THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: January 24, 2000 08:30 AM Monday; Rod Welch

Meeting Doctor Yamamoto at Kaiser on MRI for right knee.

1...Summary/Objective
2...Medical Chart Omits Communication from Patient
3...Multiple Medical Charts Confuse Physicians under Team Care
4...MRI Not Required Absent Specific Acute Injury
5...Xray Shows Right Knee Suffers General Arthritis
6...Compensatory and Cartilage Wear Causes Pain in Right Knee
7...Left Knee Prognosis Replacement Surgery in 5 Years
8...Cross Training Shoes, Biking, Circular Exercise for Knees, Strength
9...Glucosamine, Chrondroitin Treatment Follow Vendors Instructions
10...Medical Chart Doctor Yamamoto 2nd Opinion Left Knee Examination
11...Letter 2nd Opinion Doctor Yamamoto Confirming Meeting 000124


..............
Click here to comment!

CONTACTS 
0201 - Kaiser Permanente                                                                                                                                                  
020101 - Dr. Vincent E. Yamamoto, M.D.; Orthopedic Surgon  
020102 - Orthopedic Department                                                                                                                                            

SUBJECTS
Knee Examination re MRI Right Knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
Multiple Medical Charts for Each Facility                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
Patient Communication Omitted from Medical Chart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
Medical Chart Missing Information                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
1406 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1406 -    ..
1407 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
1408 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
140801 - Follow up ref SDS 72 0000, ref SDS 71 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
140802 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
140803 - Vincent confirmed Craig's recommentation that an MRI is not useful for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
140804 - the right knee. ref SDS 0 2860  He identified possible causes of pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
140805 - in the right knee due to degenerative arthritis. ref SDS 0 2860  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
140806 - right knee can become painful from compensating for loss of capability                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
140807 - in the damaged left knee.  The doctor indicated knee replacement                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
140808 - surgery will likely be needed within 5 years. ref SDS 0 HU5O  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
140809 - suggested shoes and training methods that reduce stress and loss of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
140810 - cartilage which cause pain in knee and ankle joints.  Vincent is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
140811 - taking Glucosamine and Chrodroitin.  He reports success for himself                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
140812 - and patients, but no evidence of restoring lost cartilage. ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
140813 - 1680  Vincent will submit recommended specifications for shoes that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
140814 - minimize stress during tennis and other high stress activity.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
140815 - ref SDS 0 4160                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
140816 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
140817 -    [On 000226 submitted letter to Vincent. ref SDS 74 0001]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
140818 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
140820 -  ..
1409 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1410 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1411 - Discussion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141201 -  ..
141202 - Medical Chart Omits Communication from Patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141203 - 
141204 - Met with Doctor Vincent Yamamoto in Kaiser Orthopedic Department.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
141205 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141206 - We reviewed the medical chart, as called out in Kaiser's Healthwise                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141207 - Handbook, reported on 990625. ref SDS 13 0794                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141209 -  ..
141210 - Jeanne's letter on 000120, ref DRP 8 0001, and received on 000121,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
141211 - ref SDS 72 0863, was in the medical chart record, and Vincent had                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
141212 - reviewed her letter.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
141214 -  ..
141215 - There were no communications in the record from the patient on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
141216 - purpose of the meeting, as listed in the record on 000121. ref SDS 72                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
141217 - 0863  This appears to conflict with Jeannie's report that the medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141218 - chart is automatically provided to the attending physician, and so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
141219 - would be in this case. ref SDS 72 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
141220 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141221 -     [below, this may indicate multiple medical charts are being used.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
141222 -     ref SDS 0 2065]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141224 -  ..
141225 - Vincint advised that communication from patients is not included in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141226 - Kaiser's medical chart record that is reviewed by the doctor.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
141227 - explained that some patients have threatened doctors, and as a result                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141228 - Kaiser has a policy of not communicating with patients in the medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141229 - record with the result that doctors cannot be prepared to conduct                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
141230 - productive meetings with patients.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
141231 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141232 -     [...today an article reports treatment is witheld for reasons of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
141233 -     adverse personality. ref SDS 73 0001]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141235 -      ..
141236 -     [On 050311 doctors have difficulty with communication and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
141237 -     collaboration among themselves preparing timely reports,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
141238 -     distribution, review, and feedback. ref SDS 78 PB8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
141240 -  ..
