The Diagnosis and Treatment of Iron Deficiency in Primary Care: 34,741 CBCs Reconsidered - PowerPoint PPT Presentation

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The Diagnosis and Treatment of Iron Deficiency in Primary Care: 34,741 CBCs Reconsidered
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The Diagnosis and Treatment of Iron Deficiency in Primary Care: 34,741 CBCs Reconsidered

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  1. The Diagnosis and Treatment of Iron Deficiency in Primary Care: 34,741 CBCs Reconsidered

  2. OR

  3. What I learned from 55 Gallons of Baby’s Blood

  4. OR

  5. The Diagnosis and Treatment of Iron Deficiency in Primary Care: A Qualified Failure

  6. Three Types of Prevention (Commission on Chronic Illness, 1957) • Primary Prevention, which seeks to decrease the number of new cases of a disorder or illness; • Secondary Prevention, which seeks to lower the rate of established cases of a disorder or illness in the population (prevalence); • Tertiary Prevention, which seeks to decrease the amount of disability associated with an existing disorder.

  7. Findings: The secondary prevention of IDA in toddlers is difficult. Success at CCRMC=30%, in line with four other studies. Most patients do not receive follow-up (38%) or remain anemic at follow-up (32%). Patients who remain anemic at follow-up have been affected for an mean of 147 days (range 15-836 days)

  8. Background

  9. Iron deficiency is the most common and widespread nutritional disorder in the world. The numbers are staggering: 2 billion people – over 30% of the world’s population – are anaemic, many due to iron deficiency.

  10. Why do we care?

  11. Iron is a cofactor in 200 enzymes and is important for various functions such as: Oxygen carriage in Hb Respiration Neurotransmitter synthesis Myelination

  12. Performance Problems Temporal organization of sleep WISC-R intelligence test Average math scores Written expression, motor functioning, and some specific cognitive processes

  13. Neurological Findings ( Young Humans) The hearing abilities, verbal and non-verbal sequential memory and localization Abnormal Visual Evoked Potential EEG and cognitive EPs (CEPs).

  14. Behavioral Findings (Animals) Wisconsin General Testing Apparatus, Black/White Discrimination task was acquisition of Black/White Reversal (BWR) (Monkeys). Decreased activity and stereotypic behavior (Rats). Hippocampus-dependent learning (Rats)

  15. What is the Gold Standard for the Diagnosis of ID?

  16. Bone Marrow

  17. What are the Clinical Diagnostic Criteria for Iron Deficiency?

  18. Two Clinical Models

  19. Ferritin Model (NHANES III) 2 or 3 of Following Abnormal: Low Ferritin Low Transferrin Saturation Hi Erythrocyte Protoporphyrin

  20. Body Iron Model (NHANES 2003-Onwards) A Function of Transferrin Receptor (Tfr) To 2) Ferritin

  21. Body iron (mg/kg) = -[log10 (TfR*1000/ferritin) -2.8229]/0.1207

  22. Anemia Is a Poor Predictor of Iron Deficiency Among Toddlers in the United States: For Heme the Bell Tolls Keith C. White, MD 2005;115:315–320;

  23. In this study, ID was diagnosed if >=2 of the following pertained: ferritin <10 g/L transferrin saturation <10% EPP> 1.42 mol/L red blood cells.

  24. Anemia was diagnosed if [Hb] was 110 g/L IDA was diagnosed if anemia accompanied ID

  25. Sample Cohort: 893 Toddlers ↓Hb ↓MCV ↑RDW (PPV for ID=93%)

  26. 341 Lost to Follow-up (38%)

  27. 552 Followed Up

  28. 268 “Cured” (30%) i.e. 2ndHb>11.0 g/dL

  29. 284 Still Anemic (32%) Demonstrated duration of disease= 147 days (mean) range 15-836 days

