Washington, DC, May 1, 2038 Through a strange glitch in the time-space continuum, this article, published 40 years from now, found its way into my E-Mail.

Synapse On-Line

September-October 1998

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The Thousand Patient Practice

Washington, DC, May 1, 2038

Through a strange glitch in the time-space continuum, this article, published 40 years from now, found its way into my E-Mail.

Few of us realize that the managed care companies saved American Psychiatry at the end of the last century. Before that heroic intervention, the psychiatric profession was so far gone that it didn't even realize it needed to be saved. Today, the general public is the beneficiary, and enjoys the most efficiently run health delivery product in the world. After a turbulent era of mergers and acquisitions, we can now look forward to an Insurance led Pax Psychiatrica as the big three; Southwestern Ecocare, Yankee Delivery Systems and The Munchhausen Group oversee the psychological health of two hundred and seventy million American covered lives. Gone is the fuzzy logic of the individual physician decision maker, operating alone and unmonitored, like some cowboy wandering the prairie. Today we have the gatekeeper, the caremanager and the treatment review clinician. No physician in the privacy of their examining room need ever feel lonely again.

Of course, there are still those who disagree. Some say that the patient must suffer when a hefty portion of the health care dollar is now being diverted to support a managed care infrastructure and also pay out dividends to company stockholders. (As if the advent of tens of thousands of new jobs and the creation of new investment opportunities on Wall Street were trivial matters.) How can less be more, they ask? Simple. The answer lies in the overuse of services before the turn of the century. Patients were simply given too much treatment! Once the fat was cut out of the system, there was more than enough cash around to fund these diversions. Also, our actuaries have shown that medical fees were kept artificially high. To rectify this imbalance, managed care fees to doctors have not risen for the last forty years and will have to stay fixed at their current rates for the next seventy two. That is, of course, if we assume a constant rate of inflation over the next century.

And finally, there is the question of productivity. In the bad old days, Psychiatry was dominated by psychoanalytical (si-ko-analy-ti-kal) thinking, a grossly inefficient mode of treatment. Patients were seen as frequently as once every two weeks and sometimes even more! Even the most stalwart doctor couldn't handle a patient load of more than eighty or ninety consumers. When it was proven that comparable results for talk therapy could be obtained by employing motivated college students, the patient load for the average psychiatrist floated upward to its present level of about a thousand per doctor. Allowing such a highly trained professional to get involved with anything other than medication management would be a waste of their talents. While this has become the accepted role for a modern psychiatrist, the issue of patient load remains an area of hot debate. We believe that the current standard of one thousand patients per doctor is not sustainable. Let's look at the numbers. A med. mgmt. visit has shrunk to a fifteen minute aliquot of time. Assuming that a psychitrist works eight hours a day, five days a week, forty-eight weeks a year, then they have 7,480 aliquots of time per year (4x8x5x48) at their disposal. If a typical patient is seen every three months, or for four aliquots a year, then a thousand patient practice requires only 4,000 aliquots of time, leaving 3,480 aliquots unaccounted for! If this idle portion of physician time is devoted to patient care, then the practice load can rise dramatically higher, perhaps to as much as 1,800. While our researchers have been unable to fathom why medical students are no longer flocking to the practice of psychiatry, it is comforting to know that there is still unused capacity among our present cohort of doctors. Perhaps the concept of social worker prescribing privileges should be revisited. And while some layabout physicians may complain, they now have the option of moving to the new colonies on Mars and Neptune, if they don't like the way medicine is practiced here.

(The author is a consultant for a consortium of European auto manufacturers who are negotiating for the purchase of one of the big three managed care companies.)

Marc Tarle, MD

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Psychiatry and the Law: Rumor and Innuendo

The American Psychiatric Association Ethics Guidelines have been set up is a manner to prevent spurious or inappropriate complaints from tarnishing any member psychiatrist's reputation without a well-developed, formalized assessment of the complaint's merits and validity.

In order to accomplish this, the Guidelines allow for and require the complainant to submit a written statement to the Ethics Committee chairman, outlining the specific complaint and defining its components. This initiates a pre-investigation phase, which allows for the Committee to meet with the complainant and psychiatrist to initially determine whether there is merit to the complaint and whether it is truly an ethics issue. If the Committee investigator believes the complaint to be meritorious, then the APA is notified and a formal investigation is initiated, usually leading to a full scale hearing.