141241 - This aligns with the record on 990816 that revealed a lot of missing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
141242 - information in the Medical Chart. ref SDS 21 2601                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
141244 -  ..
141245 - The policy of shielding doctors from communication with the patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141246 - conflicts with Kaiser's Healthwise Handbook that calls for patients to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
141247 - submit medical history, including symptoms, to doctors, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141248 - 990625. ref SDS 13 5740                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
141249 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141250 -    1.  What happens to this history if it is not reviewed by the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
141251 -        doctor and incorporated into the record?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141253 -         ..
141254 -    2.  Why submit information, if it is not reviewed by the doctor?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141256 -         ..
141257 -    3.  Who reviews the record, and how is critical information passed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141258 -        forward to the doctor?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
141260 -         ..
141261 -    4.  Who has reviewed the Welch record, and where is the record of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
141262 -        follow up action?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
141264 -  ..
141265 - Vincint advised that patient communication is maintained by Kaiser's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
141266 - administrative staff.  He is not sure where, because it is witheld                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
141267 - from doctors.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
141269 -  ..
141270 - He said patients can request inclusion of patient communication in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
141271 - Medical Chart in order to ensure the doctor sees information on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141272 - medical history.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
141274 -  ..
141275 - Vincint will include an explanation of this policy in his letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141276 - our meeting today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
141277 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141278 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141280 -  ..
141281 - Multiple Medical Charts Confuse Physicians under Team Care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
141282 - 
141283 - We discussed the meeting with Christy in Physical Therapy on 990816,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
141284 - that showed the report on 8 new therapies was included in the Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141285 - Chart, along with a number of patient communications, called "SDS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
141286 - records." ref SDS 21 2601                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141288 -  ..
141289 - However, this medical chart was not submitted for the meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
141290 - Craig on 990910, and so the objective of meeting to obtain an opinion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141291 - on the 8 new therapies, was not accomplished. ref SDS 23 3038 and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
141292 - ref SDS 23 7802                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141294 -  ..
141295 - Vincint recalled the article on 8 new therapies that came to his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
141296 - attention from another patient.  He said it was very helpful for due                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
141297 - diligence that patients and doctors have a comprehensive checklist of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141298 - issues to consider in evaluating treatment choices.  This aligns with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141299 - Doctor Sylvia Connolly's recommendation to obtain expert opinion on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141300 - application of these 8 new therapies in the Welch case, during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
141301 - meeting on 990625. ref SDS 13 5400  At that time, review of Kaiser's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
141302 - Healthwise Handbook found a comprehensive checklist for communication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
141303 - that makes the doctor/patient partnership effective. ref SDS 13 0806                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
141305 -  ..
141306 - The fact that the medical chart at Park Shadelands has a lot of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141307 - information that is not contained in the chart Vincent showed today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
141308 - per above, ref SDS 0 3862, suggests there are multiple medical charts,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
141309 - each with a different body of information.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
141311 -  ..
141312 - Who is responsible for reviewing the record and coordinating to ensure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
141313 - that each doctor sees needed information for effective Team Care.  Who                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
141314 - reviews for conflicting information?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
141316 -  ..
141317 - Jeanne is the Site Coordinator, and so may be involved in this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
141318 - process.  She reported on 000121 that Kaiser will roll out in late                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
141319 - 2001 a technology solution. ref SDS 72 7654  She directly coordinated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
141320 - the medical chart issue to help Doctor Yamamoto, yet the complexity of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
141321 - the process caused another failure. ref SDS 0 3862                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
141322 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141323 -     [On 000207 submitted letter on this. ref SDS 74 0004]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
141324 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141325 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
141326 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
1414 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Knee Examination re MRI Right Knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
Therapies - 8 New Proceddures                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
Xrays on Knees, 990910                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
Shoes Special Soles Relieve Stress on Knee Joints                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
Strength Relieves Stress on Knee Joints                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
Right Knee Arthritic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
Compensatory Pain Due to Left Knee Injury                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2209 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
221001 -  ..
221002 - MRI Not Required Absent Specific Acute Injury                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
221003 - Xray Shows Right Knee Suffers General Arthritis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
221004 - Compensatory and Cartilage Wear Causes Pain in Right Knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
221005 - 
221006 - Vincint clarified evaluation of xray issues for right knee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
221007 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221008 - He identified defects in the cartilage of the right knee by measuring                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221009 - a 7 millimeter cartilage separation on one side and a 5 millmeter gap                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221010 - on the other side of a slight ridge in the lower bone.  Vincent noted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221011 - that a 1 millimeter difference in these measurements is normal, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221012 - the additional millmeter establishes cartilage deterioriation in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
221013 - right knee, i.e., arthritis, which contributes to pain during heavy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221014 - physical activity.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
221016 -  ..