  30. Extraordinary Thanks to Maura Hoag

  31. AARDEN,PYRA M,MD Arora,Ravi,MD BROWN,BENJAMINA Berkowitz,Shelly, M.D. CARDOZA,MARY K,MD ABRAMSON,PAUL,MD Arpajirakul,Neary,MD BROWN,CANDIDA,MD Berletti,Charles,MD CAREY,HAROLD,DO ADAMS,DAVID S,MD Asbun,Horacio,MD BROWN,FRANKLIN B,MD Bernhard,Margaret,MD CAREY,JOSEPH C,MD AGNOST,VICTORIA,MD Ashbrook,Cynthia,MD BROWN,MICHAEL H,MD Bernstein,Wendy,MD CARIM,YASMIN H,MD AGUILAR,CONRAD F,MD Asuncion,Gloria,MD BROWN,TRACY Bhat,K.Naras,MD CARPENTER,JAMES,MD AKIN,SCOTT,MD Aulick,Harinder,MD BUI,HO Q,MD Bhatt,Veda S,MD CAVALLARO,GRACE,MD ALEJANDRE,GLORIA,FNP BANNWART,PHILIPP,MD BUI,THANH KHAC,MD Bierer,Elizabeth W,MD CEDERMAZ,HEATHER G,FNP ALEXANDER,STEVEN R,MD BARNETT,ANDREW B,MD BURCHETT,LAWRENCE R,MD Birk,Harvinder S,MD CHANG,JENNIFER,MD ALINGOG,KAREN D,MD BARNETT,ANDY S BURT, KAREN Birnbaum,Daniel,MD CHANG-YAN,HELEN,MD ANDELMAN,ROSS,MD BARRON,DANICA N,MD BURTON,JOHN T,MD Blaisch,Brian,MD CHATTEN-BROWN,JUSTIN MD ARMITAGE,DAMON,MD BASSALI,JOANNE,MD BUSK,NEAL C,MD Blanchard,Briar,MD CHATTEN-BROWN,JUSTIN,MD ARPAJIRAKUL,NEARY,MD BEACH,COURTNEY,MD BUTLER,MICHAEL JOHN,MD Bland,Gerard,MD CHEN,ANNE A,MD ARRIZABALAGA,ARIA,MD BEAN,GARY,MD BYRNE,WILLIAM J,MD Bliss,Judith,MD CHEN,STEVEN,MD ARVANITIDIS,DEMETRA,MD BEAUCHAMP,JON,MD Bahia,Alice,FNPBlosk,Sharon,MD CHEN,VICTOR,MD ASTA,LISA,MD BERGER,C FNP Baltrushes,Robin,MDBoakes,Jennette,MD CHENG,FLAVIO,MD AUERBACH,BURT J,MD BERGUER,RAMON,MD Bannwart,Phillip,MDBoegel,Mary L,MD CHERAYIL,ANNIE,MD AUSTIN,PATRICIA,MD BERNHEIM,SUSANNA,MD Barger,Joseph,MDBowers,Kenneth,MD CHEUNG,JOANNA MD Aarden,Pyra M,MD BERRY,JAMES Barrios,Jose,MDBoyd,Michael D,MD CHILCOTT,MARISHA,MD Acinas,M. Diana,MD BETTE,LUEY FNP Barrow,Roger,MDBoyd,William H,MD CHILDRENS HOSPITAL Adams,David S,MD BHATIA, SURUCHI,MD Basch,Corinne,MDBrenner,Richard,MD CHITGOPEKAR,PREETI,DDS Adler,Frederick W,MD BHATIA,RAJIV Bassali,Joanne,MDBrooks,Jerry,MD CHOU,CINNIE,MD Adona,Lolita,FNP BHATIA,SURUCHI Baumeister,Lisa M, M.D. Brooks,Kenneth R,MD CHUA,MANUEL Agnost,Victoria,MD BLACK,CHRISTIAN Beach,Courtney,MDBrown,Candida,MD CHUA,SAMUEL G.,MD Aiken,JLee,MD BLAISCH,BRIAN,MD Beadles,Kevin,MDBrown,Tracy,MD CHUN,KWAN,MD Alicaway,Edgardo,MD BLAND,GERARD,MD Beal,Jolaine P,MD Brunner,Wendel,MD CLARK,SARAH,MD Alingog,Karen D,MD BLOCH,JOY,MD Beauchamp,Jon,MDBullion,Clyde,FNP COHEN,JESSICA,MD Alperin,Michael,M.D. BOBLETT,BENJAMIN F,MD Beck,Fred,MDBuoncristiani,Amy C,MD COKER,TIMOTHY,MD Alves,Richard,D.D.S. BOND,BREA A,MD Beckley,Dennis,MDBurchett,Lawrence R,MD COLLIER,SCOTT,MD Anderson,Wayne,DO BOTELHO,BARBARA,MD Beckwith,Kirk D,MD Burt,Karen,MD COMINOS,EVE D,MD Antioch,Planned Parenthood BOUA Bellwood,Ingrid,MDButler,Derrick CORTEZ,PAUL S,MD Appel,Jason A,MD BRANDEIS,JUDSON,MD Berger,Christina M,FNP CABALLERO,RUBEN,FNP COYLE,ALICE,MD Applegate,Mitchell,MD BREWER,NATHAN Bergman,Kevin L,MD CABRERA,ROLANDO,MD COYNE,KIMBERLY,MD Arana,Sonia,MD BRIZZELL,REBECCA Berguer,Ramon,MD CAPPELLARI,ANN,MD CREMIN,DANIEL,MD

