Friday, March 30, 2007

Slow Your Ass Down.....
The Georgia General Assembly meets for 40 days each year. The 30th day is "crossover day". That is, to be considered for passage into law, a bill must clear one chamber by that day. The remainder will be shelved until next year. The so-called "super-speeder" bill SB 125 passed. The key provision is as follows:

(b) In addition to any other fines or penalties imposed by any local jurisdiction or the department, the department shall administer and collect fees for the following traffic offenses:(1) Any driver who is convicted of driving at a speed of 85 miles per hour or more on any road or highway in Georgia or 75 miles per hour or more on any two-lane road or highway in Georgia, as defined in Code Section 40-6-187, shall be classified as a 'super speeder,' and a fee of $200.00 shall be imposed;

(2) Any driver who has his or her driver´s license or driving privileges suspended pursuant to the provisions of subparagraph (c)(1)(B) of Code Section 40-5-57 or suspended for points pursuant to the provisions of Code Section 40-5-57.1 shall, upon application for reinstatement, be subject to a fee of $100.00.

(3) Any driver who has his or her driver´s license or driving privileges suspended in whole or in part for a conviction for any of the traffic violations listed in this paragraph shall, upon application for reinstatement, be subject to a fee of $200.00. For purposes of this paragraph, 'traffic violations' means a conviction for any of the following offenses:(A) Racing under Code Section 40-6-186;(B) Leaving the scene of an accident under Code Section 40-6-270; or(C) Fleeing from or attempting to elude a police officer under Code Section 40-6-395.

(4) Any driver who has his or her driver´s license or driving privileges suspended and the suspension is partially based on a conviction for any of the traffic violations listed in this paragraph shall, upon application for reinstatement, be subject to a fee of $300.00. For purposes of this paragraph, 'traffic violations' means a conviction for any of the following offenses:(A) Driving a commercial vehicle with a blood alcohol concentration of 0.04 percent or greater under Code Section 40-5-151;(B) Driving under the influence under Code Section 40-6-391;(C) Feticide by vehicle under Code Section 40-6-393.1;(D) Homicide by vehicle under Code Section 40-6-393; or(E) Serious injury by vehicle under Code Section 40-6-394.

(5) Any driver who has been declared a 'habitual violator' pursuant to Code Section 40-5-58 shall be subject to a fee of $300.00, payable upon application for a regular driver´s license. This paragraph shall not alter the fines and penalties due upon application for a probationary license as provided for in Code Section 40-5-58.

(6) Any driver who accumulates:(A) Seven to nine points under Code Section 40-5-57 shall be subject to a $100.00 fee;(B) Ten to twelve points under Code Section 40-5-57 shall be subject to a $125.00 fee; or(C) Thirteen to fourteen points under Code Section 40-5-57 shall be subject to a $200.00 fee.

To what grand cause will this go to?
(f) All fees collected under the provisions of this Code section shall be deposited in the general fund of this state with the intent that these moneys be used to fund a trauma care system in Georgia and the direct and indirect costs associated with the administration of this Code section. The Office of Treasury and Fiscal Services shall separately account for all of the moneys received under the provisions of this Code section."

The CON laws will remain as is for now.
HB 337, a bill that would have defined general surgery as a single specialty did not pass the House.

The bill discussed in this post, SB 286 did not pass the Senate, so it seems tort reform is safe for another year.

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Wednesday, March 28, 2007

Buy Him One Too......
No actual photographs, but a CT that will leave you astounded. 70-ish with a failed hernia repair about 12 years ago. Comes in after a week of nausea and vomiting. Severly dehydrated. CT obtained:

Nothing too unusual so far.....

Yellow circle around a fascial defect....

What does the yellow line point to?

Yes, gentle reader, the patient's hernia defect was so large that it could not be visualized within the scan window.

Furhter yellow lines would be redundant, methinks..

From his stomach to his rectum, everything is within the hernia sac. When this patient's PCP called me to see him we told me it looked like he "swallowed a fifth-grader". No joke there. Amazing what people will neglect.

Don't get the title? Look here.

Tuesday, March 27, 2007

Grand Rounds Vol III No.27...
Hosted this week at Medviews.