Of course many complaints are resolved and/or disposed of informally in the pre-investigation phase with no further action taken. In this event the APA is never notified and the psychiatrist's reputation remains unblemished. But all of this must be initiated by a formal letter of complaint from a specifically designated complainant.

Yet, situations have arisen on a number of occasions where psychiatrists have approached me with complaints, presented to them by a current patient of theirs about the practices of their prior therapist. The patient, him or herself, is reluctant to lodge a formal, written complaint and without that I am reluctant to take the complaint as a formal one from the psychiatrist (making the psychiatrist the complainant, which the psychiatrist is loathe to be, without the patient's active participation).

These type of complaints almost border on rumor and innuendo. Some complaints presented to me have included the following:

The patient was seen for only a few minutes by a psychiatrist for a medication evaluation, while also seeing a non-psychiatrist therapist, given a prescription and sent on his-her way, often in a managed care setting making the patient feel they have visited "McDonald's" rather than a psychiatrist.
The psychiatrist promises the patient a "cure" if the patient remains with the psychiatrist.
The psychiatrist makes derogatory remarks about other psychiatrists in the community.
The psychiatrist shares an excessive and inappropriate type and amount of personal information.
The psychiatrist charges "exorbitant" fees, significantly out of proportion to those of other psychiatrists in the area, or offers to see the patient a very "strange" hours, such as 11 pm.
While complaints such as these may be considered very vague or minimal, boundary violation may, while not rising to the level of a formal, investigatable ethics infraction, harm the personal reputation of that psychiatrist and by inference, the whole psychiatric community.

The issue for the Ethics Committee is how to handle these "complaints, rumors, innuendoes". Since they do not rise to a formal level, do we ignore them, believing that we are overstepping our mandate if we do intervene in any way? Or do we speak informally to the psychiatrist (which could result in the patient being identified, when the patient wished to remain anonymous)? We do feel an obligation to the psychiatrist and his/her reputation, but do not want to pass on information which would possibly upgrade an unproven rumor to a valid complaint. This is a real conundrum. Any suggestions would be greatly appreciated.

Alan J Tuckman, MD
Chairman, Ethics Committee

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The New Antipsychotic Compounds:

Is a Clinical Choice Algorithm Possible?

Dr. Wirshing is Professor of Psychiatry at the UCLA School of Medicine and is Chief Schizophrenia Treatment Unit at the West Los Angeles Veterans Affairs Medical Center.

The investigational studies leading to drug approval in the United States and Canada tend to involve narrowly defined, and homogenous populations of schizophrenia subjects. The generalizability of these data to more "normal" clinical populations (e.g. women, the elderly, children, subjects with concomitant medical illness, comorbid substance abuse, atypical psychotic syndromes, etc.) is highly suspect. Further, the vast bulk of these trials use conventional antipsychotics in the control treatment arm of the experiment. It is, therefore, not possible to make direct comparisons among the various newer medications of either their comparative efficacies or toxicities. In spite of these methodologic shortcomings in the data base, some conclusions can be drawn, and a few "reasonably certain" predictions made.

It is virtually inarguable that the newer medications (including clozapine) all possess lower extra extrapyramidal toxicity than their conventional counterparts--indeed this is the characteristic that loosely defines the group. Those clinical populations, therefore, that have either kknown or predictable sensitivity to neurotoxic side effects (i.e. first break subjects, children, the elderly, non schizophrenic psychotic conditions, etc.) would predictably derive the greatest benefit from this low EPS characteristic. Among the available novel agents, clozapine and quetiapine possess the lowest EPS toxicity, followed closely by olanzapine and then risperidone. When extrapyramidal toxicity--especially akathisia-- dominates the clinical picture, clozapine or quetiapine would be the first choice. However, the other toxicities associated with clozapine (e.g. blood dyscrasias, seizures, sedation, cardiotoxicity, etc.) prevent its easy clinical use, even in the cases of severe acute extrapyramidal toxicities.

