University of Pennsylvania Health System

Penn Health for Women Newsletter

Monday, May 12, 2014

PCOS and Sleep Apnea: When Snoring Shouldn't (or Can't) Be Ignored

Polycystic ovary syndrome (PCOS) is a complex condition, or group of physical symptoms, in which women experience infrequent menstruation, weight gain, acne, abnormal hair growth and fertility problems.

“Women with PCOS are at risk for other, related life-long conditions and symptoms including diabetes, high cholesterol, hypertension,” says Anuja Dokras, MD, PhD, director of the Penn Polycystic Ovary Syndrome Center. “They are also at risk for sleep apnea.”

Sleep apnea is a respiratory disorder in which a person experiences pauses in breathing. Pauses can last from a few seconds to a minute, and can occur multiple times throughout the night. “Sleep apnea presents itself as snoring, pauses in breathing followed by a gasp for breath and frequent, disturbed sleep,” says Dr. Dokras. “A partner or spouse may tell the person with sleep apnea this is occurring, or in some cases, the person with sleep apnea wakes themselves up during the night.” Snoring itself isn’t serious, but if a person is experiencing snoring with sleep apnea, the situation can have serious complications.

“For women with PCOS, sleep apnea can exacerbate other PCOS symptoms such as tiredness, difficulty losing weight, hypertension and insulin resistance,” says Dr. Dokras. “Of course, many women report feeling tired, but some also say they feel depressed and experience unexplained moodiness.”

Diagnosing Sleep Apnea

Allan Pack, MD, PhD, chief of the division of sleep medicine and director of the Center for Sleep and Respiratory Neurobiology at Penn says sleep apnea often goes undiagnosed.

“There are two different ways we can diagnose sleep apnea,” he explains. “A sleep study in a sleep lab that resembles a hotel room requires patients be hooked up to wires throughout the night. An electroencephalogram, or EEG, monitors brain activity throughout the night to determine how well an individual is sleeping, while patients are watched using respiratory monitors to see if there are pauses in their breathing as they sleep”. Dr. Pack explains “at-home” sleep studies are also an option for some patients.

“For patients without a lot of other health conditions, an ‘at-home’ sleep study can monitor sleep, and pauses in breathing,” he says. “The only difference is that an EEG study is not done in the home.”

Treatments for Women with PCOS and Sleep Apnea

Treatment for PCOS includes medication, nutritional counseling and weight loss. “Weight loss can help improve sleep apnea, but treatment for sleep apnea itself can have a marked improvement on a woman’s life,” says Dr. Dokras.

Dr. Pack says most patients can use a continuous positive airway pressure machine, or CPAP machine, to help regulate breathing throughout the night.

“A CPAP machine uses a mask with pressurized air to force the airways in the mouth and neck to remain open while the person is lying down and asleep,” says Dr. Pack. “A CPAP machine is very effective. Patients who use it report having more energy throughout the day, and less drowsiness.”

There is also a small amount of evidence that suggests use of a CPAP machine can help other metabolic functions in women with PCOS such as insulin resistance, high blood pressure and high cholesterol. For those who cannot tolerate wearing a CPAP mask throughout the night, an oral device that pulls the jaw forward may be an option for treatment.

For those who cannot tolerate wearing a CPAP mask throughout the night, an oral device that pulls the jaw forward may be an option for treatment.

"We are learning more and more that restful, healthy sleep is important for every other body function," says Dr. Dokras. "That's why it's so important women with PCOS talk to their physician about their sleep, and if they are experiencing any symptoms of sleep apnea."

Wednesday, April 23, 2014

What Women Need to Know About Endometrial Cancer

Endometrial cancer is the most common gynecologic cancer in the United States. A statistic like this can be daunting and a bit frightening, but the good news is according to gynecologic oncologist Emily Ko, MD, MSCR, assistant professor of obstetrics and gynecology at Penn Medicine, women diagnosed at an early stage generally have good outcomes.

“Knowing the symptoms of endometrial cancer is extremely important,” says Dr. Ko. “Irregular bleeding is typically the first symptom. At that point, a woman should see a physician for an exam, and all of the appropriate tests needed to make a diagnosis.” Endometrial cancer is a cancer that develops in the lining of the uterus called the endometrium. There are two types of endometrial cancer. Type 1 endometrial cancer tends to be associated with diabetes, obesity and metabolic syndrome, a cluster of conditions that includes high blood pressure, high blood sugar levels and high cholesterol.

