LINK —>   https://www.youtube.com/v/LOp-KGd4hV0?fs=1&hl=fr_FR

Produced 1-29-15.

Source: www.youtube.com

This is a video, minus the audio, produced from a powerpoint that I developed on the history of vaccinated diseases.

The focus of this presentation is kids or young adults who come down with an immunizable disease.

In the figure provided above, the two pictures present views down the pharynx of a child with diphtheria.  The white covering on the mucous membranes is due to dead organisms, respiratory passage tissue, and debris left behind by a bacterial colony residing on the air passage.  This debris essentially forms a perfect casting of the lung, and can extending more than a foot into the lung in some sections.  For the worst cases, it may extend as far down as the upper to middle bronchioles, stopping just before the alveoli are reached.  In the alveoli, oxygen – carbon dioxide exchange takes place.

In severe cases of airway blockage, the best treatment is typically a tracheotomy and/or intubation.

See on Scoop.itGlobal∑os® (GlobalEOS)

EarTrumpetandGIS7

The ways in which important discoveries come into medicine are sometimes unbelievable.  Medicine is sometimes too slow at changing its standards and protocols once important discoveries are made.

For the past twenty years, this has been the case with GIS.  The current science of spatial epidemiology is a study that has the potential to completely reform managed care and better address the rising cost concerns we are now facing.  Yet, we are still not ready for these changes, or taking on GIS at full force.

Like twenty years ago, the use of GIS remains an experimental process with most managed care and insurance agencies, and is not at all required for any annual QI or Meaningful Use reviews.  With the mining and use of Big Data now common to HIT, the industry is unprepared for this more rigorous, thorough, cost saving method of monitoring healthcare.

The following articles are examples of the application of GIS to managed care and quality assurance processes in healthcare.

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READINGS

Agency for Healthcare Research and Quality (AHRQ).   Using Geographic Methods to Understand Health Issues .  (2014/5)  Access at http://archive.ahrq.gov/research/geomap/geomap1.htm 

Panth, M., & Acharya, A. S. (2015). The unprecedented role of computers in improvement and transformation of public health: An emerging priority. Indian Journal of Community Medicine, 40(1), 8.  DOI: 10.4103/0970-0218.149262.  Accessed at http://www.ijcm.org.in/article.asp?issn=0970-0218;year=2015;volume=40;issue=1;spage=8;epage=13;aulast=Panth 

Dalton, C. M., & Thatcher, J. (2015). Inflated Granularity: Spatial ‘Big Data’and Geodemographics. Available at SSRN 2544638.  Accessed at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2544638

Lee, D. C., Carr, B. G., Smith, T. E., Tran, V. C., Polsky, D., & Branas, C. C. (2015). The Impact of Hospital Closures and Hospital and Population Characteristics on Increasing Emergency Department Volume: A Geographic Analysis. Population health management.   Accessible via http://online.liebertpub.com/doi/abs/10.1089/pop.2014.0123 

Adams, A. M., Islam, R., & Ahmed, T. (2015). Who serves the urban poor? A geospatial and descriptive analysis of health services in slum settlements in Dhaka, Bangladesh. Health policy and planning, 30(suppl 1), i32-i45.  doi: 10.1093/heapol/czu094.   Accessible via  http://heapol.oxfordjournals.org/content/30/suppl_1/i32.short 

Lee R Mobley, Tzy-Mey Kuo, Jeffrey Traczynski, Victoria Udalova and HE Frech. (2014).   Macro-level factors impacting geographic disparities in cancer screening.   Health Economics Review 2014, 4:13  doi:10.1186/s13561-014-0013-7.  Accessed at  http://www.healtheconomicsreview.com/content/4/1/13 

Simms, I., Gibin, M., & Petersen, J. (2014). Location, location, location: what can geographic information science (GIS) offer sexual health research?. Sexually transmitted infections, 90(6), 442-443. doi:10.1136/sextrans-2014-051695    http://sti.bmj.com/content/90/6/442.short 

Angier, H., Likumahuwa, S., Finnegan, S., Vakarcs, T., Nelson, C., Bazemore, A., … & DeVoe, J. E. (2014). Using Geographic Information Systems (GIS) to Identify Communities in Need of Health Insurance Outreach: An OCHIN Practice-based Research Network (PBRN) Report. The Journal of the American Board of Family Medicine, 27(6), 804-810.   dos:10.3122/jabfm.2014.06.140029.  Accessed at  http://www.jabfm.org/content/27/6/804.short . 