The newer agents also distinguish themselves from conventional compounds along endocrinologic lines. Clozapine and quetiapine do not elevate prolactin above placebo run in baseline levels and olanzapine generally induces only a mild, dose dependant, and usually transient, prolactin elevation. Risperidone, on the other hand, elevates prolactin a bit higher than its conventional counterparts. In clinical circumstances where prolactin elevation is of clinical concern (e.g. young or adolescent females, or patients with clinically pertinent intolerance of hyper prolactinemia - amenorrhea, galactorrhea, gynecomastia, testicular atrophy, erectile incompetence, etc.) clozapine, quetiapine, or olanzapine should be used. Again however, because of the predominance of other toxicities with clozapine, olanzapine and quetiapine would be superior first choices.

Other toxicities that are of clinical significance and do vary among this class include sedation, weight gain liability, and cardiovascular toxicity (due to combination of antihistaminic, HERG voltage chanel, antiadrenergic, and antimuscarinic properties). Sedation is most severe with clozapine, and is generally the titration-limiting characteristic of this compound. Olanzapine has somewhat more sedative potential than either risperidone or quetiapine but it is substantially less than with clozapine.

Weight gain is problematic with most of the new compounds, and should be anticipated whenever they are instituted. Measures to avoid weight gain are consistently more effective than those employed to remove weight induced by antipsychotic treatment. In our experience, clozapine and olanzapine have the greatest liability with risperidone and quetiapine inducing measurably smaller increases in weight. All these compounds though increase weight more than the high potency conventional medications.

Cardiovascular toxicity has become of more prominent clinical concern because sertindole was noted to be associated with more QT prolongation than conventional medications during the controlled trial experience. In addition to affinity for a1 adrenergic and H1 histaminergic receptors, the binding of these drugs at the HERG (human etheragogo related gene) voltage channel probably mediates this toxcity. While there may, in fact, be differences in the rates at which these compounds induce ventricular arrhythmias, a precise rank ordering is not known at this time. A reasonable estimate however, is that clozapine has somewhat more potential than any of the other three compounds. Orthostatic hypotension with reflex tachycardia is the other major cardiovascular toxicity induced by these drugs. Here again, clozapine is the most problematic agent, followed distantly by the other three compounds.

Quetiapine's toxic profile, while favorable in most respects, contains a theoretical increased risk of cataracts. This risk is inferred from the observation that quetiapine's use in certain animal models results in the development of cataracts. This animal toxicity has prompted the manufacturer, and the FDA, to advise slip lamp examinations before, and during, quetiapine treatment. Phenothiazines have, for years, been known to be associated with an increased risk for the development of lenticular cataracts. Chlorpromazine, in particular, is most notorious in this regard. Because the time course to the development of clinically significant cataracts is very slow, it is not our clinical habit to obtain a slip lamp examination before treatment. Instead, we perform routine clinical ophthalmoscopy before treatment (as we do on all patients) and refer only chronically treated subjects for ophthalmologic (or optometric) consultation. This way, only those subjects who are successfully treated with quetiapine, will have to undergo these more extensive, and expensive, examinations.

On the other side of the clinical equation, lies the question of relative efficacies among these compounds. For the refractory individual, (i.e. resistant to the mechanism of action of conventional antipsychotic medications) clozapine is clearly the most powerful medication. Among the other three compounds, only risperidone (Wirshing et al., 1997) has shown superior therapeutic power to conventional medications in such populations. In treatment responsive populations, both risperidone and olanzapine (but not quetiapine) appear superior to conventional drugs. Clozapine also appears remarkably better than conventional medications in moderately refractory individuals (Ames et al., 1995). A few studies have compared risperidone to olanzapine directly in heterogenous populations. These data suggest (Tran, Tollefson, Hamilton & Kuntz, 1996) that there is very little efficacy differences distinguishing these compounds, although they do, as mentioned above, have somewhat different side effect profiles.

In summary, these compounds, as a group, while clearly of lower EPS liabilities than their conventional counterparts, all have other toxicities that distinguish them. The specific clinical scenario for an individual patient may guide the clinician's hand, in choosing among these various toxic profiles. While clozapine is without question more toxic than the other three compounds, it is equally without question the most powerful antipsychotic treatment available. Thus, when toxicity predominates, clozapine will be resorted to at last, but when inefficacy is preeminent, clozapine should be tried earlier in the algorithm. Among the other three compounds, quetiapine in general, has the lowest toxicity, but with the available data, also appears to have the lowest efficacy. Choosing between risperidone and olanzapine is usually a choice between differential toxicities, as the efficacies of these compounds do little to distinguish them. Olanzapine has more sedation, weight gain, and hepatotoxicity, and is more expensive than risperidone. Risperidone, on the other hand, has more EPS and endocrinologic toxicities.