“Together with cancer treatment, it’s important for women with this type of endometrial cancer to work on other areas of their health such as weight management, exercise and diet in order to have better control of the associated issues like diabetes and high blood pressure that can affect their overall health,” says Dr. Ko. She adds that there are even some clinical trials examining the use of metformin, widely used in the treatment of diabetes, to treat pre-cancerous cells in the uterus.

Type 2 endometrial cancer tends to be biologically different and is less related to metabolic syndrome, says Dr. Ko. “This type of endometrial cancer has a different way of developing in the uterus,” she adds. “We tend to see this type of cancer more frequently in African-American women.”

Who is at Risk for Endometrial Cancer?

While there are currently no screening recommendations for endometrial cancer, it’s important women speak with their physicians about their personal risk. Endometrial cancer is typically diagnosed in women over the age of 45. Other risk factors for endometrial cancer may include:
  • Obesity
  • Diabetes
  • Family history of endometrial cancer
  • Early onset of menstruation
  • Polycystic ovary syndrome (PCOS)
  • Hormones – excessive estrogen through hormone replacement therapy or obesity
  • Tamoxifen after menopause

Gynecologic Oncologists at Penn – Part of Your Entire Team

Key to successful outcomes is early detection and coordination of your care. “As surgeons, we perform complex surgery, but we also provide chemotherapy and collaborate closely with radiation oncologists at Penn,” says Dr. Ko.

“For women with endometrial cancer, we perform minimally invasive surgery via robotic-assisted surgery or laparoscopy,” she says. She also explains that in some cases, medical management with hormones or medications, or radiation alone may be used in place of surgery – especially for women who want to preserve their uterus.

For women who are still interested in having children, Penn gynecologic oncologists work closely with reproductive medicine and fertility specialists at Penn Fertility Care, so women undergoing treatment for cancer have options for child-bearing.

“Aside from comprehensive cancer care at the Abramson Cancer Center, we offer women exercise interventions, nutritional counseling and we have access to related services like diabetes and cardiovascular care,” says Dr. Ko. “Because we all work together, it’s easy to follow patients, and share information so we know the whole picture of health.”

And, Dr. Ko adds, advances in endometrial cancer research continue. “Technology and research have allowed us to get more sophisticated in the way we view cancer so we can treat it with more personalized approaches,” she says. “Tumor biology, targeted therapy, genetics and prevention are all adding more information so we can continue to enhance the standard of care.”

Learn more about Penn's Gynecologic Cancer Team and find out what's right for you.

Wednesday, April 9, 2014

Increasing Cancer Risk - Is it in Your Genes?

In a New York column titled My Medical Choice published last year, Angelina Jolie announced she carried the BRCA gene mutation and had a double mastectomy to minimize her risk of developing breast cancer.

And for women with Lynch syndrome, another genetic condition, their medical choices can sometimes be just as complicated.

Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC), is an inherited condition that increases the risk of colon cancer and other cancers such as ovarian and endometrial cancer.

“Lynch syndrome isn’t rare,” says Anil Rustgi, MD, chief of the division of gastroenterology at Penn Medicine. “It’s estimated this inherited condition accounts for about four percent of colon cancers every year.”

Dr. Rustgi says that Penn’s nationally renowned Gastrointestinal Cancer Risk Evaluation Program evaluates and treats patients with Lynch syndrome, and helps coordinate care with other disciplines such as gynecologic oncology.

“Women who are diagnosed with colon, endometrial or ovarian cancer and who have a family history of the disease may be evaluated via genetic testing and counseling,” says Dr. Rustgi. “The general recommendation for average-risk colorectal cancer screening is a colonoscopy after age 50,” says Dr. Rustgi, “but, because of their higher risk, women and men with Lynch syndrome receive more and different types of screenings starting in their 20s.”

He adds that women with Lynch syndrome who have stopped having children may also prophylactically have their ovaries or uterus removed to prevent ovarian or endometrial cancer. Until then, women should have annual endometrial biopsies and annual transvaginal ultrasounds to evaluate the ovaries, starting between ages 25 to 35 or when the diagnosis is made.