221017 - Vincent advised that an MRI would disclose spot loss of material in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221018 - the center of the cartilage mass, that is not evident to normal xray,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221019 - and which can be repaired in some cases by injection treatments,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
221020 - and/or replacement therapies, cited in the record on 990625, leading                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
221021 - to the examination on 990910. ref SDS 23 7802                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221023 -  ..
221024 - Vincent explained the right knee assumes a greater load than the left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221025 - knee in order to compensate for injury to the left knee.  He had me                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221026 - walk down the hall, and reported observing a distinct favoring of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221027 - right knee, even though there is no mental awarensss of compensation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221029 -  ..
221030 - In strenuous activity for example running, tennis, etc., this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
221031 - compensation burden on the right knee causes pain, in combination with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
221032 - the evident cartilage loss reported today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
221034 -  ..
221035 - Under these conditions, Vincent feels an MRI is not needed, confirming                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
221036 - Craig's report on 991028. ref SDS 34 5820                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221038 -  ..
221039 - Explained urgency for MIR has subsided.   Since meeting with Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221040 - Boulris on 000910, have stopped playing tennis.  Working with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
221041 - mainstream organizations, e.g., see Medical Chart at Kaiser above,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
221042 - ref SDS 0 XF8H, efforts increased developing SDS, POIMS, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
221043 - Communications Metrics...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
221044 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221045 -              http://www.welchco.com/03/00050/01/09/01/02/00030.HTM#SY3K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
221047 -  ..
221048 - This work requires 24/7 using a computer at a desk, which precludes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221049 - athletic activity.  As a result, pain has stopped in both left and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
221050 - right knees just doing normal walking around.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
221051 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221052 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221054 -  ..
221055 - Left Knee Prognosis Replacement Surgery in 5 Years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221056 - 
221057 - Asked about left knee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
221058 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221059 - Doctor Yamamoto said that after 2 surgeries (1974, 1988), daily life,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221060 - including tennis and running, the left knee has moderate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
221061 - osteoarthritis that cannot be improved, and will worsen without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221062 - treatment and/or change in lifestyle.  Doctor Yamamoto further said                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221063 - that this significant degenerative arthritis in left knee actually                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
221064 - will continue to worsen, evident from continuing pain.  He diagnosed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
221065 - knee replacement surgery will likely be needed in 5 years.  Vincint                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221066 - feels this might be stretched out to 10 years by avoiding high stress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221067 - athletics like running, tennis, basketball, football, etc.  He also                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221068 - recommended Glucosamine Chondroitin explained below. ref SDS 0 1680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
221070 -  ..
221071 - This aligns with prognosis Doctor Boulris offered during the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
221072 - on 090910; he recommended Glucosamine Chondroitin and advised left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
221073 - knee replacement might be needed in 10 years by ending high stress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
221074 - activity. ref SDS 23 9733  A few weeks later on 990925, received                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
221075 - Craig's letter confirming prognosis that knee replacement might be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
221076 - needed in 10 years. ref SDS 26 2951                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
221077 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221078 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221079 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221081 -  ..
221082 - Cross Training Shoes, Biking, Circular Exercise for Knees, Strength                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
221083 - 
221084 - Vincint says he wears cross-training shoes for tennis because they                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
221085 - have greater cushioning in the sole than regular tennis shoes.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
221086 - advised that increased cushioning in shoes for tennis reduces strain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
221087 - on knees and so helps slow down the natural wear and loss of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
221088 - cartilage.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
221090 -  ..
221091 - Vincint will submit suggestions on athletic shoes to minmize stress,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
221092 - in his report and indicate the style or vendor that might be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
221093 - considered.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
221095 -  ..
221096 - He recommends against a vertical stair master type exercise, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
221097 - it places a lot of stress on the knee joint.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
221099 -  ..
221100 - Biking, stationary bikes, or other circular motion exercise, is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221101 - recommended to build strength and maintain motion in the knee joint.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
221103 -  ..