Sunday, March 25, 2007

You keep using that word. I do not think it means what you think it means.......
A commenter to this post takes issue with my description of EMTALA as an "unfunded mandate".
Doctor, Respectfully, you don't know what you're tal(k)ing about. EMTALA is not an unfunded mandate. It only applies to hospitals that accept medicare/medicaid. Don't like the federal rules, don't take federal money.

Let's take a look at the definition of "unfunded mandate":
An unfunded mandate is a statute that requires government or private parties to carry out specific actions, but does not appropriate any funds for that purpose.

The kind folks at Wikipedia even offer EMTALA as an example. The fact that EMTALA compliance is limited to hospitals that accept Medicare and Medicaid does not eliminate the fact that it is an unfunded mandate.

As an aside, anyone know of any full service hospitals that don't take Medicare or Medicaid? Let me know.

Wednesday, March 21, 2007

Unfair and Unbalanced......
Be warned, an ill rant follows.
While no serious threat to tort reform is forthcoming from the Georgia General Assembly this year, some small efforts are being made. An article in today's Macon Telegraph tells the plight of one who is thought to be a "victim" of tort reform: State senators try to retool immunity to ER docs:

Families like the Fretwells seem to be forgotten in the annual turf war between doctors and lawyers in Georgia's Capitol about who should be protected from malpractice lawsuits.

Like others, Rodney and Sherry Fretwell paid scant attention to the state tort reforms approved two years ago, worrying instead about making their next house payment, keeping food on the table and making sure their two young daughters were happy and safe.

But they were soon confronted with one of the least-known provisions of the 2005 law, an obscure section that makes it nearly impossible for patients to win medical malpractice lawsuits against emergency room doctors. Now their story, and others, has prompted Georgia lawmakers to propose retooling the laws and make it easier for alleged malpractice victims to make their case in court.

It started in February of last year, when Sherry insisted that her 39-year-old husband go to the Columbus Medical Center's emergency room so doctors could treat a headache that wouldn't go away after four days and numbness on the left side of his body began to grow.

A doctor there told the burly builder that the problem was likely a pulled muscle, and sent him home with prescriptions for a muscle relaxer and blood pressure medicine.

Within a few hours, Fretwell said his left side was paralyzed. He rushed back to the hospital, but the same physician told him once more he suspected a pulled muscle and sent Fretwell home.

The next morning, he was back - this time, by ambulance. His vision had blurred and his vomiting grew worse overnight. After tests, doctors confirmed he had suffered a stroke.

A month later, the family sought out a lawyer to see if they could sue. They were told if the doctors had originally diagnosed a stroke, they could have treated him with medication to reduce its severity. But the lawyers also said the new state law gives emergency room almost complete immunity from malpractice lawsuits, making a lawsuit a long shot.

Were Mr. Fretwell's physicians negligent? I don't know.
Was Mr. Fretwell an candidate for thrombolysis? I don't know.
If he had received it, would it have made a difference? I don't know.

I also don't know the hospital or physician's side of the story. And unless a suit is filed, I never will. But becuase of privacy rules these allegations are out there and unchallenged. Did the reporter call the hospital for comment? While the hospital may have been unable to do so because of privacy regulations, the reporter could have done so in the interest of fairness. Why is that important? Because such tragic stories attract the attention of those in power:

That could soon change. A bipartisan group of lawmakers, including Republican Senate Majority Leader Tommie Williams, R-Lyons, and Democratic Senate Minority Leader Robert Brown, D-Macon, say they fear the provision goes too far. They back a measure that would scrap language requiring patients to prove emergency room doctors acted with "gross negligence" in malpractice cases, a standard that forces lawyers to prove they knowingly mistreated the patients.
These same elected officials engage in some clever re-branding of the proposal:

The influential group's opposition to the changes is giving the proposal's supporters fits. Republican Sen. Seth Harp, the bill's sponsor, has taken to calling the measure "the physician's protection bill" to smooth over legislators who fear butting heads with the medical association.

He says that the "gross negligent" standard is so fuzzy that malpractice insurers are refusing to cover some ER doctors.

"It's a misfortune," says Harp, a Republican from Midland, a few miles from where the Fretwell family lives. "They're not protecting physicians and we're trying to make sure they have that coverage." The legislation faces a series of hurdles before it reaches a vote, which is why Rodney Fretwell wants legislators to know his story.
Now if that is the case, it's the first I've heard of it. This coming from the senator who voted for the bill because "I was beat, plain and simple. . . . There's no point in riding a dead horse." Who are these physicians who can't get coverage because of the "fuzzy" standard?