“Genetic testing is powerful in that it gives men and women a chance to take hold of their health by taking measures to minimize their risk,” says Dr. Rustgi. “These are not easy medical choices to make, but with proper genetic evaluation and counseling, they can be informed decisions.”

Evaluating Your Risk for Colorectal Cancer

The Gastrointestinal Cancer Risk Evaluation Program at Penn Medicine offers information, evaluation, and follow-up for people who are at increased risk to develop gastrointestinal cancer due to a personal or family history of colon polyps, colon cancer, or other gastrointestinal cancers (pancreatic, stomach, esophageal, liver). It is also important to note that a personal or family history of genitourinary cancers such as ovarian, bladder, kidney, and uterine cancer may contribute to an individual’s risk for colorectal cancer.

The program offers nationally recognized experts, led by Dr. Timothy Hoops and Dr. Rustgi, in the diagnosis and treatment of colon and other gastrointestinal cancers. Penn’s genetic counselors also have extensive experience in family history assessment, education and counseling for people with a family history of gastrointestinal cancer. The team also includes physicians and health care specialists from all needed specialties, including gastrointestinal medicine, hematology-oncology, medical genetics, radiation oncology, surgery, radiology and pathology.

For additional information or to make an appointment, call 800.789.PENN (7366) or visit PennMedicine.org/gastroenterology.

Friday, March 28, 2014

Women's Pelvic Health Informational Session

Join Penn Medicine for an informational session on Incontinence and prolapse. Did you know that nearly 50 percent of women suffer from bladder and pelvic floor disorders at some point in their lifetimes?

Bladder and pelvic floor disorders include urinary and fecal incontinence and pelvic organ prolapse (when the vagina, uterus, bladder or rectum “falls down”). Pelvic floor disorders affect women of all ages, but post-menopausal women and women who have given birth are most at risk.

Join Heidi Harvie, MD for a discussion about the signs, symptoms and latest treatment options available for pelvic and bladder floor disorders.


TUESDAY, MARCH 11, 2014 | 6:00 –7:00 PM
Penn Medicine Washington Square
19th floor | Philadelphia, PA 19104
Free parking available for attendees


Tuesday, March 25, 2014

Paternity After A Vasectomy?

That tattoo you thought was a great idea in college? Maybe not so much now. And that perm you shelled out big bucks for in 1985...probably wouldn't be a discussion with your hairstylist today.

It’s a fact of life – situations change, minds change, decisions change.
For men and couples who make a decision not to have any (or any more) children, they might decide to have a vasectomy. But what if their minds change? Or, in many cases, a relationship ends, a new one begins and all of the sudden you do want to have children?

“A vasectomy is one of the most common urologic procedures and should be considered a permanent form of contraception,” says Puneet Masson, MD, assistant professor of urology in surgery and director of Male Fertility at Penn Medicine. “That being said, approximately five percent of vasectomized men express the desire for future children and one to two percent may seek consultation regarding options for future fatherhood.”

Dr. Masson sees men who are interested in having a vasectomy. However, he advises that they should only have the procedure if they are 100 percent sure they do not want any more children. A man can also cryopreserve sperm if there is any concern that someday he may desire more children.

“Of course, we understand that life is dynamic and unpredictable and that some vasectomized men are highly interested in achieving a genetic pregnancy,” says Dr. Masson. “There are two options for these patients: vasectomy reversal, and sperm extraction. Both pathways are equally effective at achieving future children and the decision depends on the preferences of the patient/couple.”
Puneet Masson, MD, director of Male Fertility at Penn Medicine.

Reversing a Vasectomy

First, it’s important to understand how sperm is made. Sperm are made in the testicle in extremely small tubules called seminiferous tubules. This process takes approximately 60 days. Afterwards, they are slowly transported to the epididymis and continue to mature over a period of two weeks. Following this, they are ready to be ejaculated and are stored in the section of the vas deferens immediately next to the epididymis and part of the epididymis itself.

During a vasectomy, the vas deferens is cut and each end of the vas is tied, clipped, and/or burned. Thus, the semen of a vasectomized man should not contain any sperm. During a vasectomy reversal, the vas deferens is reconnected so that the man’s ejaculate contains sperm.