  32. CROWDER,KATIE,MD Cheng,Anthony,MD DESAI,MANOJ EGLI,CATHY,MD Cabrales,Raquel,MDCherayi l,Annie,MD DIAZ,ANGEL,FNP EMERY,HELEN,MD Cabrera,AlbertChilcott,Marisha,MD DIAZ,NATASHA,MD ERBE,JOSEPH Cabrera,Rolando,MDChinn,Francesa,MD DICKERSON,CHARLES,MD ERICKSON,ELIZABETH Cain,JanetChipkin,David R,MD DO,ANH TRUNG ERRICO,WILLIAM R,MD Camodeca,Frank,DDSChiu,Kwang,MD DODGIN,DAVID,MD ESCALADA,MARIA,MD Carey,Joseph C,MD Cho,Myung R,MD FEIERABEND SUSAN EVELAND,JOANNA,MD Carin,Dorothy A. Chou,Cinnie,MD DOSANJH,SANDEEP,MD EYERMAN,JAMES D,MD Carlson,Edwin,MDChun,Kwan,MD DOSHI,BELLA A,MD Egli,Cathy,MDCarmichael,Cynthia G,MD Clark,Ezra,M.D. DUNCAN,SPENCER,MD Eilerman,Sallie,MDCarpenter,James,MDCleveland,Aaron,MD DUNHAM,MIRIAM E,MD Elliff,Jo,FNPCarr,John A,MD Cohen,Jessica,MD DUONG,UYEN,MD Ellis,John,MDCarr,Walter,MDColwell,Kate,M.D. Dacker,Evelin,MDEppolito,Lawrence J,FNP Fentress,Matthew,MDCarroll,Peter,MDColwell,Kate,MDDally,Margaret,MDEveland,Joanna,MDFidler,Michael,MDCarter,Brazell,MDCominos,Eve D,MD Dalton,Laura,MDEwing,Hope,MDFielden,Jessica,MDCarter,Kimberly Y,MD Cominos,Eve D.,M.D. Daniels,Clark,MD FAREY Fish,Jeremy,MDCasebolt,Allen,MDCooperider,Larry,F.N.P. Daniels,Stephen J,MD FARMER,DONNA Fishel,Carol,FNPCatalya,Esther Q,MD Corcoran,MarthaEllen,M.D. Daniels,Stewart A,MD FARMER,DONNA,FNP Flores,JoseLuis,MDCates,Edward,MDCorona,Mario,M.D. Dao,Huy D,MD FELDMAN,ROBERT MD Forman,Stuart,MDCavallaro,Grace,MDCorser,Nancy,F.N.P. David,Sheila,MD FLETCHER,STACY,MD Foster,Matthew C,MD Cedermaz,Heather G,FNP Corser,Nancy,FNPDeSoer,Craig,MD FLORES,JOSEPH MD Franck,Sarah,FNPChamplin,John G,MD Cortez,Paul S,MD Degnan,Kevin,MD FLORIO,CECILIA,MD Franco,ArturoChan,Rodney,DPMCrane,Charles,M.D. Degnan,Nadine,MD FRASER-HULTHAGE,ANNA E,MD Frank,JEFF,MDChander,Jayshree, M.D. Crane,Charles,MDDesai,Tushar,MD FRECH,LESLIE,PHD Fraser-Hulthage,Anna E,MD Chang,David W,MD DALLY,MARGARET,MD Diamond,Jan,MD FURER,JESSICA,MD Frazer,Brad,MDChang,Smith, M.D. DAO,HUY D,MD Diaz,Jessica,MD FURTADO,MARCIA LUISE,FNP Fruman,Neil S,MD Chang,Tsu-WengDubuene,MD DASARI,RAJ Dooley,Diane,M.D. Faivre,Scott R,DDS Furtado,MarciaLuise,FNPChapman,Michelle,MD DASARI,RAJ,MD Dooley,Diane,MDFajana,Olayinka,MD GEE,JOHN Chappel,EThomas,MD DAVIS,BRIAN,MD Dorado,Francisco,MDFarey,Krista,MD GEE,JULIUS W,DO Chatten-Brown,Justin,MD DAVIS,SUZANNE,MD Dosanjh,Sandeep K,MD Farmer,DONNA,FNP GILBERT,JOHN I Chavez,Christina DAWLEY,COURTNEY A,MD Dowling,James,MDFarnitano,Christopher,MD GIRI,VASANTA,MD Chavez,Frances,MD DEHLINGER,MAIA,FNP Duir,Kimberley,MDFeierabend,Susan GLEGHORN,ELIZABETH,E,MD Chavez,Patricio,MD DENHERDER,DEBRA,MD ECHOLS,JOHN C,MD Feierabend,Susan,MD GODZICH,MICAELA C,MD