221104 - Vincint confirmed Christy's suggestion on 990816 to build strength in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221105 - the leg muscles to further reduce stress on the knee joint.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
221106 - ref SDS 21 5612                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
221107 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221108 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221109 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
221110 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2212 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Glucosamine Chondroitin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
Rosacia, 940624                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
240501 -  ..
240502 - Glucosamine, Chrondroitin Treatment Follow Vendors Instructions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
240503 - 
240504 - Follow up ref SDS 72 1680, ref SDS 29 3040.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
240505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
240506 - Vincent advised that he has been taking Glucosamine and Chondroitin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
240507 - for about 2 years and reports it has helped him alot.  He, also, has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
240508 - patients who take this treatment.  Vincent recommends treatment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
240509 - according to the vendors recommendations, as set out in Jeanne's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
240510 - letter on 000121. ref SDS 72 1680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
240512 -  ..
240513 - We reviewed reports in the Medical Letter submitted to Craig that,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
240514 - seem to relate cartilage growth. ref SDS 34 2596                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
240516 -  ..
240517 - Vincent advised that he has not seen any evidence of cartilage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
240518 - restoration.  He is not familiar with the Medical Letter.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
240520 -  ..
240521 - We did not review today the duration for taking 3 pills a day spread                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
240522 - out at approximate each meal time.  The record so far suggests this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
240523 - is a continuous regimine, that lasts for life, rather than a process                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
240524 - that completes a particular mission.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
240526 -  ..
240527 - Need opinion on problems taking Glucosamine and Chrondroitin in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
240528 - combination with Tetracycline medication for rosacea, prescribed by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
240529 - Doctor Kory Zipperstein on 940624, ref SDS 5 0001, and received in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
240530 - record on 940628. ref SDS 6 0877                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
240532 -  ..
240533 - What experience does Kaiser have on this issue?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
240535 -  ..
240536 - We did not have time to review this issue today.  It probably needs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
240537 - consideration to avoid adverse impacts.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
240539 -  ..
240540 - Glucosamine and Chrondroitin are taken 3 times a day during meals, as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
240541 - reported on 991011, ref SDS 30 9702, while rosacea treatment is taken                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
240542 - 2 - 4 times a day on an empty stomache, as shown on 940628.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
240543 - ref SDS 6 6016  Does this relieve or compound any conflict, if a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
240544 - conflict exists?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
240545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
240546 -    [On 000206 submitted letter asking about this issue. ref SDS 74                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
240547 -    0001]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
240549 -     ..
240550 -    [On 000216 received letter from Kory indicating there is no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
240551 -    evident conflict. ref SDS 75 8944]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
240553 -  ..
240554 - Over next few months tried Glucosamine Chondroitin but could not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
240555 - swallow pills, so ended efforts to try this treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
240557 -     ..
240558 -    [On 030807 case study shows personal history using liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
240559 -    Glucosamine Chondroiten and clincial research. ref SDS 76                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
240560 -    FN9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
240562 -     ..
240563 -    [On 040529 0248 report that Glucosamine Chondroitin in liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
240564 -    form relieved knee pain from hiking 3 - 10 miles per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
240565 -    ref SDS 77 MN9P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
240566 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
240567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
240568 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2406 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250401 -  ..
250402 - Medical Chart Doctor Yamamoto 2nd Opinion Left Knee Examination                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250403 - 
250404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250405 - Later received Doctor Yamamoto's Opinion Consultation memo saying...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250406 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250407 -    1.  KAISER PERMANENTE, WALNUT CREEK                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250409 -         ..
250410 -    2.  THIS REPORT HAS BEEN TRANSCRIBED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250411 -        BUT NOT REVIEWED BY DICTATING PHYSICIAN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250412 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250413 -    3.  2ND OPINION CONSULTATION - ORTHOPEDICS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250415 -         ..
250416 -    4.  DATE.......................... 01/24/2000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250418 -         ..
250419 -        PATIENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250423 -         ..
250424 -    5.  PHYSICIAN                     REFERRING PHYSICIAN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250425 -        V. Yamamoto, M.D.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250427 -         ..
250428 -    6.  HISTORY: This patient is a 54-year-old Caucasian male who has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250429 -        complaints of post activity pain involving both of his knees,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250430 -        left equally with the right. His left knee, he however has a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250431 -        more chronic history of having previous problems and surgery. He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250432 -        had a previous open meniscectomy on his left knee in the 1970's.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250433 -        He subsequently had an arthroscopy of the left knee in 1988 on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250434 -        his left knee. He pretty much says that he is not fully                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250435 -        recovered from his left knee arthroscopy in 1988 and still had                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250436 -        some chronic symptomatology involving his left knee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250438 -         ..