A vasectomy reversal typically takes four to six hours and is done under general anesthesia. Afterwards, the patient is able to go home the same day. Following a healing period, the man is “allowed” to resume unprotected sexual relations. Due to swelling in the vas deferens, which occurs as a natural part of healing, it may take up to a year before sperm are visible in the ejaculate. If the more complicated connection is done (vas to epididymis), it may take up to 18 months.

“What all patients should understand is that there is no guarantee that a pregnancy will be conceived through natural means following a vasectomy reversal,” says Dr. Masson. “Though most studies report a ‘natural’ pregnancy rate between 50 and 70 percent, some couples may still choose to participate in assisted reproductive therapy following a vasectomy reversal and do in utero insemination (IUI) and/or in vitro fertilization (IVF).”

Retrieving Sperm

“A sperm extraction procedure is also an excellent option for vasectomized men who desire future children,” says Dr. Masson. A percutaneous epididymal sperm aspiration (PESA), testicular sperm aspiration (TESA), microsurgical epididymal sperm aspiration (MESA), and microsurgical testicular sperm extraction (microTESE) are procedures that directly extract sperm from either the epididymis or testicle. This can be done under local anesthesia, conscious sedation (aka “twilight anesthesia”), or general anesthesia, and can be completed in about an hour.

“What is important to understand is that all sperm extracted must be used in conjunction with IVF, where a woman undergoes an egg retrieval procedure and the sperm must be injected directly inside the egg,” Dr. Masson says. “After a few days, the developing embryo is placed into the woman’s uterus. Excess sperm that was not used for fertilization is usually cryopreserved and stored for future IVF cycles.”

All vasectomized men who are interested in future genetic children should be counseled on both options. A full female evaluation is also recommended, as this may aid couples in making an informed decision. Penn Fertility Care is committed to understanding a couple’s reproductive goals and preferences. Our team includes physicians, nurses, and financial counselors who can discuss all aspects of fatherhood after a vasectomy and individualize a plan for future family planning.

Wednesday, March 12, 2014

Men Are From Mars (But So Are Women)!

He might have a man cave… and she might take up most of the closet space. He might not stop for directions… and she might ask at every light.
There may be a lot of differences between men and women, but when it comes to preventing cardiovascular disease, it turns out there may not be many differences at all. Susan Brozena, MD, heart failure specialist and medical director for Penn Cardiology Radnor, says getting back to basics for cardiovascular health is a good preventative idea for men and women.
“When we talk about prevention of heart disease — for anyone — we always make sure we talk about exercise, good nutrition, quitting smoking and preventative tests and checkups,” says Dr. Brozena. “These are true for both men and women.”
Dr. Brozena says a main difference in heart disease prevention in men and woman is the use of hormone replacement therapy (HRT), which may lead to an increased risk of cardiovascular disease. “Most studies show that women who use HRT in the short term — one or two years — don’t increase their risk of heart disease,” says Dr. Brozena. “However, long-term usage of HRT — more than a couple of years — may increase risk.” Dr. Brozena adds that not many women are using HRT for long-term treatment of menopausal symptoms anymore.
Know your risk.
Schedule an appointment with a cardiologist today,

or call 1-800-789-PENN.

He Said, She Said?

Heart disease is still the number one killer of women in the United States and is more deadly than all types of cancer. While there may be no differences in the prevention of cardiovascular disease in men and women, Dr. Brozena says the warning signs of heart disease can be different. “When more women recognize the signs of heart disease, or a heart attack, more women can seek treatment earlier,” says Dr. Brozena.
Heart disease symptoms in women are different than in men. “Symptoms of a heart attack in women may include dizziness, jaw pain and nausea or other gastrointestinal discomfort,” says Dr. Brozena. “The first symptom isn’t always a severe pain in the chest like we see on television and in movies. It can be much more subtle than that.”
And, as Dr. Brozena points out, many women dismiss the symptoms because they simply don’t have the time to get sick. “As women, we are usually the caregivers and managers of the household,” she says. “Often times, women brush off pain or an odd feeling or sensation simply because they don’t have the time to step away from their daily life and focus on themselves.”
Heart Attack Symptoms and Heart Disease Risk Factors infographic

Thursday, February 27, 2014

What Women Aren't Talking About

Some women deal with it as if it were a rite of passage in motherhood, or something they just have to “deal with” with age – that tiny bit of urine that comes out when she laughs or jumps up and down in an exercise class. It’s estimated that nearly 50 percent of women suffer from bladder and pelvic floor disorders at some point in their
lifetime.