Moving beyond the narrow clinical confines of schizophrenia, one finds even less controlled data to guide our collective decision making processes. Clozapine has shown some power in schizoaffective and rapid cycling bipolar populations. Studies are currently under way to determine whether these properties are shared by olanzapine and risperidone. In our clinical laboratory, neither risperidone, nor olanzapine, is as powerful as clozapine at affecting clinical improvement in a mood disordered population. On the other hand, risperidone (Brecher, Janssen Research Foundation, Clyde & the Risperidone Study Group, 1997), but not olanzapine (Satterlee, Tollefson, Reams, Burns & Hamilton, 1995), has been demonstrated to induce improvements in both psychosis and behavior, in agitated and demented elderly subjects.

As our clinical and experimental experience with these compounds accrues, it is predictable that they will show differential utility in the various non-schizophrenic syndromes that require the use of antipsychotic pharmacotherapy. Further, because the diagnosis of schizophrenia is associated with less sensitivity to extrapyramidal neurotoxicity than non schizophrenic diagnoses, these lower EPS compounds will virtually replace conventional medications in such populations. Also, if these newer compounds ultimately demonstrate themselves to be safer than their predecessors when used chronically (i.e. have lower liability to induce tardive dyskinesia) then these medications might reasonably be used in populations that currently have an unacceptable risk benefit ratio (i.e. refractory anxiety disturbances, severe attention deficit disorder, adolescents with developmental delay and interpersonal violence, somatoform disorder syndromes, severe PTSD, etc.). Empirically, these medications (especially risperidone) are being used in these non-schizophrenic syndromes for the reasons outlined here. These "non-classic" uses are theoretically and medically defensible, but they should be resorted to cautiously, and the doze ranges used and the titration employed, should be lower and slower, than in the schizophrenic syndromes.

Summary

The atypical antipsychotics offer substantial benefit over standard neuroleptics in several parameters of antipsychotic pharmacotherapy. Although only one drug, clozapine, has been definitively demonstrated to have efficacy in treatment-refractory patients, it is likely that additional studies will find that others of this class of drugs work similarly in such patients. The relative lack of associated EPS, the reduced impact on prolactin levels, and the improved efficacy on negative symptoms in schizophrenic patients, make these novel drugs attractive alternatives to standard antipsychotic therapy. Future studies should help delineate differences amongst the atypical drugs, allowing clinicians to assign priority for use of the drugs in various clinical circumstances.

William C Wirshing, MD

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West Hudson Dinner CME Program

Mixes Science and Politics

On Friday May 8, 1998, at the Inn at Central Valley, we had a very successful meeting. This was an opportunity to hear and learn from our own district branch members (Les Citrome, M.D., Nigel Bark, M.D., and Jan Volavka, M.D.) as they discussed atypical antipsychotics. Drs. Herb Peyser and Ed Gordon were invited to speak by our executive committee to discuss the APA and NYSPA to our members. Dr. Peyser, is a trustee and on the Board of the APA. The APA is composed of 75 district branches (DBs). 45 of these are state organizations. New York has 13 DBs, California has 5 DBs. All the DBs are grouped into seven areas. Dr. Peyser reports that the collections of these DBs into the Area groupings are "meaningless". As all of us know we are Area II, and Herb Peyser is the elected trustee from our area. There is some consideration of the idea of combining all district branches within the state into a single state branch. This idea was previously tabled but our new APA president-elect, Dr. Richard Munoz, is reconsidering this. Dr. Peyser reported that there have been some DBs which have decided by themselves that they want to combine forces and organize in one DB at the state level. But there may be a great difference between Texas which recently formed a state DB which has some 1500 psychiatrists and NY with 13 DBs and has some 4900 psychiatrists. At the meeting there was a clear endorsement of a position the we would not endorse such a state DB.

