Category Archives: Case Profiles

Duane Graveline

The enclosed article composed by Dr. Malcolm Kendrick once again focuses on the statin drugs, which are almost routinely prescribed by most practicing physicians.

In many instances this may be contrary to the patient’s best interests as evidence of adverse reactions continue to accumulate. Clearly this topic requires further analysis without bias.

I never met Duane Graveline in person, but we communicated regularly. He was a doctor who trained as an astronaut with NASA. Sadly, he never made it into space. He was also a dedicated researcher and aerospace doctor https://en.wikipedia.org/wiki/Duane_Graveline

Superficially at least, a very conventional doctor, he was found to have a high cholesterol and his doctor put him on statins. He was initially grateful for this, firmly believing that raised cholesterol caused heart disease.

He then suffered an episode of transient global amnesia (TGA). A scary event, where you forget who you are or where you are, for a short period. Initially, he feared that he had suffered a stroke, but he had not. He stopped his statin, then re-started, and suffered another episode of TGA. His doctor assured him that the statin could not have been the cause.

However, he began to research transient global amnesia and a possible connection with statins. He found many other people who had suffered exactly the same symptoms – whilst on statins. An adverse effect still not listed, or accepted, by the medical profession. The normal response is that… statins don’t do that.

Following this, and with his faith in statins and the cholesterol hypothesis, seriously damaged, he concentrated his efforts into looking at all of the potential adverse effects that these drugs may cause. He had been repeatedly told that statins were absolutely safe and side effect free. He had been confidently informed that his own adverse effects were nothing to do with statins. A sadly familiar story to me. However, he no longer believed such reassurances, and set about trying to discover the truth.

One area where he focussed attention, probably due to his background in aerospace medicine, was a growing concern that any airline pilot taking a statin could suffer an episode of TGA – and simply forget how to fly the plane [an issue he raised that worries me still].

Shortly after (I am not entirely sure on the timeline here) he developed Amyotrophic Lateral Sclerosis. Called Lou Gehrig’s disease in the US – I believe. This condition is normally fatal within a couple of years. But his syndrome did not develop that rapidly. He believes, and so do I, that his ALS was caused by statins, and was therefore not true ALS. Difficult to prove, but there have been many other recorded cases, and the WHO issued a warning about a possible association between statins and ALS.

In time Duane became the most outspoken critic of statins – that I know of. He wrote books on the subject, including ‘Lipitor, thief of memory.’ And ‘The statin damage crisis.’ He set up the website spacedoc.com where he collected an immense amount of data on statins and adverse effects data.

There was also ground-breaking research on co-enzyme Q10, trans-fatty acids and much else to do with CVD. In addition to this, he was gathering and compiling data from the FDA Medwatch database, and putting together an extensive and scary list of all the reported statin adverse effects [the tip of an iceberg]. For example, he calculated at least eight hundred recorded deaths from rhabdomyolysis.

He was not a zealot. He believed that statins do have benefits in CVD. He believed these benefits were due to anti-inflammatory actions – nothing to do with lowering cholesterol levels. Following from this, he thought that the beneficial, anti-inflammatory, effects of statins could be obtained at very low doses. Doses that would not cause severe adverse effects. We disagreed on the inflammatory aspect of CVD – but agreed on pretty much everything else. He sent me papers he had written, asking for my input and editing. I obliged when I could.

He was an energetic man, an honest man, and a man who was trying to do his best to help people, even into his ninth decade. He will be sorely missed.

https://drmalcolmkendrick.org/2016/09/06/duane-graveline/

Current Research on the Management of Pain

May 10, 2016

A recent study at McGill University found that light therapy can be used as a non-invasive approach in chronic pain management. Researchers were able to treat mice with light sensitive neurons in a region of the brain responsible for cerebral transmission. Once exposed to light, these neurons ended up reducing their bioelectric activity effectively shutting off the neurons and their pain producing ability. The researchers found that the pain relieving effect of the light treatment persisted even after therapy was concluded.

Results show that acute blockade of Nav 1.8+ terminals reduces pain transmission and that prolonged inhibition of peripheral input causes short-term analgesia, outlasting the optical stimulation.

(Report published by Montreal Neurological Institute, April 21, 2016)

This illustrates one of several ways in which light affects function of the central and peripheral nervous system. Unlike other approaches for controlling brain activity, such as the use of drugs, this type of therapy can be precise both in terms of timing and types of cells affected.