The law not only affects EM physicians, but anyone who provides care under these circumstances. The relevant section of the law is as follows:
In an action involving a health care liability claim arising out of the provision of emergency medical care in a hospital emergency department or obstetrical unit or in a surgical suite immediately following the evaluation or treatment of a patient in a hospital emergency department, no physician or health care provider shall be held liable unless it is proven by clear and convincing evidence that the physician or health care provider´s actions showed gross negligence.
Now what brought his article to my attention was this post at Peach Pundit in which the author states that "the legislature was intent on punishing GATL members than improving the conditions in the state."

I disgagree with that assumption. This provision was designed to soften the EMTALA trap. For those not in the medical field EMTALA stands for the Emergency Medical Treatment and Active Labor Act,or the largest unfunded mandate put forth by the federal government. The trap that requires physicians to provide emergency care to individuals without regard for the ability to pay. As my handful of readers know, EMTALA does not provide any shield of immunity for physicians. So physicians are forced to take on full liability, with no guarantee of payment.
Others have discussed the problems with EMTALA, and others have discussed the tax relief legislation that has been proposed. I myself am in favor of a system in which physicians providing care required by law under EMTALA are immunized like any other government physician.

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Tuesday, March 20, 2007

Grand Rounds Vol III, No. 26
Visit Dr. Blackman for this week's best of the medical blogosphere.



Thursday, March 15, 2007

Match Stats 2007........
Congratulations and best wishes to fourth year medical students today. The match offers a yearly look at how medical students are "voting with their feet", determining the specialites that have the greatest appeal.

According to the NRMP 27944 applicants were vying for 21845 positions, a record number.

This years statistics may be found here, on page 4.

For surgery:

Surgery offered ten more positons than last year, and fewer of them were filled by US grads. 46 more IMG's will be surgical interns this year than last, and surgery maintains almost a 100 percent overall fill rate.

For internal medicine:

Medicine remined relatively static, with about 43 percent of spots filled by international grads.

For family practice:

FP increased both its' US and total fill percentages by one and three percent respectfully. However, FP continues to take a beating, as 108 (4 percent) fewer positions were offered this year.


Pediatrics did slightly better, offering fifty more positions than last year. They filled them, as well as six more.


Overall little change from last year. OB/GYN continues to climb from its' low of 743 positions filled in 2004.


EM did very well this year. 37 more positions were offered and 74 more were filled than last year with the majority of the increase of filled positions held by US grads.


Anesthesia had another good year, but the percentage of US grads in the upcoming class fell compared to last year. This may represent a "ceiling" for the US grads intereseted in anesthesia as the number of positions offered rose 4 percent over last year and has risen twenty-three percent since 2003.


Radiology continues to be very competitive, with a rise in the positions held by US grads.

So to no surprise, FP continues to do poorly, while radiology and surgery do well. EM looks to be the big "winner" this year. What is truly amazing is that there are only 141 radiology slots out there.

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Wednesday, March 14, 2007

Leaving Disgusta.......
The talk of a branch medical campus in Athens has many in Augusta worried. From the Atlanta Journal-Constitution:Augusta bristles over talk of a UGA-med school link

Augusta —- With its sprawling campus, hundreds of medical students and millions in research dollars, the Medical College of Georgia has long been a jewel for this city east of Atlanta.

People in Augusta want to keep it that way.

For weeks, lawmakers and politicians here have waged an increasingly vocal turf war over plans to open an MCG campus in Athens, fearing the Augusta school would play second fiddle to the flagship if a joint UGA/MCG program goes forward as planned.

The expansion to Athens is based on a lack of space in Augusta. The largest classrooms can only hold about 200 students, and there are plans to expand beyond that number.

University system Chancellor Erroll Davis, along with MCG president Daniel Rahn and dean Douglas Miller, tried to calm fears in this community, answering questions about what the Athens campus would —- and would not —- be.

"The medical college is going nowhere," Davis told the crowd. "The focus will remain here."

On Friday, Gov. Sonny Perdue reiterated that point during his own trip to the city. He was in Augusta to announce a new T-Mobile customer service center, but instead was asked to respond to those who worry the expansion to Athens is the beginning of the end for MCG.