The board which oversees all activities of the APA and, of which Dr. Peyser is a member and our representative, must approve all initiatives and legislative agendas which are generated by the many committees within the APA and its legislative affiliates. They have fiduciary responsible for the APA. The board is composed the speaker of the assembly, 7 area trustees, 3 at-large trustees, the president, two vice presidents, treasurer, secretary, and a member in training. This is the group which hired Steven Mirin, MD, to serve as the new Medical Director of the APA. The APA has worked on many issues for psychiatry. The increase in Medicare reimbursement was the highest any specialty received (8%). It is anticipated that there will be further increases in our reimbursement as there are several work groups that the APA has commissioned. First, they are looking at the cost of our offices which has been undervalued and will be factored into formulas which are used to establish our billings. Second, they are involved in CPT codings which have a direct impact on our billings, and they have been very active in several of the strategies employed by the American Psychological Association, allowing psychologists to admit and prescribe medications.

Ed Gordon, also a psychiatrist and area II representative is very involved in NYSPA. NYSPA has been very active in the suit against Medicaid. About two years ago they won the suit against Medicaid where Medicaid was refusing to pay claims when they were the secondary and Medicare was the primary, This suit resulted in a $68,000,000 payout to physicians. Dr. Gordon speculates that approximately $10,000,000 was paid out to psychiatrists in N.Y. State. There is a second suit that they are initiating which is to pay psychiatrists additional monies. An additional lawsuit returned $300,000 of Medicare money to physicians. They were also responsible for having inpatient psychiatric coverage for Pataki's Child Health Program. Lastly, they are continuously involved in patients' rights and insuring their benefits with their insurers. In fact they need to hear from psychiatrists about the troubles they are facing with insurers. They are doing this with Jeff Gold, working with the Attorney General of NYS, Dennis Vacco's office. If you have information, please call Seth Stein.

Finally, Dr. Gordon was very pleased to report that the West Hudson DB with approximately 155 members or 3% of the total number of psychiatrists in the NY DBs, donated $1600 at the Friday meeting, which was 10% of the donations to NYSPA from the DBs. He wants to thank everyone for their generosity.

Roger M Harris, MD

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Public Affairs Activities Abound

I would like to thank NAMI-FAMILYA of Rockland County(National Alliance for the Mentally Ill- Family Advocates of the Alliance for the Mentally Ill) for presenting me with one of the 1998 Exemplary Psychiatrist Awards on June 17, 1998. Special thanks to Co-Presidents Rena Finkelstein and Mel Zalkin and the entire board for the wonderful award night! The National Alliance for the Mentally Ill sponsored an award breakfast for the winners of the Exemplary Psychiatrist Award at the 1998 American Psychiatric Association’s convention in Toronto.

The award recognizes local Psychiatrists who have contributed to greater understanding of brain disorders, have worked publicly to eliminate stigma or publicly fought discriminatory policies against people with brain disorders. At that breakfast, Laurie Flynn, Executive Director of NAMI spoke about the importance of destigmatizing mental illness and the important role that psychiatrists play with both patients and family members. Peter Wyden, who wrote the book "Conquering Schizophrenia," spoke about the struggles that he has faced for the past twenty five years as the father of a schizophrenic son. He spoke about the fact that the greatest psychiatrists had the skills of listening, caring and deep compassion.

NAMI-FAMILYA of Rockland County’s reception on June 17, 1998 at the Rockland County Department of Mental Health, also honored Gerry Trautz, a consumer advocate who is employed by the Mental Health Association as a residence counselor at VIP House. He was the recipient of the 1998 Florence Gould Gross Award. Gerry has played an important role in educating the public about mental illness, as well as empowering and helping others afflicted with these brain disorders and in advocating for improved services and legislation to benefit the population. Congratulations to Gerry Trautz on an award well deserved!! Gerry is an active member of our mental health coalition. He has spoken at many of the coalition programs, including the public forum 1997, college program, and clergy programs. He is truly a wonderful role model for those who have mental illness and gives tremendous hope to those who suffer with the illness.

Meanwhile, the Mental Health Coalition is busy planning for Mental Illness Awareness Week! Our public forum is scheduled for October 21, 1998 at 7:30 PM at Town Hall in New City. We will have outstanding speakers who will tell about their struggles with mental illness. One of the speakers will be Suzanne Vogel-Scibilia, MD, a Psychiatrist from Beaver, PA. Dr. Vogel-Scibilia was the recipient of the Exemplary Psychiatrist Award in 1992 and 1996. In 1996 she received the Super Supporter Award from the Beaver County Mental Association in 1996 and the National Consumer Advocacy Award from the Institute of Behavioral Health. In 1997, she was named Psychiatrist of the Year from the Pennsylvania Alliance for the Mentally Ill.

