 |
Ear, Nose & Throat Associates |
|
|
|
|
|
 |
|
|
|
 | This Month's Articles:
|
|
|
|
July 2008 News Archives
|
July 1: HPV Linked to Better Survival, Advance
Researchers at the University of Michigan Comprehensive Cancer Center have found a series of markers that indicate which patients are more likely to survive cancers of the base of the tongue and tonsils (Journal of Clinical Oncology, July 1, 2008).
Most notably, they found that cancers linked to HPV, or human papillomavirus, are the most responsive to current chemotherapy and radiation treatments, while tumors that express high levels of a certain growth factor receptor are the least responsive and most deadly.
The researchers call these and other markers a promising step in the direction of tailored, individualized treatment for a type of cancer that can have dramatic impact on essential abilities such as swallowing and speaking.
"The chemotherapy and radiation therapy we use to treat this type of cancer is very aggressive. If we can identify those patients most likely to respond, we could reduce the intensity of the therapy for those likely to have the best outcomes," stated Thomas Carey, PhD, professor and distinguished research scientist at the U-M Kresge Hearing Research Institute and co-director of the head and neck oncology program at the U-M Comprehensive Cancer Center. "At the same time, we hope to identify new treatments that specifically target those tumors that we know are not responding to current therapies." Dr. Carey was the senior author on both papers.
Cancers of the tonsils and the base of the tongue have increased in recent years, in what Dr. Carey calls an "epidemic" of HPV-induced head and neck cancer. This has occurred at the same time that declines in smoking rates have led to a decrease in the incidence of other types of head and neck cancers. HPV is the virus that can cause cervical cancer and is the target of a new vaccine.
"The biggest challenge is how best to treat patients with tumors that stem from tobacco and alcohol use as opposed to tumors linked to HPV. We now know they're two different cancers," said study author Francis Worden, MD, assistant professor of internal medicine at the U-M Medical School.
In this study, researchers treated 66 patients with advanced oropharyngeal cancer, which includes cancer of the tonsils and the base of the tongue. Study participants were given an initial course of chemotherapy to gauge the tumor's response. Those whose tumor was reduced by more than half of its original size received a full course of chemotherapy and radiation given simultaneously. Patients whose tumors did not respond were referred for surgery.
Fifty-four of the 66 participants responded to the initial chemotherapy. Of that group, 62 percent are alive today without evidence of cancer, and 73 percent fully preserved their organs.
Participants whose cancer did not respond to the chemotherapy and radiation went on to receive surgery. The researchers found that even with surgery, only 4 of 11 patients survived.
"For most patients, the chemoradiation was very effective. But a subset of patients still do not do well. Our next step was to look at the biomarkers to see if we could determine which patients were responding to treatment, based on the tumor biology," said Dr. Carey, who is also associate chair and professor of otolaryngology and pharmacology at the U-M Medical School.
By looking biopsies taken before treatment, the researchers found 64 percent of the tumors were positive for high-risk strains of HPV. Almost all of the HPV-positive tumors responded to initial chemotherapy and 78 percent of those patients survived with their organs preserved. Of the HPV-negative study participants, only four of 15 survived. In addition, the researchers found that patients whose tumor expressed a marker called EGFR had worse outcomes.
"The combination of markers was an important indicator. Patients whose tumors expressed high levels of EGFR did poorly. But those who had high EGFR and were also HPV-positive had some protection. Patients with high EGFR and low HPV fared the worst. This is a step in the direction of affecting future treatment," said Bhavna Kumar, a research laboratory specialist who was the lead study author.
The researchers also found that tumors with low expression of a protein called p53, combined with high expression of another protein, BCLXL, also had poor outcomes. These markers provide additional targets for potential new therapies.
About 35,300 Americans will be diagnosed with head and neck cancer this year, according to the American Cancer Society.
Additional study authors were Julia S. Lee, Gregory T. Wolf, Kitrina G. Cordell, Jeremy M.G. Taylor, Susan G. Urba, Avraham Eisbruch, Theodoros N. Teknos, Douglas B. Chepeha, Mark E. Prince, Christina I. Tsien, Nisha J. D'Silva, Carol R. Bradford, Huong H. Tran, Kun Yang, David M. Kurnit, Joshua A. Bauer, Nancy Wallace, Tamara Miller, and Heidi Mason.
Funding for the studies was from the National Institutes of Health, a U-M Specialized Program of Research Excellence (SPORE) grant in head and neck cancer, the U-M Comprehensive Cancer Center, and the State of Michigan.
|
Return to 2008 News Archive Page
|
July 2: New Ear Tube Device Helps Treat Infections Faster, U.S. News
Stainless steel rod reduces time of anesthesia, number of instruments inserted into canal
WEDNESDAY, July 2 (HealthDay News) -- A new device meant to make surgical treatment of ear infections safer and faster has been developed by a University of Virginia team.