  33. GOLDIN,MARK,MD Gordon,Amy S,M.D. HINES,PAMELA Hearst,David,MDHurtado,Martin,MD GONZALEZ,DIANE,MD Goren,Alvin,MD HINMAN,PRISCILLA Hejinian,Anna,M.D. JACKSON,JONATHAN,MD GORDON,NAYVIN, MD Gorodetsky,Alexander,M.D. HINMAN,PRISCILLA,MD Helmstein,Jean,FNP JACOBSEN,TORSTEN P,MD GRAHAM,OLIVER Z,MD Gould,John E.,M.D. HJORTSVANG,ERICK,MD Henderson,Ellen,MD JAN,BRIAN A GREEN,ANGELIQUE, MD Graham,Regina R,MD HO,MINH,MD Henderson,Lorre,MD JELTEN,GERI GREEN,JON,MD Graves,Gretchen D,MD HOFFMAN,WILLIAM Y,MD Henson,Jennifer,MD JENKINS,SHEILA,MD GREEN,TRINH,MD Graves,Gretchen D.,M.D. HOFFMANN,DONALD,MD Herbst,Mark D,MD JENKINS,WILLIAM,MD GRIESAU,BARBARA,FNP Graves-Matthews,Mcheko,M.D. HOFSTADLER,GUENTER,MD Hernandez,Estela,MD JEUNG,JOAN J,MD GRIMES,GARY,MD Green,Trinh M,MD HOLMES,MICHELLE,MD Hernandez-Lopez,Maria,MD JIANG,XIAOHUA,MD GRIMES,JANET,MD Greenberg,Steven A. HOOD,ROBERT,MD Herrera,Lionel,MD JOHNSON,GWENDOLYN,MD GRISHAM,JULIE,MD Grimes,Janet M,MD HOPKINS,J,M.D. Higgins,Cheryl,FNP JONASDOTTIR,SOFFIA,MD GROSS,JOEL,MD Grondahl,Joseph M,MD HOPKINS,JAMES M,MD Hilaman,Brad L,MD Jacobs,Beverly,FNP GROSS,LAURA MD HAGLUND,KIMBERLEY,MD HOWARD,RENEE,MD Hilty,Jill,M.D. Jacobs,Jeffrey,MD GROSS,LAURA,MD HAHN,DAVID,DO HSIEH,CHARLOTTE,MD Hiner,Sharon,MDJacobs,Lyn GROSSFELD,JODI HALPIN,TIM,MD HSU,CARL, MD Hines,Pamela,M.D. Jagust,William,MD GROSSNICKLE,ELLEN,MD HAMILTON JR,GEORGE,MD HUBIAK,MELISSA,MD Hines,Pamela,MDJain,Nidhi,MD GWALANI,TULSIDAS,MD HANLIN,DOUGLAS,MD HUMELBAUGH,GIA Hinman,Priscilla,M.D. Javaheri,Shahin M,MD Gallegos,Emmanuel L,M.D. HANSEN,ANNIKEN,MD HUYNH,HUONG,MD Hinman,Priscilla,MDJayasekera,Neil S,MD Gee,Lance,MD HANSEN,ERICA D,MD Haglund,Kimberley,MDHo,Ada M,MD Jayasekera,Neil,MDGeorge,Lily,MD HARMATZ,PAUL R,MD Hamilton Jr,George E,MD Ho,Delphine K,MD Johnson,Alonza,M.D. Gerardi,William,M.D. HARRISON,STEVEN,MD Hamilton,Gwendolyn,M.D. Hobert,DKent,MDJohnson,David,M.D. Ghori,Imtiaz HASTINGS,JACK,DDS Hamilton,Gwendolyn,MDHofstadler,Guenter W,MD Johnson,Gwendolyn,M.D. Ghori,Imtiaz,MD HAY,SUNATHARA,DO Hammond,Geffrey,MDHogness,Christopher,MDJohnson,Robert N.,M.D. Ghotbi,Mo,M.D. HAYES,DEBORAH,MD Hansen,Anniken B,MD Holbrook,Helene,FNPJohnson,William,M.D. Gilbert,Arnold,M.D. HEANEY,DANIEL,MD Hansen,Erica D,MD Holmes,Michelle M,MD Johnson,Yeva, M.D. Gillis,Lesley A,FNP HEISLER,STEPHEN,MD Hanson,Kenneth,ODHopkins,James M,DO Jolton,Francine,M.D. Gladden,Jennifer,MD HELLMAN-WYLIE,CYNTHIA,FNP Harris,Charles R,MD Howard,Phyllis,FNPJolton,Francine,MDGlatt,Patricia,M.D. HELMSTEIN,JEAN Harris,Charles,MDHsieh,Charlotte J,MD Jones,Anthony E,MD Glatt,Patricia,MD HENCH,ANNE Harris,Homer W,MD Hsu,Carmen,MDJones,Jeffrey,M.D. Godzich,Micaela C,MD HERNANDEZ,ESTELA,MD Harvey,Ann,MDHsu,Hwei-Jung,MDJones,Kenneth L,MD Goldstein,David N,MD HERRON,SHERYL,FNP Hass,Leif R.,M.D. Hubiak,Melissa,MD KAJI,TROY T,MD Goldstein,David,MD HERTZ,BRIAN,MD Hatcher,Byron,MDHuie,Fredric D,MD KALRA,SUMITA K,DO Gonzalez,Ruben,MD HILL,PATRICIA,FNP Hay,Donald,MDHuie,Fredric,MD KAMALNATH,JACINTHA Goodman,James,M.D. HILLMAN,LORENA F,MD Hay,Sunathara,DOHumphrey,Kenneth,MD KANE,LESLEE,MD Goodman,Susan R.,M.D. HINDI,ROBERT, MD* Hayes,Elizabeth,MDHunt,Thomas,MD KANG,HANNA,MD