Ana Lopez de Fede, Kathy Mayfield Smith, John Stewart.  The Role of Geography in Health Care Spending and Monitoring Services Use.  A Getis-OrdGi* Statistical Hot Spot Analysis of SC Medicaid Paid Claims per Capital by ZCTA.  Policy and Research Institute on Medicaid and Medicare, Institute for Families in Society, University of South Carolina.  Accessed at http://ifs.sc.edu/NewPRMM/Products/HotSpotAnalysisMethods.pdf 

David Moskowitz, Bruce Guthrie, Andrew B. Bindman.  (2012). The Role of Data in Health Care Disparities in Medicaid
Managed Care.  Medicare & Medicaid Research Review, 2(4), E1-E15.  Accessed at  http://www.cms.gov/mmrr/Downloads/MMRR2012_002_04_A02.pdf 

Peter W Gething, Fiifi Amoako Johnson, Faustina Frempong-Ainguah, Philomena Nyarko, Angela Baschieri, Patrick Aboagye, Jane Falkingham, Zoe Matthews and Peter M Atkinson.  (2012).  Geographical access to care at birth in Ghana: a barrier to safe motherhood.   BMC Public Health 2012, 12:991  doi:10.1186/1471-2458-12-991  Accessed at http://www.biomedcentral.com/1471-2458/12/991 

Michael Sparer (2012). Medicaid managed care:
Costs, access, and quality of care. RESEARCH SYNTHESIS REPORT NO. 23. SEPTEMBER 2012. Robert Wood Johnson Foundation. Accessed at
http://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf401106

Paul Guttry. (2012). 21 NOV 2012 RESEARCH & IDEAS
What Health Care Managers Need to Know–and How to Teach Them . Working Knowledge. Accessed at http://hbswk.hbs.edu/item/6933.html

Peter J. Cunningham. (2011). State Variation in Primary Care Physician Supply: Implications for Health Reform Medicaid Expansions. HSC Research Brief No. 19. March 2011. Accessed at http://www.hschange.com/CONTENT/1192/

Tomas J. Philipson, Darius Lakdawalla,Dana Goldman. (2010). Addressing Geographic Variation and Health Care Efficiency. Lessons for Medicare from Private Health Insurers
July 19, 2010 | American Enterprise Institute. Accessed at http://www.aei.org/publication/addressing-geographic-variation-and-health-care-efficiency/

America College of Physicians. (2010). RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE, UPDATED 2010. ACP, A Position Paper. Accessed at https://www.acponline.org/advocacy/current_policy_papers/assets/racial_disparities.pdf 

American Hospital Association.  (2009).  Geographic Variation in Health Care Spending: A Closer Look. American Hospital Association.  November 2009.  Accessed at file:///C:/Users/Brian/Downloads/twnov09geovariation.pdf

Sylvester J. Schieber, Chairman. Dana K. Bilyeu, Dorcas R. Hardy, Marsha Rose Katz, Barbara B. Kennelly, Mark J. Warshawsky, (2009). The Unsustainable Cost of Health Care. Social Security Advisory Board, September 2009. Accessed at http://www.ssab.gov/documents/TheUnsustainableCostofHealthCare_508.pdf

Donald M. Berwick, Thomas W. Nolan and John Whittington. (2008). The Triple Aim: Care, Health, And Cost. Health Affairs, 27, no.3 (2008):759-769. Accessed at http://content.healthaffairs.org/content/27/3/759.full.pdf+html

Dummer, T. J. B. (2008). Health geography: supporting public health policy and planning. CMAJ : Canadian Medical Association Journal, 178(9), 1177–1180. doi:10.1503/cmaj.071783 Access at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292766/

Daniel Callahan, (2008). “Health Care Costs and Medical Technology,” in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing. Book for Journalists, Policymakers, and Campaigns, ed. Mary Crowley. (Garrison, NY: The Hastings Center, 2008), 79-82. Accessed at http://www.thehastingscenter.org/Publications/BriefingBook/Detail.aspx?id=2178