250439 -    7.  He, however, had noticed over the last two years pain in both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250440 -        of his knees after he would play tennis.  He said that he would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250441 -        initially play tennis, he would have some soreness but would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250442 -        actually feel better as he played and then about 2 hours                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250443 -        afterwards, he would have excruciating pain involving both of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250444 -        his knees.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250446 -         ..
250447 -    8.  He has not played tennis since October 1999 and has devoted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250448 -        himself to his professional work.  He said since not playing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250449 -        tennis and since pretty much doing sedentary activities,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250450 -        working mainly at his computer 24 hours a day', he has not had                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250451 -        any knee pain since October.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250453 -         ..
250454 -    9.  He said that the pain in his knee is not well localized.  It is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250455 -        more or less diffuse and he cannot say where specifically his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250456 -        knees hurt when they do hurt.  He has recently started                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250457 -        glucosamine and chondroitin in combination.  He does not do any                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250458 -        exercise or any physical activity currently.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250460 -         ..
250461 -   10.  PHYSICAL EXAMINATION:  The patrient appears to be a little bit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250462 -        overweight. He ambulates with a slight limp that favors his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250463 -        left lower extremity with a shortened stance of phase on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250464 -        left compared with the right during ambulation.  He has a mild                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250465 -        deqree of soft tissue swelling diffusely in the left knee when                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250466 -        compared with the right.  The right has absolutely no swelling                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250467 -        or effusion.  He has absolutely no tenderness. throughout his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250468 -        right knee.  He has no detectable ligamentous laxity to his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250469 -        right knee with no varus or valgus laxity and negative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250470 -        Lachman's.  Negative anterior and posterior drawer.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250472 -         ..
250473 -   11.  His left knee currently is non-tender to examination. He has no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250474 -        varus or valgus laxity to his left knee and negative 'Lachman's to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250475 -        his left knee. His ROM is slightly restricted on the left when                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250476 -        compared with the right. Extension appears full in both knees                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250477 -        but flexion, he lacks approximately 10 to 15 degrees on the left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250478 -        compared to the right.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250480 -         ..
250481 -   12.  X-rays reveal a moderately advanced arthritis involving his left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250482 -        knee. He has mild degenerative changes noted in his right knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250483 -        on the medial side with some joint space narrowing and some                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250484 -        irregularity of the medial femoral condyle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250486 -         ..
250487 -   13.  IMPRESSION/PLAN: This patient has moderately advanced arthritis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250488 -        involving the left knee. Has mild arthritis in the right knee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250489 -        Also appears to have some compensatory pain involving the right                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250490 -        knee when he does higher level activities because he favors his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250491 -        left lower extremity during these high impact activities.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250493 -         ..
250494 -   14.  I agree completely with Dr Boulris that the patient is best                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250495 -        advised to avoid the hard court tennis surfaces and softer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250496 -        surfaces would be much more important and that doubles tennis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250497 -        would be much more advisable thafr singles tennis.  I did,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250498 -        however, also emphasize the importance of cross training                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250499 -        modalities involving low impact activities, especially                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250500 -        stationary bike, some activities such as lightweight weight                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250501 -        trained to strengthen the lower extremities.  Also elliptical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250502 -        machine in the patient's health club to keep the knees                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250503 -        conditioned and the muscles around the knees well conditioned.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250505 -         ..
250506 -   15.  Also strongly encouraged proper shoe wear with maximal cushion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250507 -        and built in arch supports to provide the cushion on his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250508 -        joints.  Also reconunended trying glucosamine 500mg 3 times                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250509 -        a day with chondroitin 400mg 3 times a day,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250511 -  ..
250512 - This aligns with prognosis Doctor Boulris offered during the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250513 - on 090910; he recommended Glucosamine Chondroitin and advised left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250514 - knee replacement might be needed in 10 years by ending high stress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250515 - activity. ref SDS 23 9733  A few weeks later on 990925, received                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250516 - Craig's letter confirming prognosis that knee replacement might be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250517 - needed in 10 years. ref SDS 26 2951                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250518 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250519 -            [On 030807 case study shows personal history using liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250520 -            Glucosamine Chondroiten and clincial research. ref SDS 76                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250521 -            FN9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250523 -             ..