Using optogenetics to control pain transmission would appear to be a much more targeted approach to chronic pain relief than today’s more common methods, such as use of opiates, which cannot be localized or prescribed with the same precision as a beam of light.

Another recent study from MIT shows that optogenetics could be used to control obsessive compulsive behaviour in mice by working to turn off the hyperactive neurons responsible for the compulsive behavior patterns.

These research projects explore some of the mechanisms which are activated by appropriately designed Laser Therapy Devices and protocols utilized.

Fred Kahn, MD, FRCS(C)

Hopefully a Light at the End of the Tunnel?

Hopefully a Light at the End of the Tunnel? – A commentary on an article from the Globe and Mail, Monday, July 13, 2015.

Reflections on Home Care and Community Clinics as depicted in the Globe article.

All too often the principals who form and control the organizations providing the type of care discussed, have been awarded government contracts to render these services, as rewards for working on political campaigns donating funds to parties and actively aiding politicians to become elected.

The result – the care provided is generally third rate and in many instances, may be counterproductive to the objective intended. Whereas bureaucrats state that these programs save millions of dollars in health care; in essence, more frequently they prolong existing problems at a prohibitive cost. In too many instances, those who propose to render this “high quality care?”, have minimal understanding of the medical aspects of these clinical problems and how to resolve them.

Although I have not directly investigated these organizations as time does not permit, patients that present who have been treated by these groups have seldom been well served and indeed in too many instances, their lesions have become more extensive over prolonged courses of treatment.

One might conclude that this is simply another example of politicians rewarding their friends with lucrative financial contracts and making a mockery of Canadian health care with regard to patient focus.

There is a great deal more to wound care for example than periodic debridement, dressing changes, etc. and often these archaic methods perpetuate an increase in the dimension of these lesions until the limb is amputated or the patient expires.

Quality care unfortunately requires understanding of the pathology, a thorough and careful individual assessment and properly directed therapy, not budgets and outmoded methodologies, which in the long-term are much more expensive than focusing on the problem and resolving it in a meaningful, appropriate fashion.

read the full article here: http://www.theglobeandmail.com/news/national/ontario-shifting-home-care-to-private-clinics-as-province-seeks-savings/article25476203/

Commentary

Statins and their utilization continues to be controversial. Increasing evidence is being presented that their therapeutic value may be open to question.

The two articles provided stimulate independent thought with regard to their status. What is clear is that they provide monumental income to the manufacturers and that physicians have been conditioned to prescribe them, something that clearly requires further discussion and evaluation. The articles speak for themselves.

https://www.spacedoc.com/articles/a-case-for-low-dose-statins

http://www.huffingtonpost.co.uk/dr-aseem-malhotra/great-statin-con_b_9607316.html?utm_hp_ref=uk&ncid=tweetlnkushpmg00000067

Off The Shelf Medications – Regulatory Bodies – Caveat Emptor!

Whereas it is preferable to wish people success in their endeavours, particularly those that will benefit others, while hopefully adhering to the truth, unfortunately in our current culture events contrary to these objectives do occur. Schadenfreude is not high on my list of aspirations but sometimes it conveys a benign sense that perhaps truth still extends to some corners of our society.

To wit – a recent newspaper article indicated that a class action had been filed against ColdFx, a concoction that has been marketed more than vigorously in Canada, and presumably other jurisdictions, over the past 10-15 years.

Canadians alone have spent more than a billion of their hard earned dollars on this apparently worthless medication, which for over a decade had been touted as a cure for colds. There were also references to the preventative factor, reducing the symptoms of infections, along with shortening the duration of the problem – none of which are evidently true.

At one time a well-intentioned salesperson representing that company brought samples to my office and I had the opportunity to review the components. Although I am no expert on reviewing the ingredients and contents of medications, this one appeared to be primarily just another form of ginseng, along with a number of other obscure materials. Clearly there appeared to be nothing within the compound that should confer specific health benefits, yet regulatory bodies approved its sale.

Immediately all the large pharmacies, including the chains, had displays close to their front entrances where you could not miss the ColdFx presence. A banner boldly stating that colds, viruses, etc. were conquered, along with many articles reporting that patients who used the compound fared significantly better than those who did not. What could be more convincing?