John Carroll. (2007). How Doctors Are Paid Now, And Why It Has to Change. December 2007. Accessed at http://www.managedcaremag.com/archives/0712/0712.docpay.html

Sarah Hudson Scholle. (2007). Efforts to reduce racial disparities in Medicare managed care must consider the disproportionate effects of geography. The American journal of managed care (Impact Factor: 2.17). 02/2007; 13(1):51-6. Accessed indirectly via http://www.researchgate.net/publication/6575638_Efforts_to_reduce_racial_disparities_in_Medicare_managed_care_must_consider_the_disproportionate_effects_of_geography

Stefane M Kabene, Carole Orchard, John M Howard, Mark A Soriano and Raymond Leduc. (2006). The importance of human resources management in health care: a global context.
Human Resources for Health, 4:20 doi:10.1186/1478-4491-4-20. Accessed at http://www.human-resources-health.com/content/4/1/20

William H. Frist.  (2005).  Overcoming Disparities in U. S. Healthcare.  Health Affairs, 24, no.2 (2005):445-451.  doi: 10.1377/hlthaff.24.2.445 . Accessed at  http://content.healthaffairs.org/content/24/2/445.full.pdf+html 

Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong 2nd, O. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public health reports, 118(4), 293.  Accessed at  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497553/ 

Martin Sipkoff. (2003). Nine Ways to reduce Unwarranted Variation. Managed Care, November 2003. Accessed at http://www.managedcaremag.com/archives/0311/0311.variation.html

David M. Cutler, Louise Scheiner. (1999). The geography of Medicare. Accessed at http://www.federalreserve.gov/pubs/feds/1999/199918/199918pap.pdf

Mark Rosenberg. (1998).   Medical or Health Geography? Populations, Peoples and Places.   INTERNATIONAL JOURNAL OF POPULATION GEOGRAPHY 4, 211-226 (1998).

http://www.geo.hunter.cuny.edu/~dgreimer/TEMPALSKI/rosenberg%5B1%5D.pdf

Sarah Curtis and Ian Rees Jones. (1998). Is there a place for geography in the analysis of health inequality? Sociology of Health & Illness.. 20(5), 645-672. ISSN 0141–9889.
Access at http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.00123/pdf

See on Scoop.itGlobal∑os® (GlobalEOS)

Measles in Disneyland should be a wake-up call for the anti-vaccine movement. Magicians Penn and Teller show us why anti-vaccination is nonsense.

Source: www.kevinmd.com

Hey. It’s magic. Better magic than prescribing to anti-vaccs.

See on Scoop.itGlobal∑os® (GlobalEOS)

QUOTE:  “A report calls CDC’s commitment to lab safety “inconsistent and insufficient.” The report also says “laboratory safety training is inadequate.””  

 

A reminder that respect from the public is also very important.  These are the events from this past year which were preventable (even if just in an ideological sense).  They should be used to define the goals for the up-coming year.  Notice that two quality of care related needs have been included (limited coverage by SES, and ethnicity/race).  

Source: edition.cnn.com

A good reminder of how we got this way is to simply look back at the past year’s events.  Since March 2014, we have had several global disease outbreaks or concerns arise in the news, about 1/5th of which really could have been managed better–the rest are status quo for surprising outbreaks and such.  This 20% that weren’t well handled have "issues", we can call it, with poor management and preventive health practices.  Another 10-20% also have public health related medical practice problems, that are the consequence of mistakes made at the clinical level, by provider or management and administration.  But the bulk of medical emergencies do have a certain amount of unpredictably that make them hard to predict will emerge–hard to prepare for.

 

But once the signs of a problem are there, those 20% (or maybe 30%) of events we could have taken preparatory action for, should have been managed professionally and quickly in due time.

 

The problems arise when we don’t respond to an emergency in time.  The fact that this in the past years has involved several kinds of emergencies, tells us the system is in really deep trouble.  Now if we add to this our poor responses to natural disasters, there is much more to complain about, and god forbid, should another 9-11 event happen, odds are we will not respond any better to this disaster as we did to the prior.  