  34. REITZENSTEIN,JONATHAN,MD Ringo,Patrice M,MD SCHREIER,HERBERT M.D. SPOONER-DEAN,KERRY,M.D. RHODES,GREGORY A,MD Risgalla,Edward,MD SCOTT,MALAIKA M,MD STALLINGS,RONALD,MD RIDDEL,JIM,NP Roberts,Jessica B,MD SEBAN,OLIVER,MD STEBER,BRIAN,MD RILEY,JENNY,MD Roberts,JohnPaul,MD SEED,CHRISTINA,DO STEELE WOODALL,VICKY,FNP RINGO,PATRICE,MD Robinson,Curtis,M.D. SEGALL,SERGE S,DDS STEELMAN,MARIA,MD RISGALLA,EDWARD,MD Rodarte,Christopher,M.D. SHAH,NISHANT H,MD STEFFENSON,SANDRA,MD ROBC Roe,Taiyun,MD SHAH,SAMIR,MD STEIN,MICHAEL R,MD ROBERTS,JESSICA,MD Romero-Duran,Adolfo,MD SHAIN,PHILIP,MD STEINER DOOHAN,NOEMI,MD ROE,TAIYUN,MD Roos,Joan A,FNP SHANAHAN,ROBIN,MD STEINHART,RACHEL,MD ROHWEDER,DANIEL A,MD Roos,Joan,FNP SHATZ,ARNOLD,MD STEIRN, FNP Schaffer,Sarah,MD ROMERO-DURAN,ADOLFO,MD Rosenfeld,Jack,DDS SHAW,MAYA S,MD STEIRN,FNP Schaplow,Reagan,MD ROMO,CECILIA Rosenthal,Macey H,MD SHEFA,MEHDI,MD STETTNER,MICHAEL,FNP Schechtman,Andrew,MD ROSENTHAL,PHILIP MD Rosenthal,Macey,MD SHEFA,Q,MD STEUBLE,B Scheffer,Jonathan L,MD ROSENTHAL,PHILIP,MD Ross,William,M.D. SHELDON,WILL C,MD STYCH,DEBORAH,FNP Scherzberg,Maureen,FNP ROSS,CHRISTINE,MD Rudlowski,Teresa,MD SHELTON-PRYOR,RUTH E,MD SWARZENSKI,BARBARA,MD Schnake,Ann L,FNP ROUX,JOAN W,MD Rush,Philip,MD SHOVLIN,PATRICIA M,MD Saffier,Kenneth A,MD Schnake,Ann,FNP RUDA,STEPHEN,DO SACHDEV, NEELAM,MD SIEGAL,JENNIFER Saffier,Kenneth,MDSchneider,Jeanette E, M.D. Rafal,Robert,MD SACHDEV,JANAK,MD SIEGEL,ALAN,MD Safianoff,David,MDSchreiber,John,MDRandles,Bradley,MD SACHDEVA,SURESH,MD SILVERSTEIN,STUART C,MD Saito,Hideto,MDSchwamberger,Shelle,MDRapa,Katarzyna W,MD SAHEBKAR,FARHAD M,MD SIMMONS,JILL (HILTY) Salceda,Irene A,PA Schwartz,Jerrold,MDRaphael,David,MD SALSBURG,ELIZABETH L,MD SIMON-WEISBERG,DEBORAH,MD Sam,Michel,MDSchwedes,Judith,MDRaumer,Sheila,MD SAMPSON,OLIVIA,MD SINHA,NANDA,MD Sandler,Andrea E,MD Scott,Malaika M,MD Reedy,David B,MD SANDLER,ANDREA,MD SKOCHKO,GREG,MD Sandler,Maurice,MDSeawell,Elaine O,FNP Reese,Cote SAPIEN,ROBERT E,MD SMITH Sands,Michael,MDSeawell,Elaine O.,FNP Reif,Paul,MD SARASUA,JAMES,MD SMITH,CHRISTINE B,FNP Santiago,Daniel E,MD Severson,G. Kaye,FNPReilly,Brenda,MD SAUERLAND,EBERHARDT,MD SMITH,THOMAS J,MD Sapien,Robert E,MD Shaffer,Ingeborg,MDReisman,Jeanne,MD SAVAGE,CYNTHIA,MD SOLIS,ROBERTO A,MD Sarvasy,Paul,MDShah,Nishant H,MD Render,Rebecca M,DO SCHAFFER,GERALD, MD* SOLOMON,DAVID J,MD Sarvi,Saunaz,DDSShalen,WilliamReynolds,Nancy,MD SCHEFFER,LISA G,MD SONG,JACK,MD Saucedo,Jesus,M.D. Sharma,Aditya,MDReynolds,Vera,FNP SCHESSER,JONATHAN,MD* SORIA,RAFAEL,MD Savage,Cynthia J,MD Shaw,Howard,FNPRiccio,Adrienne,RN SCHIFFMAN,LOLLY,MD SORRELL,ARTHUR,MD Savage,Walter T,MD Shaw,Maya S,MD Rice,Abraham C,MD SCHMIDT,D SCOTT,MD SPAIN,ALAN J,MD Sayani,Sam,MDShaw,MichaelRiedel,JFrederick,MD SCHNEIDER,LUREE,MD SPANGLER,LINDA,MD Siegel,Alan L,MD Sheldon,WillC,MD