250524 -            [On 040529 0248 report that Glucosamine Chondroitin in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250525 -            liquid form relieved knee pain from hiking 3 - 10 miles per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250526 -            day. ref SDS 77 MN9P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250528 -  ..
250529 - 2nd Opinion Memo Doctor Yamamoto continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250531 -   16.  Should these modalities not work, then I would agree with Dr                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250532 -        Boulris again with consideration of synvisc injections to his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250533 -        left knee.  I would not at this point recommend cortisone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250534 -        injections to his knee unless he had more of an acute flare-up                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250535 -        of arthritic symptoms.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250537 -         ..
250538 -   17.  I also discussed with him the issue of MRI and at this point in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250539 -        time, agree with Dr Boulris that I do not feel an MRI is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250540 -        currently indicated in his right knee being that he has more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250541 -        chronic symptoms and being that he is asymptomatic for the last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250542 -        three months since not playinq tennis.  If, however, he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250543 -        developed more acutely painful symptoms with or without an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250544 -        injury and if these symptoms do not resolve, an MRI could be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250545 -        considered in the future and the patient was made aware of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250546 -        this.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250548 -         ..
250549 -   18.  A letter has also been dictated to the patient summarizing this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250550 -        and should be included in the medical record.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250552 -  ..
250553 - The doctor's letter is entered below. ref SDS 0 0H64                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250555 -         ..
250556 -   19.  VINCENT YAMAMOTO, M.D.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250557 -        D: 01124/00 T: 01125/00                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250558 -        VY:amp                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250560 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250561 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250562 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250563 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250565 -  ..
250566 - Letter 2nd Opinion Doctor Yamamoto Confirming Meeting 000124                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250567 - 
250568 - About a week after the meeting today received following letter from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250569 - the doctor, saying...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250570 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250571 -    1.  Kaiser Perrnanente Medical Offices                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250572 -        1425 S. Main Street                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250573 -        Walnut Creek, California 94596                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250574 -        (925) 295-4000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250581 -         ..
250582 -    2.  January 24, 2000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250583 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250591 -         ..
250592 -    3.  This correspondence is sent to you regarding our office visit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250593 -        today.  In review, I want to mention the things that we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250594 -        discussed today regarding treatment of your knee problems in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250595 -        both knees.  It appears that you have a moderately advanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250596 -        arthritis involving your left knee which has had two prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250597 -        operations including the previous open meniscus surgery and the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250598 -        subsequent arthroscopy.  Your x-rays do show significant                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250599 -        degenerative arthritic change involving the left knee.  Your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250600 -        right knee also has equal symptoms when you play tennis by your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250601 -        report and I do note on x-ray that you do have a mild degree of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250602 -        degenerative change on the inner part of the right knee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250604 -  ..
250605 - Diagnosing "moderately advanced" and "significant degenerative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250606 - arthritic change in the left knee, aligns with the doctor's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250607 - examination memo, per above, ref SDS 0 6S4K, and further with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250608 - discussion during the meeting at Kaiser Orthopedics Department, also                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250609 - above. ref SDS 0 HU5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250611 -  ..
250612 - Doctor Yamamoto's letter continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250613 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250614 -    4.  In addition, as I explained to you that because of your more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250615 -        significant arthritis on your left knee and the previous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250616 -        injuries to your left knee, you are compensating for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250617 -        injured left knee and putting more demand on your right knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250618 -        when you play higher level of sports.  This I refer to you as a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250619 -        "compensatory pain".  Subsequently, this would explain some of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250620 -        the symptoms in your right knee with activity.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250622 -         ..
250623 -    5.  My recommendations at this point in time would be to start                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250624 -        taking Glucosamine and Chondroitin with a dose of Glucosamine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250625 -        500 mg 3 times a day and Chondroitin 400 mg 3 times a day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250627 -  ..
250628 - Aligns with Vincent's memo per above. ref SDS 0 6S70                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250630 -  ..
250631 - Recommending Glucosamine Chondroitin aligns with the doctor's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250632 - examination memo, per above, ref SDS 0 6S70, and with discussion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250633 - during the meeting earlier today, per above. ref SDS 0 1680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250635 -  ..