Again, in our culture where an overwhelming avalanche of false advertising in all channels of communications exists, it is sometimes heartening to see that retribution in some form can still occur, punishing deliberate falsehood and hopefully its perpetrators, if they are still around.

So much for placing your trust in pharmacists, regulatory bodies and the machinery employed in promoting fraud. Events of this nature do not provide a sense of comfort when relying on the so-called “watchdogs” and selective regulatory bodies controlling the protection of our state of health.

COMMENTARY – December 2015

Today in medical practice, the focus on pain management exceeds the attention provided to the etiological factors that cause pain and other symptoms. Clearly the focus of the causative elements should be the focal point of research and therapy.

The administration of measures to mitigate the pain often permits the pathology to become more severe to the degree that pharmacological and sometimes surgical solutions fail to contain the progress of the disease involved, along with the severity of attendant symptoms.

At Meditech we recognized this paradigm many years ago and have always focused on the causative factors involved, rather than mitigating or masking symptoms. This would appear to be the logical approach, however one not followed in current medical practice.

As a growing number of physicians present at our facilities for personal treatment, our practice is beginning to influence an increasing number of these individuals to become leaders of what we feel is a more rational and elegant approach to the treatment of pathologies, particularly when no proven or conventional method of resolution currently exists.

Chronic joint pain, secondary to systemic, traumatic and degenerative causes, can be immediately and sometimes rapidly resolved with the application of Laser Therapy and without the production of adverse effects. Many surgeries, including joint replacements, exploratory procedures, etc. primarily to reduce the degree of pain, can therefore be avoided. This is particularly important in the approach to the treatment of back problems, again, a condition resulting secondary to a number of diverse factors.

As we are all aware, the treatment of cerebral concussion (TBI) is receiving an immense amount of international attention and our therapeutic approach to this problem, developed and refined over the past decade, has become extremely relevant.

Moreover, at this time we are pleased to state that we have developed an almost universally effective therapeutic approach based on the understanding of the brain anatomy, physiology and function.

Our recently completed 26-page treatise on the treatment of the various categories of concussion is being more widely recognized at some university located concussion clinics as it delivers effective therapy devoid of any adverse effects. A number of organizations who have become aware of this technology are in contact with the principals at Meditech with the thought of establishing concussion clinics worldwide.

Dr. Norman Doidge’s book “The Brain’s Way of Healing”, which resonates with so many physicians and patients afflicted with a diverse number of medical conditions, has stimulated an international response to his message which brings patients to our clinics in ever increasing numbers.

Eventually logic will always prevail, despite the obstructions posed by insurance companies, regulatory bodies, governments and others who would pose impediments for reasons not always clear.

Health care needs to change and Meditech, with its innovative solutions, is at the forefront of this sentinel movement.

Clarification of Controversy – Class III vs. Class IV Lasers

Clarification of Controversy – Class III vs. Class IV Lasers

The article below hopefully will permanently put to rest the inappropriate claims made for the efficacy of Class IV vs. Class III or IIIB Lasers. The article clearly delineates the controversy utilized in advertising these forms of Laser Therapy which creates significant confusion for begineers attempting to find their way in the field of Laser Medicine.

Dr. Jan Tuner’s objective summary of this matter should clarify the facts involved and enable clinicians to make appropriate choices with regard to the therapy systems they acquire for optimal benefit to their patients.

Low Level Lasers in Clinical Practice – Jan Tunér DDS

The use of low level lasers is increasing in medical applications. This treatment modality offers several advantages by promoting wound healing, reducing inflammation, edema and pain. But for those thinking about adding a low level laser to their clinic, it is wise to look for unbiased information before any investments are made.

There are many different lasers on the market with different wavelengths, different combinations of wavelengths and output power. Most of these lasers are in the so called Class 3B, meaning lasers with a maximum power of 500 milliwatts (mW). Lasers with higher power are in the Class IV and having powers between 501 mW up to 15 000 mW (15 W) or more. The classification has nothing to do with the therapeutic effects but is solely based upon the risk of retinal damage. Which type of laser is then the best buy? To answer this question, we need to look at some facts.