"We've invested hundreds of millions of dollars here in the last few years. We'll continue to do that," Perdue said. "One of the challenges of a medical education is the patient load. We've already overextended our capacity for patients here in this area. We're already exporting some of our residents out to other areas to get that clinical training. So it's a natural extension. The Medical College of Georgia is going to thrive right here in Augusta."
MCG is limited by geography as well, as this map shows:

The yellow area contains University Hospital and physician's offices. The red area contains public housing, green commercial, and blue is Payne College. MCG is contained fairly well.

The view from above:

Compare to the site in Athens:

The red line outlines the Navy School property, the yellow line to Athens Regional Medical Center. While the area may be smaller, what you cannot see is the close to 800 acres of land in Clarke county alone that the University owns, and the additional facilities there.

More reaction from Augusta:
Barbara Simms, an Augusta state representative, said she worries medical students will chose Athens over Augusta if given the choice. The expansion proposal has "been met with sheer terror," she said.
Having grown up in one of those places, and attended school in both, I can state that Ms. Simms' concerns are well-justified. The history between MCG and UGA has always been contentious, with MCG playing the role of the stepchild:
MCG's past to understand the skittish reaction of Augustans.

Since MCG's founding in 1828, the scrappy college has fought off numerous attempts by lawmakers to close the school or move it to Athens, he said.

In 1909, a Northerner named Abraham Flexner, who was sent around the country by the Carnegie Foundation to inspect medical colleges, recommended the Augusta campus close its doors.

"If the University of Georgia were to break the slender thread that connects them," he declared at the time, "the school could not survive the amputation."

Augusta residents and school officials balked, promising to make the school an integral part of UGA. The Legislature passed a bill giving UGA sole control over the Augusta school's property and assets and, over the next 20 years, the college operated solely as the medical department of UGA.

In the 1930s, the Board of Regents shut it down, citing a lack of classroom space and funding, and Augusta residents again rallied around their school, sending telegrams, letters and petitions to the regents. Gov. Eugene Talmadge, a regent, went to Augusta and, after seeing the public support for the school, promised to reopen it. But it wasn't until the 1950s that the medical college finally shed its ties to UGA and became a free-standing school, the only public health sciences college in the state.

So the apprehension is well-placed.

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Tuesday, March 13, 2007

Grand Rounds Vol II, No. 25...............
Held this week at ScienceRoll.



Sunday, March 11, 2007

Distributing the Beans.......
From The Wall Street Journal, a change in how donor kidneys are allocated: More Kidneys For Transplants May Go to Young
The nation's organ-transplant network is preparing a major change in how it rations scarce kidneys that would favor young patients over old in an effort to wring more life out of donated organs.

The new policy is being developed by the United Network for Organ Sharing, the nonprofit body that develops organ-distribution policy under a government contract.
Surgeons and others leading the process expect the final proposal will rely significantly -- though not exclusively -- on the concept of "net benefit," which seeks to give kidneys first to those who will benefit most from them.

"Waiting time is arbitrary," said Alan Leichtman, a University of Michigan kidney doctor helping to craft the policy. "It seems like a real shame that we're not being better stewards of the organs."
Time on the list usually trumps all concerns, but the scarcity of available organs has caused some to reconsider this. Looking at the numbers:
Deceased donors provided 10,816 kidneys for transplant in 2005. Another 6,500 came from living donors, who usually give to a close friend or relative. But those organs fall far short of meeting demand, and the waiting list for a kidney has grown to more than 70,000 people. The reasons include the surge of diabetes, a principal cause of kidney failure, and the aging U.S. population. Some 4,000 people die waiting each year
Not all of those in the transplant community are pleased that the rules may be altered;
The concept is gaining traction among transplant doctors but creating anxiety for some patients and surgeons who worry the new system won't be fair to all. "Is it correct or permissible for the system to say the five or six more years of life that a 60-year-old is going to get are less valuable, less important than the 15 more years of life the 30-year-old is going to get?" asked Richard Freeman, a transplant surgeon at Tufts-New England Medical Center in Boston.......
......Supporters of keeping the current approach say it's the fairest because it ensures that those waiting, if they hold out and stay alive, will eventually make it to the top of the list.