 

October 2013 (the cases of measles that struck the Palisades Mall in Hudson Valley NY) gave us the warning we needed to be prepared for the 2014 Measles outbreak via Disneyland.  My April 2014 posting noted our lack of preparedness in this matter (need I say, living in close proximity to the  2013 outbreak, I have the right to know and experience needed to realize the dilemma we are in.)

 

The medical field itself knew it was not ready in May 2014, before the famed 2014 outbreak, it was realized that "Measles is making a comeback." [The Disney outbreak initiated in December  2014.]

 

The border crisis with people coming into this country caused some hype, in June; that too became true and is the reason Disneyland could be so successfully infected.  

 

But these are not the main concern with this posting.  The main concern here boils down to one thing–poor management and leadership.   Safety procedures are not abided by at CDC.  Record keeping was historically poor, and so we are still finding those old 1950s vials of small pox we put away for the moment, perhaps to send later to some biosecurity/bioterrorism storage facility.  Imagine what might have happen had that rubbish made it to the landfills instead of the incinerator, by a third party company hired to clean out the building for renovation or leveling.

 

Technology wise, the public masses are better informed that the leaders.  I know that childhood diseases can spread because of what I saw in my neighborhood for twenty years in the Pacific Northwest, after talking openly with neighbors who weren’t on any health insurance (even MCD), and who refused to immunize their children.  The fact that Bot users knew about Ebola before other in WHO or healthcare is a scary finding–it’s like having to rely upon your ham radios more than your TV or regular battery-run AM/FM radio during the cold war era.  If I were a survivalist, I would interpret this as a sign to invest in a new multifaceted high tech shortwave communicator.

 

The medical world in general has been lazy about some technology.  GIS is one of the best examples of this.  It is heavily used by national programs, for internal reasons only.  Theoretically it has epidemiological, preventive care use, but is rarely employed by experts for meeting such needs.  We know this because neither the spatial diffusion prediction models nor ecological models for what Ebola was have rarely been mentioned or published with much determination.  Even more, as always, this technology is used mostly as a retrospective tool; not a preventive tool.  Could the flight of Ebola positive cases to Houston, to New York, where ever, been prevented?  It’s easy to say no, not having developed a system to base your decisions upon.  The Middle Eastern respiratory Infection and Chikunkunya could not have been predicted for their outbreaks.  The latter could have been ecologically assessed more thoroughly and successfully.  Makes you wonder which ones (zoonotics) are going to arrive in 2015, the some tick disease, or perhaps a south american encephalitis, or perhaps Bos Tb infecting our cattle?  Like the one article states: "Mapping could help stop ____ spread", if it were engaged by the right experts.

 

Our concerns about polio are too few.  We use the Herd Theory as the reason for this.  But disease regression is happening apparently; if the herd theory continues to fall apart as a useful paradigm, we’ll need to address once more the return of poliomyelitis (but there are still several more countries that have to be penetrated first by it). 

 

Because we have done little to deal with ethnicity differences in health, and poverty related differences, we do have even worse issues to contend with in upcoming years.  Cultural emergence in the US is going to make some diagnoses and diseases become more prominent, be they of an infectious or physical/ physiological nature (culturally-link cardiac abnormalities, genetics diagnoses, etc.) , or of a cultural philosophy and behavioral cause (infibulation, culturally-bound syndromes).

 

These are not so much directly CDC related–CDC cannot regulate the in-migration of people who believe is some of these controversial behaviors and practices.

 

But CDC can oversee and regulate its own workers and their fellow workers in the health care field more efficiently–like teaching MDs not to be so self-egotistical about the improbability that they could cause the next epidemic, by allowing a patient to not be treated, or refusing to place their own self into CDC-recommended quarantine.  Common sense is apparently not a physician’s (or nurse’s) primary skillset.

 

In the end, we must link these problems to managers and directors.  Of course, the president or CEO is often who we try to blame and expel.    But that individual alone is not the cause.

 

Rewriting the rules does not eliminate the problems.  Having a committee developed to oversee past behaviors and uncover the mistakes will not suffice.  Ultimately, leadership has to change for this program to get better.  Then the policies need to be rewritten.  Finally, the right skilled individuals need to be hired, so the agencies can catch up on their IT skills, especially the ones they cannot employ that well, for the moment.  