  35. Siegel,Jennifer,M.D. Stone,David,MDTreatment,Nurse WARNE,THOMAS,MD Weiner,Ira,MDSigmond,Herbert,MDStringer,Penney C,MD Tremain,Steven,MD WASHINGTON,SHARON D,MD Weingard,Herbert,MD Simon-Weisberg,Deborah,MDStrych,Deborah,FNPTruman,Kirsten C,MD WATERS,SHANNON,MD Weinreich,Don H,MD Singh,Deviner,MDSu,Cindy W,MD Tsai,Clark S,MD WATSON,JOHN,MD Weiss,Stephen,MDSkinner,Harry,MDSuchow,David,MDTsai,Tsuong,MD WEBB,KINARI,MD Weng,Christiana Y,MD Slauson,Dana L,MD Sutherland,Sonia,MDTsang,Jennifer,MD WEI,ALAN,MD Werner-Crohn,Mindy,MDSlauson,Dana,MDSwartz,Aubrey,MDTysell,James R,MD WEIGOLD,SCOTT,MD Wernham,Aaron A,MD Smallhorne,Violet,MD TAI,DENICE K,MD Tysell,James,MD WEILAND,DAVID S,MD Westerman,Jennifer,FNPSmick,Kathryn,MDTANG,JOYCE,MD Tzvieli,Ori,MDWEINMAN,CHRISTIAN,MD Whalen,Jon,MDSmith,Daryl,MD TANTOD,BHAKTI,MD UDENYI,NKECHINYERE,MD WENG,CHRISTIANA,MD White,Keith C,MD Smith,James,MD TAVERNIER,LAURA,MD UNASSIGNED PCP WHINNERY,CATHERINE,MD White,Keith,MDSmith,Jeffrey V,MD TAYLOR,DENISE UNDERWOOD,VIRGINIA,MD WHITE,CHRISTINE,FNP White,Matthew P,MD Smith,Nora,MD TODD,MICHAEL,MD UNIS,CLAIRE,MD WHITE,NEAL,MD White,RalphDevere,MDSmith,T,MD TODD,RODNEY,MD Urcuyo,Sergio,MD WHITE,VANEIDA,MD White,Thomas,MDSobel,Daniel,MD TOMASULO,MICHELE,FNP VALVERDE WHITEHAIR,BREA,MD Wildfire,Gila,MDSolomon,David J,MD TORNABENE,FELICIA,MD VALVERDEE WHITEHALL,JUDI,MD Wille,Mark,MDSong,Jack J,MD TREATMENT,NURSE VAN HANDEL,MARK,MD WHITTEN,LAURA F,MD Williams,Kathryn,MDSorensen,Gregg S,MD TREYGER,LEONID,MD VAN MEURS,DIRK,MD WIDDER,DONALD J,MD Williams,Tanya M,MD Spalding,Joanne,MD TZVIELI,ORI,MD VAN ORDEN,FRANK,MD WILDFIRE,GILA,MD Wong,Bryan M,MD Standefer,Charlotte B,MD Tai,Denice K,MD VAN SCHAVEN,EMILY,MD WILLIAMS,ROGER,MD Wong,DAN K,DDS Standefer,Charlotte,MDTangco,Angelita,MD Van Duren,Michael,M.D. WIXOM,PHILIP A,MD Wong,Michelle,MDStanger,Jennifer,MDTantod,Bhakti D,MD Van Duren,Michael,MDWadle,DawnMarie,MDWong,Sharman,ODStanger,Jonathan R,MD Taylor,Denise,MD Van Konynenburg,Kristin,MDWagner,Andrea,MDWright,Lara M,MD Staniotes,Lizabeth N, M.D. Taylor,Opal I,MD Vastine,David R,MD Wagner,David,MD YANG-SHARMA,PATRICE,MD Steinberg,Jonathan D,DPM Tendero,Clarissa,MD Von Rydingsvard,Milton,M.D. Walker,Scott,DDS YASUL,JOSE,MD Steinberg,Susann,M.D. Tenduf-La,Tenki,MDVonbuettner,Marion,MDWalker,Susan J,MD YATES,RACHEL L,MD Steinhart,Rachel,MDThedinger,Blair,MDVonrydingsvard,Milton,MDWalker,William,MD YOO,DAVID,MD Steirn,Cathy,FNPThomas,Cecilia,DDS WAGNER,DAVID,MD Walsh,John R,MD Yang-Sharma,Patrice,MDStephens,Claudell,MDThomas,Michelle,MD WALKER,BRADLEY,MD Walsh,Judith M,MD Yasul,Jose I,MD Stephenson,Linda,FNPTimmerman,Laura A,MD WALKER,MIGNON,MD Walsh,Judith,MD ZAKS,CAMILO C,MD Stern,Richard S,MD Toma,Louay,MD WALSH,JOHN,MD Warne,Thomas R,MD ZELAN,SAUL,MD Stewart,Jerome,MDTomasulo,Michele,FNP WANG,CATHERINE,MD Warner,Deborah,MDZaks,Camilo C,MD Stinson,Mark,MDTrapnell,James,MD WANG,LINA,MD Wasko,Janet,FNPZaks,Walter,MDZimmerman,Daniel,MDZerweck,Bradley W,MD Zamani,Christopher,MD