These disorders can be sources of embarrassment and impact a woman’s lifestyle.

Bladder and pelvic floor disorders, also known as urogynecologic disorders, include any pain or dysfunction in the uterus, cervix,vagina, bladder or rectum. Urogynecologic disorders a effect women of all ages, but post-menopausal women and women who have given birth are at most risk. A urogynecologist is an obstetrician/gynecologist who specializes in pelvic floor disorders.The sudden urge to empty the bladder for no apparent reason, or urine leakage when coughing or sneezing is called urinary incontinence.

There are two types of conditions that cause urinary incontinence: stress incontinence and urge incontinence.

“When we talk about leaking urine from coughing, sneezing, laughing or  exercising, that’s stress incontinence,” says urogynecologist Pamela Levin, MD, assistant professor of obstetrics and gynecology at Penn Medicine. “As women age, or have children, the urethra and surrounding muscles of the bladder can lose their strength.”

Dr. Levin says even women who haven’t delivered babies vaginally and have had cesarean sections, can suffer from stress incontinence. “Pregnancy itself can put stress on the pelvic region, which can weaken the muscles and supporting structures,” says Dr. Levin.

Pam Levin, MD
Stress incontinence can be treated with physical therapy including Kegel exercises or the use of a pessary, a removable appliance similar to a diaphragm that is inserted into the vagina to strengthen the pelvic muscles. In some cases, collagen injections may also be used to help minimize urine leakage from the bladder. Named after Dr. Arnold Kegel, Kegel exercises strengthen the muscles that create the pelvic floor.

“To locate the pelvic floor muscles, women should imagine they are trying to stop a flow of urine or keep from passing gas,” says Dr. Levin. “When they have located these muscles, they should hold and squeeze them for a few seconds, then release.”It’s recommended women work their way up to holding and releasing these muscles for 10 seconds at a time, and repeat up to three sets of 10 squeezes every day. In harder to treat cases, surgery is recommended.

A sling procedure may be used to support the urethra and bladder.

During the operation, a sling created from FDA-approved  mesh is inserted behind the urethra to support the weakened pelvic muscles. Urge incontinence is a type of urinary incontinence that many people refer to as the “gotta go” syndrome.“Women with urge incontinence, or overactive bladder syndrome, experience sudden, strong urges to empty their bladder and can experience urine leakage,” says Heidi Harvie, MD, director of Penn Urogynecology at Pennsylvania Hospital. “Overactive bladder is caused by nerve damage in the bladder, which makes its treatment more complex.” The first line of treatment, says Dr. Harvie is to reduce the amount of fluids women drink. She also recommends women practice Kegel exercises.“Medications can block some of the nerves in the bladder,” says Dr. Harvie. “While these medications are safe, they can have side effects such as dry mouth and constipation.”
Hedie Harvie, MD

Two other alternative treatments: sacral nerve stimulation, or a bladder pacemaker; and Botox® injections can also be effective in treating urge incontinence.A bladder pacemaker is a reversible treatment that uses mild electrical pulses to stimulate the nerves going to the bladder. It acts like a cardiac pacemaker and is placed during an outpatient procedure. Botox injections treat overactive bladder by relaxing the muscles of the bladder.

Pelvic Organ Prolapse 

Pelvic organ prolapse, also called vaginal prolapse, is a condition which the structures that stabilize the uterus weaken and the uterus falls or slides out of place into the vaginal area.Vaginal prolapse can be caused by conditions that stress the pelvic floor muscles such as childbirth or hysterectomy, as well as the decrease in estrogen experienced during menopause. Its treatment depends on the severity of the condition.A pessary may be used to hold the uterus in place,but for women who do not respond to this treatment a surgery called sacrocolpopexy may be recommended.“Sacrocolpopexy, also called pelvic floor reconstruction, secures the pelvic organs in place with surgical mesh,” says Dr. Harvie. The mesh is attached to the cervix and stronger ligaments in the pelvis thereby lifting and holding pelvic organs in place. “This surgery can be performed robotically so, women can leave the hospital within a day with minimal incisions, less blood loss and have a quicker recovery.”

Dr. Levin, adds: “A woman shouldn’t have to face incontinence or pelvic organ prolapse alone. We offer thelatest procedures, and work together to choose the best treatment to meet her needs.”