"We need a system which offers hope to all regardless of age," said Glenda Rosenbloom, a liver-transplant recipient, at a recent forum in Dallas organized by UNOS. Ms. Rosenbloom, who spoke on behalf of the Transplant Recipients International Organization, said she is in her 60s.
The rationale is that younger recipients do better than older ones.
Statistics show that age is by far the biggest factor predicting how long someone will live after a transplant. A typical 25-year-old diabetic will gain an extra 8.7 years of life from a transplant, while a typical 55-year-old diabetic will gain only 3.6 extra years, according to the Scientific Registry of Transplant Recipients, a private group in Ann Arbor, Mich., that tracks data under a government contract. Other factors affecting survival include underlying illness and whether a person is overweight or has had a previous transplant. They, too, are included in the "net-benefit" calculation.

Transplants performed under the existing system generate about 44,000 extra years of life for the people who receive new kidneys each year, according to the registry. If all kidneys were distributed using a net-benefit calculation, that number would rise to more than 55,000 years, it says.

The registry has also calculated how the ages of recipients would change if net benefit became the decisive factor. The calculation shows that the share of kidneys going to patients in their 20s would rise to 19% from 6% today. Just 2.7% of kidneys would go to patients 65 and up, versus nearly 10% today.

Young diabetics would get a particular boost. They typically do poorly on dialysis -- where a machine performs the blood-cleansing function of the kidney -- but well with a transplant. Older diabetics who developed the disease as adults now get 18% of the kidneys but would get just 4.5% under a pure net-benefit system.
The final plan may take age into account, so older patients get older kidneys:
The committee is likely to revise the net-benefit formula to account for how long someone has been on dialysis, Dr. Stegall said. Under the leading idea, he said, the healthiest kidneys would be distributed through a formula that relies largely on net benefit, while the formula for kidneys coming from older or sicker donors would give greater weight to time on dialysis.

In effect, this system would tell older people who have been on dialysis a long time that they could still have a shot at a kidney, but the chances would be much better if they took a lesser-quality one. Patients, working with their doctors, could calculate the odds and decide how poor a kidney they were willing to accept.

This system could have the added benefit of getting more patients to accept marginal kidneys when they are offered, experts said. As it is, patients near the top of the waiting list often pass on these kidneys when they become available, knowing they will remain at the top of the list for the next high-quality kidney.(Emphasis mine)

So, the recipients game the system as well, it seems. But there is one issue that UNOS isn't planning to touch with a ten foot pole:
The UNOS committee has sidestepped one explosive issue. Computer modeling shows that African-American patients do better than average on dialysis and therefore gain less "net benefit" with a transplant. The committee specifically ruled out using race as an explicit factor in allocating kidneys.

A sidebar of the article summarises the upcoming changes:
ISSUE: Perfect matches
Current policy: Donor kidneys that match a recipient on all six antigens are automatically given to that recipient. About one in five kidneys is allocated this way. Regions that receive kidneys from other areas must pay back the donor region with a future kidney.
Possible change: Eliminate these "zero mismatch" trumps, which provide less of a medical advantage than they once did due to better drugs. Eliminate paybacks.

ISSUE: Waiting time
Current policy: Transplant candidates get one point for every year they have been waiting on the list, making this the dominant factor in kidney allocation
Possible changes: Substitute time on list with time on dialysis; use time as a secondary factor in allocating kidneys, particularly for the best-quality kidneys

ISSUE: Children on the waiting list
Current policy: Kidneys from donors under age 35 are automatically offered first to children under 18, if any are on waiting list in same region.
Possible change: Policy not likely to change.

ISSUE: Living donors
Current policy: Living donors who have given away one of their two kidneys or any other organ get extra points if they need a kidney transplant
Possible change: Likely to maintain advantage for prior living donors

ISSUE: B blood type
Current policy: No special treatment. Because there are more patients than donors with B type blood, the wait is much longer. Black patients are more likely to have B blood type, so they are particularly disadvantaged.
Possible change: Allow some A blood type kidneys, which are compatible with A or B patients, to be offered to B-type patients.

ISSUE: Highly sensitized patients
Current policy: Some patients have antibodies that make them unable to accept 80% of kidneys and get extra points to help them snag those kidneys that are a good match
Possible change: Likely to maintain advantage for highly sensitized patients

These are issues dealing with the distribution of a rather fixed supply, suitable kidneys from agreeable donors. What is not mentioned is one idea that could increase the availability of organs, payment to donor families.
The pro payment side believes that the number of available organs would increase and that most of the other players int the game benefit financially, the donor's family should as well.
Those opposed to payment raise objections based on ethical concerns such as exploiting the poor and other unsavory procurement methods.
Another potential way to increase donors would be to adopt an opt-out system as currently seen in Europe.
A old white paper from UNOS can be found here.

