader in minimally invasive

West Florida Hospital

surgery with 29 trained, experienced and compassionate physicians.

West Florida Hospital Offers TIF Procedure

Ten existing procedures are performed in the gynecologic, urologic,

West Florida Hospital now offers the revolutionary TIF (Transoral

and cardiothoracic specialties and another four procedures are currently

Incisionless Fundoplication) procedure, a completely incisionless,

planned, totaling 14 different surgeries utilizing the two da Vinci robots

clinically-proven surgical approach to treating gastroesophageal reflux

at Baptist Hospital. Baptist is committed to offering advanced technol-

disease (GERD). Utilizing the ExophyX surgical device, the surgeon re-

ogy that benefits patients and support physicians. To learn more about

constructs a durable anti-reflux valve and tightens the LES (Lower Esoph-

minimally invasive surgery options visit eBaptistHealthCare.org/Robotic-

ageal Sphincter). This reestablishes a barrier to reflux and restores the

Surgery or call 850.469.2053.

competency of the gastroesophageal junction, essentially correcting the root cause of GERD. TIF is performed safely, quickly, and with minimal

Baptist Medical Group Opens New Primary Care Practice in Gulf

patient downtime by West Florida Hospital general surgeons Jon Moore,

Breeze.

M.D. and David Tenniswood, M.D.

Quality internal medical care and prompt appointments are now

available at Baptist Medical Group’s newest primary care office located at 1118 Gulf Breeze Parkway, Suite 101 on Gulf Breeze Hospital’s campus.

The office will offer convenient appointment times, including some evening hours. Visit BaptistMedicalGroup.org or call 850.916.3680 to learn more.

Sacred Heart News Sacred Heart Exploring Affiliation with Bay Medical Center in Panama City

Bay Medical Center in Panama is negotiating a possible joint venture

with Sacred Heart Health System and LHP Hospital Group, Inc. The three organizations plan to negotiate a long-term lease under which a Sacred Heart-LHP joint venture would lease the assets of Bay Medical Center and operate the hospital for 40 years. An agreement will be subject to the approval of the Bay Medical Board of Trustees and the Bay County Commission.

LHP is a privately-held company established to provide essential capi-

tal and expertise to not-for-profit hospitals and hospital systems. Bay Medical Center, a 323-bed hospital owned by Bay County, would be operated

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MECOP Reminder

3rd Annual Stroke & Neuroscience Symposium October 28, 2011 Sacred Heart Conference Center Greenhut Auditorium RSVP: (850) 416-4842 or scprice@shhspens.org

Member Benefit: The Health Care Attorney On Call Hotline (561) 306-5699 View and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the board of directors, staff or advertisers. The editorial staff reserves the right to edit or reject any submission.

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