The device, which combines three of the tools used in the surgical implantation of ear ventilation tubes, has shown promising results in clinical trials.
Each year in the United States, about 2.2 million children need to have tubes implanted for the treatment of chronic ear infections (otitis media) with effusion. The tubes are inserted to relieve pressure and fluid build-up.
"Currently, the procedure is tedious," team co-leader Shayn Peirce-Cottler, an assistant professor of biomedical engineering at the university's School of Engineering and Applied Science, said in a prepared statement.
"Small tubes two to three millimeters in diameter are inserted using four different instruments. The new insertion device facilitates safer, easier insertion. It reduces the time of anesthesia and reduces the number of instruments inserted into the ear canal, which, in turn, reduces the risks for the patient," Peirce-Cottler said.
The new stainless steel device consists of hollow rod with a collar that holds the ear tube in place. This allows the surgeon to apply force to insert the tube with one motion.
"The more times that you put an instrument in and out of the ear canal, the greater the risk of damage to surrounding structures, the wall of the ear canal, or even the tympanic membrane," team co-leader Dr. Bradley Kesser, an ear-nose-throat surgeon at the University of Virginia Health System, said in a prepared statement.
"The skin of the ear canal is some of the thinnest skin in all of the body, so one little touch on this skin, and it starts to bleed. If you have bleeding in the ear canal, you can't see anything. So then, you have to remove the blood and get a clear surgical field before you can safely put the tube in," Kesser explained.
More information
The American Academy of Otolaryngology--Head and Neck Surgery has more about ear tubes.
|
Return to 2008 News Archive Page
|
July 3: New Combination Of Tests Measures Child's Ability To Taste And Smell, ScienceDaily
Researchers have developed a series of tests that for the first time accurately measure the normality of taste (gustatory function) and smell (olfactory function) in young children, according to a new study published in the July 2008 edition of Otolaryngology -- Head and Neck Surgery.
The study, authored by researchers in Australia, determined that most children age 5-7 can identify a majority of 16 different test odorants that can measure smell function, along with four common tastes that describe taste function.
The identifiable odorants include: floral, orange, strawberry, fish, chocolate, baby powder, paint, cut grass, sour, minty, onion, Vicks Vapo-rub, spicy, Dettol (liquid antiseptic), cheese, and gasoline (petrol). The identifiable tastes represented each section of the tongue palate: salty, bitter, sour, and sweet. As a result, a series of three tests, the Wholemouth Taste Test, the Regional Taste Test, and the Odor Identification Test, are able to offer sufficient information to diagnose the level of function of both taste and smell in young children.
Previously, the ability to measure a child's capacity for smell and taste was neglected across the world because no suitable clinical test existed (many similar tests used for adults are too lengthy for a child, and test for smells and tastes that may not be well known to the majority of children). With the development of such a test, physicians can now consider chemosensory dysfunctions in a diagnosis. The loss of taste and smell can be caused by a number of diseases and medications, along with disorders ranging from nasal and sinus disease to head trauma to middle ear surgery and infections.
The study's authors are David G. Laing, PhD; Carolina Segovia, MSc; Therese Fark; Olga N. Laing; Anthony L. Jinks, PhD; Julia Nikolaus; and Thomas Hummel, MD. They are associated with the University of New South Wales, in Kensington, Australia.
|
Return to 2008 News Archive Page
|
July 6: Tinnitus patients have a friend in zebrafish, Chicago Tribune
Researcher seeks a solution with help from aquatic allies
Professor Ernest Moore hasn't named the zebrafish in his Northwestern University laboratory, where he researches drugs for tinnitus (ringing of the ears). But if he did, he says, he would name his favorite one Rose, after one of his mentors.
"Professor Rose not only trained me in audiology, but taught me not to expect hearing problems to get a lot of attention or funding," recalled Moore. "When you have hearing problems, you're not bleeding. You look just fine. It is a widespread but hidden problem."
Moore should know. He has tinnitus himself, he says, thanks to his childhood hunting expeditions and his years in the military leading to too many guns fired too close to his ears.
Now, with a little help from his gilled buddies in the lab, Moore is one step closer to helping fellow tinnitus sufferers with a drug. Later this year, he plans to test his trial drugs on tinnitus patients through clinical trials with physicians. Some of the drugs, he notes, are already on the market for other purposes.
Moore uses zebrafish for several reasons. "They have inner ears like ours, we know a lot about zebrafish genomes, they are transparent and they are prolific egg-layers," he said. Best of all, they tell him when he induces tinnitus in their inner ears by swimming erratically. Then, he can tell when a drug resolves the condition.