So.....go sign your donor cards.



Tuesday, March 06, 2007

The Commotidization of Dr. Angell.......
Kevin linked to a Boston Globe article about the unintended consequences of increased patient autonomy.
Once upon a time, the answer was simple -- doctors made the decisions. They gave you the diagnosis (if they chose to) and they told you what to do about it. Your job was merely to follow "doctor's orders."

Fortunately, those days are gone. Starting in the 1970 s, a long-overdue patients rights movement arose, exemplified by the recognition of living wills to enable people to refuse life support and by requirements that patients give their informed consent before undergoing treatment or participating in research. In effect, the relationship between doctors and patients was renegotiated to incorporate patients' wishes into medical decisions. Doctors were expected to offer advice on the basis of their expertise, but patients would decide whether to take it.
Certainly that is better than the bad old days, isn't it?
In just a few decades, we've swung from one extreme to another. The shift is reinforced by various "consumer-directed" health system reforms that place more of the financial burden on individuals. Patients are sovereign purchasers who choose from a menu of options put before them by their doctors. They search the Internet for information and compare notes with friends to help make their choices. For their part, doctors lean over backward to be neutral.
Ah yes, as Uncle Ben Parker put it in Spider Man:
"With great power comes great responsibility"

While the patients enjoy increased autonomy in the medical decision-making process, they (and physicians) have enjoyed less autonomy in other ways, thanks to the rise of the third party payor:
Adding to doctors' hands-off attitude is the fact that managed care made some people suspicious ; they worried that doctors (or the health plans for which they worked) might have a financial interest in recommending a particular course of action. One way for doctors to deal with that concern was to be non-directive. Also, primary-care doctors came under great pressure to see patients quickly, and it takes less time simply to present options than to evaluate them and make decisions jointly. When specialists are involved, primary-care doctors may rely on them to guide decision making, even though there may be several specialists involved and no coordination among them.
So the physicians and patients have both been reduced to commodities, replaceable parts in the big health care machine. It has left a bitter taste in everyone's mouth.

The physician's don't care for it because it reduces their stature in the physician-patient dynamic. Admin types (hospital and insurance company) have greater influence in areas that in the past the physician alone held sway. The economics of medicine have changed as well, with declining reimbursements and increased expenses. With this loss of "power" has not come a diminishment of responsibility. Older and wiser physicians than myself have pointed this out before.

The patients like the fact that they are "empowered" as never before. The Internet has provided patients with a vast amount of information. Some good, some bad, some ugly. They need help to figure it out and with their physicians "bending over backward to stay neutral" that help may be hard to come by. It is often easier for physicians to lay out the options and say "take it or leave it". They want well-rested and well-rounded physicians, but chafe at the fact that their Doctor is not available to them 24/7.

So what are patients and physicians doing about it? For physicians the response is along "generational" lines. The younger crowd, finding themselves treated as tradesmen, begin to act like them. They share call, limit their workhours (or have it done for them) and base career decisions primarily on lifestyle and family concerns. They are more likely to work for a large group practice, or be employed by a hospital. They are less likely to belong to their local medical society, since those meetings take away from "personal time". Medicine is more like a job than a calling. The older physicians continue to muddle along, counting the days until they retire. Some criticize the younger physicians on their behavior, but others understand their reasoning. Who's right and who's wrong? Both and neither.

The patients who are motivated and resourceful enough to make their decisions with the limited help provided can thrive. Unfortunately not all patients have the resources, time or motivation to do so. They oftentimes make the wrong choice. Those that can afford it may seek out a "concierge" environment. Others may be swayed by the information to seek alternative therapies.

The best advice for patients in Dr. Angell's column is this:
As patients, your best bet is to ask your doctors what they would do in your place, and persist until you get a straight answer. If nothing else, that forces doctors to imagine being in your shoes, at least for a moment, and it may cause them to think more deeply about what you should do.


Grand Rounds Vol. 3 #24.........
Themeless and seamless this week by GruntDoc.


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