Manufacturers of Class IV lasers often claim that the high power increases the depth of penetration into tissue. This is not correct. Several of these lasers have a 980 nm wavelength, and the penetration of this wavelength is considerably less than that of the more conventional 808 nm wavelength. Since the penetration at 980m nm is poor, this means that there is more heat buildup at the skin. And laser phototherapy is not about heat but about photochemical reactions. As for the high power, it causes no increase of the penetration depth. The study by Joensen et al. [1] showed a static depth of penetration of 810 nm over time. It is true that high power quicker produces more photons at the level of the maximum penetration, but this is not necessarily beneficial. Studies have shown that low doses and long time is more effective for the reduction of inflammatory processes [2], whereas high power and short time are inhibitory. Inhibition is actually a part of LLLT. By using high energies, the pain transmission in nerves is temporarily slowed down [3]. This is a useful option in many situations of acute pain. But on the other hand, the inflammatory background of the pain is also inhibited and the actual healing is slower.

Another aspect of the depth of penetration is the heat produced by strong lasers. This is particularly a problem in patients with dark skin or dark hair. The therapist needs to use a sweeping motion over the target to avoid pain. With a non-contact technique you lose upwards of 50-85% of the incident light through reflection and back-scattering from the skin [4], which means that only 15-50% of the light leaving the laser aperture is actually making it into the tissue. A Class3B laser does not cause any pain reaction due to heat, so it can be used with contact and with pressure. With contact, more light it forced into the tissue. And by using pressure, blood, being the main absorber of the light, is reduced in the area and the light can more easily penetrate the ischemic tissue. The pressure will also lead the laser probe closer to the target. Thus, a Class 3B laser can penetrate deeper into tissue than a Class IV laser and can therefore saturate the target faster. The heat buildup by Class 4 is negative and some manufacturers add cooling to the beam. Others offer pulsing to allow for heat dissipation. The latter actually lowers the energy, so the suggested advantage of the high power is contradicted.

Proponents of Class IV lasers often claim that a larger area can be treated much faster. A cluster of Class 3B lasers can do the same thing and with the advantages mentioned above. The target area of physiotherapeutic problems is frequently rather small in size, but certainly often larger in chiropractic procedures. However, it does not necessarily take 15 W lasers to cover large areas. The goal of such therapy is to identify the precise locations of the problems and to apply a sufficient energy to that area, rather than to cover a large area and hope for the best.

Manufacturers of Class IV lasers frequently make references to the literature. Remarkably, these references are generally Class 3B studies. The Class IV studies are still few and sometimes surprisingly biased. One paper (5) claims that Class IV laser produced better healing of oral mucositis than “a standard Class 3B laser”. But the “standard Class 3B laser” turned out to be a very weak laser pointer. There are still no studies where the effects of traditional Class 3B lasers have been reasonably well compared to Class IV lasers.

Class IV laser manufacturers often claim that this type of laser saves time. It ain’t necessarily so, as Porgy sings. In the epicondylitis study by Roberts (6) the time spent was 5 minutes. Using a 3B laser in firm contact over tender points and a sweeping motion over the actual condyle (being very superficial), sufficient energy at the targets can be applied in 2-3 minutes. The authors swept over an area of 45 cm². By spreading the light over a large area, using a wide beam area and irradiating from a distance, the dose became 6.6 J/cm² and the power density only 22 mW/cm², which is very low. So in spite of using 10 000 mW and an energy of 3.000 J, the power density was low and the time long. This shows that high power does not necessarily save time.

In the study by Kheshie (7), Class 3B and Class IV lasers are compared in their potential efficacy on knee osteoarthritis. At least that is what the authors and the average reader would believe. However, this is another case of apples and oranges. The “high intensity laser” disperses its light over a large and not well defined area, but quite large. If supposed to be 100 cm², the intensity would be in the level of a regular LED, 15-25 mW/cm². Hardly within the known therapeutic window. In comparison, a 3B cluster of 4 x 200 mW laser diodes with small apertures (= high local intensity) is held over the patella. Not a very good approach for knee OA, but what is worse is that the laser was held stationary for 30 minutes! This is bioinhibition, for sure! (Around 1500 J over a knee). The conclusion of the abstract is: “HILT combined with exercises was more effective than LLLT combined with exercises, and both treatment modalities were better than exercises alone in the treatment of patients with KOA.” Yes, obviously, and two inadequate protocols managed to result in positive outcomes. Says something about the potential of LLLT. But it says nothing about any advantages of Class IV over Class 3B lasers. And the flaw cannot be identified in the PubMed abstract due to shortcomings in the reporting of parameters.