See on Scoop.itEpisurveillance

Low vaccination rates are likely responsible for the large measles outbreak that began at Disneyland in California last December, a new analysis suggests. The researchers estimated that the MMR (measles, mumps and rubella) vaccination rate among the people who were exposed to measles in that outbreak may be as low as 50 percent, and is likely no higher than 86 percent. Since the beginning of this year, 127 cases of measles in the United Stateshave been linked to the Disneyland outbreak, according to the Centers for Disease Control and Prevention (CDC). Because measles is such a highly contagious virus, vaccination rates of 96 percent to 99 percent are necessary to prevent outbreaks, Majumder said.

Source: news.yahoo.com

How much more proof did we need? (These are several year old V-code maps.)  ‘Tis a shame when programs that are initiated for prevention become the last to know.

See on Scoop.itGlobal∑os® (GlobalEOS)

Doubts about the effectiveness of traditional Chinese medicine remain.

Source: qz.com

One of the least known facts about traditional chinese medicine in western society is that it has several times been supported by the western medical traditions for the time.  

 

In fact, the first time we see evidence for this happening is during the 17th century, when French travelers and explorers were traveling through the orient, publishing books about their experiences in which they included the curious philosophies that Chinese doctors had, regarding pulse therapy, tongue diagnosis, moxibustion, their materia medica philosophy and their use of "accupuncture"–and how much it resembles their use of "fire", one of the four galenical elements, to define their four humours principle.  

 

Acupuncture and its various offshoots were practiced on and off as a variation on the increasingly popular form of electropathy methods of healing.  For much of the 17th and 18th century, it was the parallels that could be drawn between the ancient humoural theories, the discovery of the sympathetic nervous system, and the more recent "nervous energy" or excitement theory of the late 1700s that facilitated the addition of acupuncture into western practices by 1810-1820, in both western Europe and the U.S.  

 

During the late 1800s, early 1900s, Chinese medicine regained its popularity, due to the relatively large numbers of practitioners engaged in this healthcare tradition.  Not only were members of Asian cultures in the U.S. taking advantage of this form of health care, so too were some of the alternative healers of western allopathic medicine, ads for which appear in many US urban region newspapers.

 

The twentieth century has several periods when allopathy tries to first understand the philosophy underlying Chinese medicine, and then determine whether or not it fits into the western allopathic paradigms.  There are a number of interesting arguments posed by allopaths trying to explain the many who experienced acupuncture at work–the parasympathetic nervous system reasoning was following by the endocrine system paradigm at the turn of the century, which in turn has been followed by allopathic arguments trying to claim "natural opiates", enkephalins, neuroendocrine system, and most recently, psychoneuroimmunological reasons as to why this philosophy keeps finding new supporters.  Countering these were traditional claims regarding placebo effect, belief system related "cures", psychosomatics, and mindbody influences.  (Recall the popular point therapy faith now implemented for fibromyalgia treatment.)

 

This recent increase in interest in Chinese medicine is focused in part on the materia medica once again.  With Chinese herbal remedies, the world health belief system has transformed from its 18th century existence, relying heavily upon ginseng root and smilax root flour, to its late 20th, early 21st century period of curiosity about ginkgosides and their impacts on aging glial cells in the brain.

 

The most common feature to all of these periods of acceptance, withdrawal and change in traditional Chinese versus "traditional western" allopathic medicine is that a belief system is required and must be adhered to for the healing effect to take place.  In many cases, physicians have little to no control over what the body and its owner decide what to do, no matter what the cause might turn out to be–believe it, or not.

 

 

 

 

See on Scoop.itGlobal Health Care

Epil_LTCCosts_4charts4

I recently completed a major portion of an ongoing research project I have been involved with over the years–the evaluation of the cost of long term care to epileptics in the past, and how we can use it to predict the cost for epilepsy care for upcoming decades.

My method of analysis was quite simple.  I took the historical data for specific case(s) and then used the consumer price indexing adjustment formula for inflation to adjust all past costs to the present.  I then took the real case data, which resulted in very low risk of need for future care once the “crisis” was complete soon after the age of 45, and expanded it by creating a slightly riskier pre-catastrophic event period (no high cost events) and an ongoing post-crisis/catastrophic event period, with similar activities as those of the previous years, leading up to high cost long term care accomodations.