  36. KASTEN,THOMAS,MD Keller,Lisa K,MD LEGGETT,MICHELLE Lee,Rebecca,MDKAUR,RAMANDEEP,MD Kelley,Juliette,MSS LEHMAN,TARA,MD Legg,Jill J,MD KEATING,LIAM,MD Kelly,Olga D,MD LEIGH,ERICA,MD Lehman,Tara A,MD KEBEBEW,POSITRON,MD Kemmet,Rebecca K,MD LEIGHTON,LYNETTE Leong,Craig,M.D. KELLY,KRISTEN Kershnar,Rebecca L,MD LERMAN,BENJAMIN S,MD Leong,Rudy,M.D. KELLY,OLGA,MD Keswani,Anita,MD LEWIS, NANCY E,MD Levin,Robert,M.D. KENT,ZACK,MD Kim,Hye-Kyung,MD LEWIS,BRAD,MD Levin,Sara K,MD KERLEY,SARA,MD Kleinerman,David I,MD LEWIS,ELISE,MD Lewis,Elise A,MD KERSHNAR,REBECCA,MD Kleinerman,David,MD LEWIS,STEPHEN B Lin,Alice,MD KEVAN, JONATHAN Kline,Todd M,MD LIN,ALICE,MD Lindsay,R. J.,M.D. MAYLAND,GABRIEL,MD KHAN,FARINA,RN Knight,Robert,MD LIN,JANET,MD Lindsey,David,M.D. MCADAMS,LANCE,MD KHOURY,RONALD,MD Koo,Ralph A,MD LIN,MARGARET,MD Lipson,John H,MD MCBRIDE,PAMELA,MD KIBELSTIS,THOMAS,MD Kramer,Theresa,MD LINDE,BRIAN,MD Lively,Daniel, M.D. MCCARTHY,CLAIR,MD KISSINGER,CATHY,FNP Kulinsky,Ilya,MD LINN-MAKUA,LIZABETH,FNP Lockhart,Ann B,MD MCCARTHY,EVE A,FNP KONKK Kullar,Ravjeet K,MD LIPSON,JOHN H,MD Loeliger,Scott F,MD MCCORMICK,JANE,MD KOO,RALPH A,MD Kumar,Pradeep,MD LOCKHART,ANN,MD Long,THOMAS MCCOY,THOMAS C,DO KRUTZ,REBECCA A,MD LAI,JAY LOEFFLER,ANN M,MD Longoria,Anthony M,FNP MCDANIEL,MARC KULLAR,RAVJEET,MD LAM,WENDY LOELIGER,SCOTT,MD Lopez,Carlos,M.D. MCDONALD,THOMAS,MD KULOVSKY,SUSAN M,DO LAMANUZZI,SARAH MD LONGORIA,ANTHONY M,FNP Lopez,Hector J.,MD MCENTEE,AMY,MD KURUVILLA,PRAMITA,MD LAXAMANA, DARLEEN DDS LOTRIDGE,JESSICA,MD Lucey,Bette B,FNP MESSINGER,JEFFREY,MD Kailikole,Theresa,MD LEACH,RANDY A,MD LUCEY,BETTE,FNP Lum,Karen, M.D. MEYER,JACOB M,MD Kaji,Troy T,MD LEAVITT,JONATHAN LUM,KAREN Luong,Lien,MD MEYER,JENNIFER,MD Kalkstein,Stephen W,MD LEE,BRIAN,P,MD LYONS,MICHAEL,MD MACCHOR,NADAL MEYER,LEIF Kalra,Sumita K,DO LEE,DANIEL A,MD Lackman, M. MD MACEDO,JOSEPH,MD MILLER,DAVID,MD Kamalnath,Prakash J,MD LEE,ERIN M MD Lantz,Donald J,MD MAHAR,DIANA,MD MILOJEVIC,DIANA MD Kang,Hanna,MD LEE,GEORGE,MD Lantz,Donald,MD MAHONEY,JOHN MINDY WERNER-CROHN, MD Karell,Manuel L.,M.D. LEE,JAMES, MD Lares,Beatriz,M.D. MALIK,RITU,MD MIRAMONTE, SHELLY Karpf,Esther,FNP LEE,KAI-MAN,MD Laxamana,Darleen G,DDS MANUNTAG,WILFRED MIRANDA,KRISTEN Kartun,Karen F,MD LEE,MICHAEL Lee,Daniel A,MD MANUNTAG,WILFREDO,MD MOELLER,KRISTIN,MD Katz,Samuel,MD LEE,SCOTT,MD Lee,Eun-Kyu,M.D. MARTINEZ,DAVID,MD MOHR,ARWEN,MD Katzman,Kenneth A,MD LEE,SU-MAY,MD Lee,John M,MD MARTINEZ,MICHAEL S,MD MONTANDON,MICHELE,MD Katzman,Kenneth,MD LEE,TABESSA I,MD Lee,John,M.D. MATSUNAGA,ALISON T,MD MOORE,JUDE J,MD Kaufman,Douglas,MD LEGG,JILL J,MD Lee,Michelle,MDKeating,Liam,MDMORAN,BRIDGET,FNP