This year’s program should be an inspiring and memorable presentation!! Be sure to save this date!! Your presence at the Forum is extremely important and shows you care! The Chairpersons for the project are Carol Olori, CSW and Rena Finkelstein. Look for upcoming flyers which will give more details about our speakers!!

Our elementary school project this year will be at the George Miller Elementary School in Nanuet on October 15, 1998. We will be working again with the Rockland Players (from the Mental Health Association), who will put on three skits (Divorce, Depression, and Attention Deficit Disorder). These will be followed up by small classroom discussion and an art project. We could definitely use extra help in this project!! If you are interested in doing community work, please call me at 914-364-2428.

Finally, on November 1, 1998, the Coalition will be doing depression screenings at the Dominican College Health Fair. Last year, this was a tremendous success. People actually waited on line for depression screenings! If you would like to participate in this project (even 1 hour is a great help), please call for the chairperson for this event, Roz Fields at 639-7400 (extension 22).

As you can see, public affairs is alive and active. However, we need more psychiatrists to help!!! Our next meeting is Thursday, September 10, 1998 at Rockland County Department of Mental Health, Building F Conference Room! New members are always welcome!

Lois Kroplick, DO
Chair, Public Affairs

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Comments

[Liona]

Good words.

[Eirik]

Hei sånn

14. Januar 1814, måtte kong Fredrik 6. gi frå seg Noreg til kongen av Sverige. Det 434 år lange unionsfelleskapet mellom Danmark og Noreg var slutt. Sjølv om det var dette året Noreg fekk si eiga grunnlov, hadde Sverige førebudd seg til krig mot Noreg. Noreg med sine 30 000 dårleg utrusta soldatar hadde ingen sjans mot dei 40 000 – 50 000 krigstrena svenske soldatane. Felttoget varte i snaue to veker, og sjølv om der var kampvilje, trekte Kristian Fredrik (norske kongen) dei norske styrkane tilbake. Men i staden for å halde fram stansa Karl Johan (svenske kongen) framrykkinga, og innleidde forhandlingar. Og same året den 14. august, vart det underskrive våpenkvile i Moss. Avtalen slo fast at den norske kongen skulle forlate landet, og overgi landet til svenske kongen.

I 1905 reiv Noreg seg laus frå Sverige, og spørsmålet då var kva statsform Noreg skulle ha. Det blei klargjort under ein folkeavstemming, då fleirtalet heller ville ha kongedøme, enn republikk.

I år er det hundre år sidan unionen mellom Noreg og Sverige blei oppløyst med fredelege midlar. Dermed er det også snart hundre år sidan Noreg blei ein "verdsborgar" med ein eigen stemme i det internasjonale samfunnet.

Sidan Noreg låg i skuggen av Danmark frå 1380 til 1814, veit nordmenn kor forferdeleg det er å leve i undertrykking i sitt eige land. Dansk vart innført som det einaste offisielle skriftspråket, og språket er kanskje det viktigaste som kjenneteiknar eit folk, og når eit folk ikkje får løyve til å skrive eller snakke sitt eige morsmål, vil identiteten til det folket forsvinne. Nordmenn fekk heller ikkje ha sitt eige flagg, eller sin eigen konge. Både eit flagg å og ein konge spelar ei stor rolle til eit lands identitet.

Nelson Mandela sa eingong:

A man who takes away another man’s
freedom is a prisoner of hatred. He’s
locked behind the bars of prejudice
and narrow mindness. I am not truly
free if i am taking away someone
else’s freedom, just as surely as i am not
free when my freedom is taken away from me.

Det var slik Nelson Mandela forklarte kor viktig det er for eitt menneske å få leve i fridom. Og den som tar eitt menneskets fridom, vil sjølv leve i undertrykking!

med vensam helsing

Eirik

[Merete]

I Danmark vi gør gældende, at for at forbedre den offentlige sundhed og forebygge sygdom, er det bydende nødvendigt med tiltag, der specifikt adresserer mænds sundhed

Merete

[Gunnar]

Der står intet om, hvor mange penge der skal bruges på at forebygge sygdomme. Området bliver glemt.

Der er foreløbig ingen udsigter til, at noen kommer i gang med seriøst at forbedre vores sundhed.

Gunnar