Friday, November 22, 2013

Five GI Symptoms No Woman Should Ignore

When it comes to gastrointestinal conditions, symptoms can be as mild as a nagging stomach ache, or as serious as a sharp pain that lasts all day.

“Any symptom that lasts more than a few weeks, or causes interruptions in sleep or your daily schedule should not be ignored,” says gastroenterologist, Farzana Rashid, MD, at Penn Medicine Radnor. “However, there are several symptoms that should never be ignored, as they could be the sign of a more serious problem.” Dr. Rashid says the following gastrointestinal (GI) symptoms should never be ignored:

Blood
GI bleeding is not normal and needs to be evaluated. There are many different causes of GI bleeding including an ulcer, hemorrhoids and cancer. “Anyone experiencing blood in the stool or blood in vomit needs to be formally evaluated,” explains Dr. Rashid. “At Penn Medicine Radnor, physicians perform procedures like endoscopy, colonoscopy and capsule endoscopy, which uses an encapsulated camera to view the GI tract, in order to evaluate and diagnose GI bleeding.” These procedures are also available on Saturday mornings to accommodate patients.

Change in Bowel Habits
Farzana Rashid, MD,
Women who notice a change in bowel habits should seek evaluation.“If you are passing less frequent stools than you were, or if you have diarrhea that lasts longer than two weeks, you should be evaluated by your health care provider,”says Dr. Rashid. “Diarrhea can be a symptom of something simple like a change in medications or an infection, or more complex like celiac disease or inflammatory bowel  disease.”And when it comes to constipation, what is normal? “The answer depends,” says Dr. Rashid. "You know your body the best.There is no rule that states you must have a bowel movement once a day, but if you notice you are going a lot less frequently than you are used to, you should see a physician.”

Long-Standing Heartburn
Since the advent of over-the-counter medications that treat heartburn, many women have become used to self-medicating to treat their frequent heartburn. “Over-the-counter medications are okay, but if symptoms are not getting better in a few days, you should seek medical attention,” says Dr. Rashid. That’s because long-standing heartburn can be a symptom of something more serious. Long-standing heartburn from acid reflux can cause other problems down the road. “It’s also important to understand that prolonged uses of some over-the-counter medications can have certain side effects including the possible increased risk of bone fractures,” adds Dr. Rashid. General guideline — if you are experiencing frequent heartburn, see your doctor.

Difficulty Swallowing
If you have problems coordinating your swallowing, difficulty getting food from your mouth down your esophagus, or you feel like food keeps getting stuck in your chest, it’s important to consult with a physician. “Difficulty swallowing or getting food through the esophagus into the stomach can mean  there is an inflammation or some sort of narrowing or blockage within the esophagus,” says Dr. Rashid. “An upper endoscopy or a barium esophagram can be done to see what is going on. Also, Penn offers swallow studies, which are useful for patients who have problems coordinating their swallowing.”

Anemia
When most people think of anemia, or low iron in the blood, the first thing that may come to mind is diet. While having a balanced diet rich in iron can help raise low iron levels in the blood, there may be other causes of iron deficiency. “Women experiencing frequent and/or heavy menstruation may develop anemia,” says Dr. Rashid. “But anemia can also be a symptom of bleeding or malabsorption within the GI tract.” In other words, even adjustments to one’s diet may not have an effect if the body is losing blood or isn’t obsorbing the nutrients. “Symptoms of anemia include feeling tired, dizzy, having heart palpitations, or being short of breath,” says Dr. Rashid. “A blood test can determine if someone is anemic; however, only GI testing can determine if there is a cause within the GI tract.”

Gastroenterology Services at Penn Medicine Radnor
At Penn Medicine Radnor, there are seven gastroenterologists,who are experienced in gastrointestinal disorders, including colon cancer evaluation, irritable bowel syndrome, gastroesophageal reflux disease,GI bleeding and celiac disease. Dr. Rashid says a multidisciplinary approach to care at Penn means patients benefit from the expertise of all specialties within the health system. Patients have access to radiology services, pharmacy, and laboratory testing on site at Radnor. “Women who come to Penn have access to nationally recognized leaders not only in gastroenterology, but in all specialties,” she says. “We all work together, which means more comprehensive care under one roof.”

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