  37. MORGAN,JAMES,MD Martinez,Michael S,MD Morrison,Chantal L,DO PABERS,JOHN,MD Perez,Edith,MD MORRISON,CHANTAL L,DO Matsumura,Gary,MDMueller,Robert A,MD PACKMAN,SEYMOUR,MD Perez,Greta,MD MOULTON-BARRETT,REX,MD Matsunaga,Alison T,MD Murai,Sarah E,MD PAIGE,THOMAS,MD Perez,Pauline,MD MOZA,JOSEPH,MD Mattka,F J,DDS NAIMA,IRAJ,MD PALMER,NANCY,MD Perez,Peter J,MD MUNNICH,JO MARIE,MD May,Daniel,MD NATION,ROMAN,MD PALOMINO,MICHAEL A,MD Perez-Baron,Gina,MD MURAI,SARAH,MD Mbanugo,Ogo S,MD NAVEL,DAVID,MD PALOMINO,MICHAEL A,MD Perez-Salinas,DaliaMacDannald,Harry,MDMbanugo,Ogo,MD NAVEL,JAMIE,MD PAYNE,CHELSEA,MD Perlas,Maria K,MD MacDonald,David J,MD McAnich,Jana,MD NGUYEN,DAO M,MD PEHLING,JAMES R,MD Perry,Alison W,FNP MacDonald,David,MDMcAninch,Jack W,MD NGUYEN,LOAN,DO* PEPPER,DAVID,MD Peterson,William J,MD Macedo,Joseph J,MD McCabe,Robert,MD NGUYEN,MYHOANG,MD PEREZ,JUAN,MD Pham,Julie,DOMadrigal,Teresa,MDMcCoy,Thomas C,DO NIX,DEBBIE,FNP PEREZ-BARON,GINA,MD Picker,Robert,MDMagbitang,Fereyes,MDMcDaniel,HMarc,MDNagel,Charlotte,MD PERLAS,JANE,FNP Pierson-Brown,Leigh,FNPMahan,BernadetteMcDonald,Diana,FNPNavel,Jamie M,MD PESSL,ERICH,MD Pilcher,David W,MD Mahar,Dennis,MDMcDonald,Michael Nelson-Munson,Karen,MD PETERSON,AARON,MD Pillai,Sangita S,MD Mahar,Diana H,MD McNabb,Thomas R,MD Nguyen,Myhoang P,MD PETERSON,WILLIAM J.,MD Pinto,Natasha J,MD Maher,Patrick,MDMcNeil,Sarah,MDNidorf,David,MD PETTIT,CHARLES R,MD Pitman,Dorothy,M.D. Maher,Terry,MDMelny,Richard,MDNix,Debbie,FNP PHAM,AN T,MD Pizzo,Anthony,FNPMakhoul,Nicolas E,M.D. Mendoza,Julio,DDSNordensjo,Anna K.,M.D. PHELPS,BRIAN,MD Polzin,David,MDMakhoul,Nicolas E,MD Mendoza,Zenaida M,MD O'LEARY,MAURA,MD PIERSON-BROWN,LEIGH,FNP Porter,William,MDMakow,Adele,MDMendoza,Zenaida, M.M.D. O'MEANY,JUAN F,PA PIERSON-BROWN,LEIGH-ANNE,FNP Pramanik,Rajiv,MDMalik,Geeta,M.D. Meyer,Jacob M,MD OLDHAM,DEREK,RES PINTO,NATASHA,MD Public Health,PittsburgMalik,Rajiv,MDMeyers,Leif E,MD ONISKO,NANCY,DO POLLICK,CHRISTOPHER,MD Public Health,RichmondMalik,Ritu,MDMiller,Barry,M.D. OWENS,MELISSA K,MD PONOMAREFF,GEORGE,MD Puell,Michael A,MD Mallen,Peter R,MD Miller,Daphne,M.D. OZAETA,LEE,MD POPULIS,AMELIA Puell,Michael,MDMandiberg,Robert L,MD Miller,Fred,MDOlsen,Harvey,MD PRAMANIK,RAJIV,MD QADIR,MALIHA,MD Mansour,Karim M,MD Miller,Laura FNP Olsen,Richard,M.D. PRESCOTT,STACY MD QUIDES,KATHY,N.P. Manuntag,Wilfredo P,MD Miller,Michael,M.D. Olsen,SteveN PRIVATE DOCTOR QUINONES,LISA M,MD Maramonte,Shelly M,MD Milojevic,Diana,MDOlson,Donald,MD PRYSI,SCOTT,MD Quinones,Lisa M,MD Maramonte,Shelly,MDMoeller,Kristin A,MD Onisko,Nancy S,DO Paige,Thomas N,MD RANA,FARAH,MD Marchand,Erin,MDMohr,Arwen E,MD Osborne,David F,MD Palmer,Nancy K,MD RAO,KALPANA,MD Maron,Steven,MDMontandon,Henri E,MD Osborne,Frederick M,MD Parkison,Gary,M.D. RAPA,KATARZYA,MD Marten,Timothy,MDMontandon,Michele M,MD Owen,KennethDale,M.D. Pearson,Meg RASKIN,GORDON,MD Martin,Albert E,DDS Morrell,Rose E,MD Owens,Nancy,M.D. Pehling,James R,MD REEDY,DAVID B,MD Martin,Gail E.,M.D. Morrell,Rose,MDOwens,Nancy,MDPepper,David R,MD REILLY,BRENDA,MD