Summing up, any Class IV laser used within its limitations can be a positive addition to a clinic. However, there are several therapeutic limitations and a suitable Class 3B laser can do whatever the Class IV laser can, and at a lower cost. Low level laser in itself is very rewarding, so keeping to the facts should be enough to impress any customer.

class 3 vs class 4 lasers

References

Joensen J, Ovsthus K, Reed R K, Hummelsund S, Iversen V V, Lopes-Martins R A, Bjordal J M. Skin Penetration Time-Profiles for Continuous 810 nm and Superpulsed 904 nm Lasers in a Rat Model. Photomed Laser Surg. 2012; 30 (12): 688-694.
Castano A P, Dai T, Yaroslavsky I, Cohen R, Apruzzese W A, Smotrich M H, Hamblin M R. Low-level laser therapy for zymosan-induced arthritis in rats: Importance of illumination time. Lasers Surg Med. 2007; 39 (6): 543-550.
Chow R T, David M A, Armati P J. 830 nm laser irradiation induces varicosity formation, reduces mitochondrial membrane potential and blocks fast axonal flow in small and medium diameter rat dorsal root ganglion neurons: implications for the analgesic effects of 830 nm laser. J Peripher Nerv Syst. 2007; 12 (1): 28-39.
Al Watban FAH (1996) Therapeutic lasers effectiveness and dosimetry. Biomedical Optical Instrumentation and Laser-Assisted Biotechnology, NATO ASI Series E Applied Sciences, Vol 325, 171-183.
Ottaviani G, Gobbo M, Sturnega M, Martinelli V, Mano M, Zanconati F, Bussani R, Perinetti G, Long C S, Di Lenarda R, Giacca M, Biasotto M, Zacchigna S. Effect of Class IV Laser Therapy on Chemotherapy-Induced Oral Mucositis: A Clinical and Experimental Study. Am J Pathol. 2013; 183 (6): 1747-1757.
Roberts D B, Kruse R J, Stoll S F. The Effectiveness of Therapeutic Class IV (10 W) Laser Treatment for Epicondylitis. Lasers Surg Med. 2013; 45 (5): 311-317.
Kheshie A R, Alayat M S, Ali M M. High-intensity versus low-level laser therapy in the treatment of patients with knee osteoarthritis: a randomized controlled trial. Lasers Med Sci 2014; 29 (4): 1371-1376.

Author CV at http://tuner.nu/curriculum-vitae

The Truth, The Whole Truth and Reality

This article was recently forwarded to me by Dr. L. Rudnick, an experienced Laser Therapist and retired chiropractor in Tucson, Arizona. The article certainly provides food for thought and establishes a number of points that are in my opinion, meritorious.

The Truth, The Whole Truth and Reality

For decades, it has been stated that chiropractic and then light therapy were not science-based like mainstream medicine. According to physicians, medicines are termed an evidence-based scientific therapy.

During the course of taking care of patients, I most frequently found that they were taking prescribed medications to deal with their chronic pain. These include, among many, naproxen, methocarbamol and amitriptyline. Naproxen is described as a non-steroidal anti-inflammatory, methocarbamol is a muscle relaxant and amitriptyline is an antidepressant.

I am always interested in the possible side effects of all medications, therefore I checked my trusty Physician’s Desk Reference (PDR), which contains all information regarding pharmaceuticals from the companies producing these medications. More interesting than the side effects was a section that dealt with how the medications actually work. For naproxen it states “it isn’t known how this medication works to decrease pain, inflammation and fever. It may help reduce swelling by lowering levels of prostaglandin, a hormone-like substance”. For methocarbamol it states “the mechanism of action of methocarbamol in humans has not been established”. For amitriptyline it states “its mechanism of action in man is unknown”.

The fact is that the use of pharmaceuticals is more of a trial and error process than so called “science”.

“Take this several times a day for 10 days and let me know how you are feeling” can hardly be classified as scientific.

Evidence-based medicine that relies on medications for which there is no understanding of how they work is not science. In reality and truth if you will, healthcare and all of its many disciplines involves the art of applying scientific principles, not scientific facts, and all too often, little truth. It would appear that some doctors are simply more artistic than others.