250636 - Doctor Yamamoto's letter continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250637 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250638 -    6.  Also, I emphasize the importance of shoe wear.  I would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250639 -        strongly recommend a very well cushioned sole shoe with a built                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250640 -        in arch support, more on the lines of a cross training type of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250641 -        shoe with the maximal air cushion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250643 -  ..
250644 - Recommending well cushioned shoe wear with arch support aligns with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250645 - discussion during the meeting, per above, ref SDS 0 XH69; and, with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250646 - the doctor's memo. ref SDS 0 6S70                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250648 -  ..
250649 - Doctor Yamamoto's letter continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250650 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250651 -    7.  I also recommended that you do cross training should you want                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250652 -        to play tennis and this would include a regular stationary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250653 -        bicycling program and even some light weight training to build                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250654 -        the strength in your legs and in your knees.  Also, again I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250655 -        would like to emphasize the importance of warming up on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250656 -        stationary bike or the elliptical machine prior to playing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250657 -        tennis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250659 -         ..
250660 -    8.  In terms of more long-term treatment should your left knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250661 -        symptoms not improve with these modalities, then I would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250662 -        consider the Synvisc injections as had been recommended by Dr                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250663 -        Boulris and myself as an alternative option for treatment of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250664 -        arthritis.  It was not my recommendation at this point in time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250665 -        to give you a cortisone injection and I would reserve this more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250666 -        for acute flare-ups of your left knee arthritis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250668 -  ..
250669 - For some reason, Doctor Yamamoto's letter does not present long term                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250670 - prospect of knee replacement in 5 years without interventions, e.g.,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250671 - glucosamine chondroitin, and while continuing high impact activities,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250672 - e.g., tennis; nor that continuing degenerative osteoarthritis will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250673 - likely require knee replacement in 10 years even avoiding high impact                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250674 - activities, discussed during the meeting earlier today, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250675 - ref SDS 0 HU5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250677 -  ..
250678 - Doctor Yamamoto's letter continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250679 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250680 -    9.  In reference specifically to the MRI ofthe right knee, it was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250681 -        my opinion to you that a MRI currently would not be helpful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250682 -        At this point in time, a MRI would not change the treatment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250683 -        options recommended nor would it help currently with improving                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250684 -        diagnosis.  However, I did mention to you that if in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250685 -        future, you have a more acute injury involving your right knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250686 -        or an acute flare-up of your right knee which does not improve                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250687 -        in a short term, you should again be seen and a MRl may be more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250688 -        beneficial at that point in time to diagnose more acute type                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250689 -        injuries.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250691 -         ..
250692 -   10.  You also requested that I specifically mention in this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250693 -        correspondence that I did not have any of your own personal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250694 -        correspondence letters to Dr Boulris or to Ms Jean Bradley at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250695 -        this office visit.  Present at this office visit were your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250696 -        x-rays of your knees from two prior occasions and also the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250697 -        dictated outpatient consultation by Dr Boulris dated September                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250698 -        10, 1999.  If there are any further questions or needs, please                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250699 -        feel free to contact this office.  I have given you my                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250700 -        professional card with the telephone number.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250702 -         ..
250703 -   11.  Sincerely yours,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250705 -         ..
250706 -   12.  Vincent amoto, M.D.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250707 -        Department of Orthopedics                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250708 -        Kaiser Walnut Creek Medical Offices                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250710 -         ..
250711 -        VY;rkt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250712 -        DO: 1-24-00                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250713 -        DT: 1-27-00                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250715 -         ..
250716 -        CC: Member Services                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250717 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250718 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250719 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250720 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250721 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250722 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250723 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250724 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250725 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250726 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250727 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250728 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250729 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250730 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250731 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250732 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250733 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250734 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250735 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250736 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250737 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250738 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250739 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250740 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250741 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250742 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250743 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250744 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250745 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250746 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250747 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250748 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250749 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250750 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250751 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250752 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250753 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250754 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250755 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250756 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250757 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250758 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250759 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250760 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250761 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250762 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250763 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250764 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250765 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250766 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250767 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250768 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250769 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250770 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250771 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250772 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250773 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250774 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250775 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250776 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250777 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250778 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250779 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250780 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250781 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250782 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250783 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250784 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250785 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250786 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250787 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250788 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250789 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250790 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250791 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250792 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250793 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250794 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250795 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250796 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250797 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250798 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250799 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250800 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250801 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250802 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250803 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250804 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250806 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
Distribution. . . . See "CONTACTS"