This methodology is based in part upon methods used to perform a similar analysis back in the late 1990s.  I added to this technique, more data on the costs for health care visits, screenings, labs, prescription drugs, CNS testing, emergent care events, etc., etc.  than utilized in previously published studies.  I also engaged in a full cost analysis of living costs, assuming the patient had no other health condition that might impact results as a covariant.

The emergent care event(s), and subsequent crisis for these cases was a neurosurgical process (left anteromesial temporal lobectomy, applied to this diagnosis for child and adults with the implied CPS or TLE ICD noted in the graphs above.)

For the baseline case, the surgical process is assumed to be 100% effective, performed at the midlife of the patient’s life.    This lowest risk case is also assumed to recover completely from the crisis and return to education and/or work without further complications (essentially representing a “cure”).

The moderate risk case continues to experience post-surgical seizure events, although less at first, but over time requires new testing, new medications, further tests and screening, changes in therapies, etc.

The high risk case is assumed to have ongoing debilitating conditions develop even after the surgery is completed, as the seizures recur and reduce quality of life over the next 20 years.

The costs for each of these cases up until the age of 57/58 yo were then reviewed (again. starting with real time/life costs for care data for the baseline case).  The other two were then evaluated.

Based on changes in cost over time, and their linear versus polynomial form, a prediction modeling equation could defined for each of the moderate and high risk cases (formulas were different), to determine how much ongoing medical care for this health status would cost the system ,first by the age of 65 (retirement year, if any were still employed), and finally, by the age of 80.

The results of this study demonstrated that the long term cost for lifetime care for a patient with epilepsy, who reaches the age of 80, but requires special housing in the later years due to long term complications, could easily reach 10 MILLION DOLLARS (much of this due to long term care demands).

(All additional costs were not CPI adjusted for future inflation, but the prediction model equation takes much of the trend with inflation into account).

The moderate risk cases (presumably the majority of cases in this age range), cost the taxpayer-funded healthcare system (preretirement years=Medicaid; post-retirement=Medicare) a little less than five million dollars.

What makes this analysis different is the inclusion of costs for social services related services and intervention events, for all stages in the a patient’s  life, from childhood years through college and early employment years, into hospitalization and post-hospitalization/post-surgical years (counseling, neurosurgical counseling, neurosurgical testing,  WAIS, and post-surgical occupational and cognitive speech therapy reviews were included.)

Each of these two types of patients was also assumed to receive continued MCD/MCR assistance for the rest of his/her life, including Section 8 and Food Stamps coverage, to name a few of the additional costs not fully evaluated in the older forms of this study performed back in the late 1990s.

No early mortality was assumed for these cases.  Since people with active, ongoing epilepsy are normally assumed to demonstrate a reduced lifespan of about 10-20 years, this could be considered the one flaw in this analysis.  With such a reduction in longevity, a significant number of these two high cost groups would die off well before the age of 70.

Nevertheless, this provides a reason for engaging in more aggressive, early interventions into epilepsy care.  The recovered individual cost the system nearly a half-million dollars in real money, a little less than one-million dollars once these costs are CPI adjusted.  And such an outcome (“the cure”) is an infrequent event.

In sum, the moderate case can cost anywhere from 4 to 5 times more than the recovered epileptic.

The highest risk cases can cost the system as much as 12-fold, according to this analyses.  Even if we cut this amount in half, we are still talking about an additional 6 million dollars in cost of care over time.

These amounts per patient by the way represent costs per year that are higher than what most individuals earn in these same age groups, were they employed.

Each case therefore represents a reduction in taxpayer income for the country, with each dollar traded over for each dollar required of the medicaid or medicare systems.  This amount doubles for high risk patients.

More importantly, the cost for caring for a typical high risk patient between 70 and 80 years of age will cost the system about a quarter million dollars per year.

The total cost for the care of retired people with epilepsy in upcoming years has been estimated to be in the billions, with about one million people who are now eligible for this health care assistance, should they still be around about 20 to 25 years from now.

For more on this study, go to  https://altonenb.wordpress.com/  

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