Dr. L. Rudnick

References:

Physician’s Desk Reference, 69^th Edition, 2015.

Medsave.govNZ

www.drugs.com

Commentary: Hospitals ‘deeply sorry’ for lung cancer misdiagnosis

This commentary is in reference to a recent article published in the Toronto Star:

http://www.thestar.com/life/health_wellness/2014/11/14/hospitals_deeply_sorry_for_lung_cancer_misdiagnosis.html

The press or media, as it is commonly termed, whether indulging in sensationalism or good investigative reporting, definitely has a sacred place in our society, and deservedly so, as the case cited in this instance illustrates. In my recent memory, at least over the past decade, we have had the debacle at Sick Children’s Hospital in Toronto, where a number of cardiac deaths occurred under circumstances which have never been fully explained. Then there was the frenzy over a drug undergoing clinical trials for the treatment of sickle cell anemia which involved a major generic pharmaceutical manufacturer. My interpretation of that situation was that the manufacturer attempted to force the principal researcher in charge of the trials to alter the results. Many lawsuits resulted and may still be operative. The same manufacturer has recently been charged by Health Canada with producing contaminated drugs under substandard conditions. Many lawsuits have ensued and are still ongoing. Then we heard about the major mix-up with the incorrect pathological interpretations of breast cancers in Newfoundland and now this matter of a lung tumour. It is certain that the latter is not an isolated instance. Periodically we hear about the incompetent pathologist who may be undergoing personal stress, utilizing inappropriate drugs or may even be suffering from a mental illness. Clearly, as history would indicate, these cases are never simple, however they indicate a persistent and probable growing trend.

How many radiological studies, pathological interpretations and routine blood tests are reported incorrectly on a daily basis? If I may hazard a guess, probably somewhere between 3-10%; at the same time, even 1% would be too high and validates the growing hazard of lack of care and responsibility and today’s gold standard of mediocrity. Realistically the percentage, whatever it may be, is undesirable, particularly if one is the patient involved.

Fortunately, the individual in this instance had the intelligence and the resources to obtain another opinion, which for the average individual is generally not possible. The move the patient made clearly saved his life. Most importantly, it demonstrates again the lack of care and attention and the substandard fashion in which our society functions.

In a medical system controlled by governments, insurance companies and the pharmaceutical industry, primarily interested in their individual vested interests, this trend is hardly surprising. Unfortunately, no one is taking the necessary steps to counter this trend. Only education and legislation can arrest and reverse these occurrences and no one appears to be interested in these processes.

For the individual physician, it is still of the utmost importance to listen to the patient tell their story and to perform a thorough physical examination. Invariably, this will provide the correct diagnosis, which can then be confirmed, if necessary, by the appropriate studies and tests. This simple and effective approach to healthcare has long fallen by the wayside. No significant medical education reviews have been carried out since the Rockefeller Report (the Flexner Study), was performed between 1910-1915.

Further evidence of the deterioration of health care is portrayed by the banners with their bold slogans adorning the hospitals on University Avenue in Toronto. Much is stated that is simply not true. The banners advertising these fundraising efforts which promise to help sick children, provide cures for cancer, etc. appear to be primarily directed to generate the millions of dollars required by the propagators of these efforts under the guise of helping the sick and underprivileged. The money being mined by these industrial fundraisers, after their not inconsiderable portion has been amputated, ends up in the same government financial pool as our tax dollars, which are treated as the politician’s personal hoard, to disburse at their discretion. Clearly, this is an inappropriate manner in which to fund healthcare and unless our leadership changes, or at least changes course, these events will become more prevalent. Why have these inappropriate and, from my perspective, adverse activities enmeshed the healthcare system? The answer: excessive regulation devoid of intellectual input, along with the destruction of independent thought and the status of the individual. Everything must become systematized and conform to the frequently inappropriate regulations of the bodies that control all activities in this area. 1984? — more like 3084. Fundraising has become an enterprise that only serves its own interests and the patient is merely used as a pawn to achieve their objectives.

At this time, it is best for the independent practitioner to focus on preventative medicine, encourage the ingestion of a healthy diet, exercise in moderation and avoid the politics and misrepresentations of the health, food and nutritional industries.

Protect your health through education and the adoption of an appropriate lifestyle.

Fred Kahn, M.D. FRCS(C)

Commentaries, Insights & Case Reviews