According to the National Institute on Deafness and Other Communication Disorders (NIDCD), about 25 million adult Americans suffer from tinnitus, sometimes called "head noise." Patients hear noises that don't exist, ranging from whooshing to screeching. It can be caused by a head injury, loud noises, age, atherosclerosis, tumors or certain antibiotics. High blood pressure, nicotine use, overuse of salt or caffeine, stress and loud noises can make tinnitus worse for constant sufferers or trigger it for on-and-off sufferers.
So many veterans are returning from the Middle East with tinnitus that the Department of Veterans Affairs says it is the No. 1 service-related disability among those who have served in Iraq and Afghanistan. In addition to the vets, Baby Boomers are now adding presbycusis (gradual hearing loss resulting from aging) to damage caused by too-loud rock music, giving them an ideal recipe for tinnitus.
The typical tinnitus sufferer sees many doctors before finding relief or giving up, says Dr. Alan Micco, assistant professor of otolaryngology at Northwestern University. "Most of the tinnitus patients I see have already been told they have to live with it," he said. "There is no cure, but there are many things we can try."
The most common treatment is masking, which means using a "white noise" such as from a fan, to mask the ringing during the night when it keeps patients awake. Or, patients use a tinnitus masker, which looks like a hearing aid but delivers constant white noise, as needed. Sometimes treating some of the triggers helps, such as taking antidepressants to reduce stress.
For severe cases, doctors in clinical trials are trying brain surgery.
"This is the last resort," said Micco. "But it can be that bad."
Jon Passini of West Chicago says he understands. After an ear infection left him with severe tinnitus and hyperacusis (extreme sensitivity to noise), he visited several doctors. They prescribed steroids and, when those didn't work, told him there was nothing else they could do for him.
Passini's case was so bad that he had to withdraw from most activities. "The normal sounds my grandkids made were so loud, it was like a knife sticking in my ear," he said. "I went from a very outgoing person to an introvert."
So a doctor friend led Passini to audiologist Jill Meltzer at the North Shore Audio-Vestibular Lab in Highland Park and Long Grove, where he tried neuromonics. He wore a MP3-like device that delivered customized auditory stimuli, embedded in music, for about three hours a day until the noise subsided. "Your brain learns to ignore the ringing," Passini explained. Now, he wears it occasionally, he said, "for maintenance." The treatment gave him his life back, he says.
Passini encourages other tinnitus sufferers to explore every option. "What doesn't work for one person may work for someone else," he said. "Don't give up."
|
Return to 2008 News Archive Page
|
July 7: Heading off hearing loss, Star Tribune
MP3 players with their earbud-style headphones increasingly are linked to hearing loss. Protect your ears by following experts' advice.
By TONY GONZALEZ
Samantha Harper and Francheska Salcedo wait for their bus at S. 6th Street along Nicollet Mall, all a-dangle with hoop earrings, purses and the white cords of their MP3 player headphones.
"Right now, it's up all the way," says Harper, 19, of Minneapolis, referring to her MP3 player's volume, which competes with the urban din at the corner. "It depends on my surroundings. If I were at home, it wouldn't be."
"I listen to my music all day, every day," says friend Salcedo, 18, also of Minneapolis, whose headphones crackle with music. "I've read about headphones causing pressure on the eardrums, but I can't live without my music," she says.
So it goes at bus stops and beyond, as headphone users balance their love of listening with thoughts of the increasingly frequent hearing studies that call out earbud-style headphones as harmful to hearing. Local audiologists say solid data are tough to come by, but that anecdotally, hearing loss seems to be rising for listeners of all ages.
New headphones touted as being safer may help, but common sense still trumps technology for protecting your hearing, the experts say.
"At the end of the day, all that matters is the length of time exposed to a certain level of volume," said Dr. Nissim Khabie, medical director of Ear, Nose & Throat Specialty Care, with several clinics in the Twin Cities area.
He has cautioned some patients and parents of young earbud users, but awaits more hard data.
"The general rule of thumb is, if you're done with something and there's ringing [in the ears], you've done some damage. And it accumulates over time. Once you've done that damage, you're susceptible to even more damage," Khabie said.
According to the American Academy of Otolaryngology, volume from MP3 players has been measured at 115 decibels -- well over the 85-decibel danger level. Some doctors recommend the "60/60 Rule" for safe listening: Use a portable music player for no more than 60 minutes a day, with headphones at 60 percent volume.
|
Return to 2008 News Archive Page
|
July 10: Stunning return and a vital vote, Boston Globe
By Susan Milligan
Globe Staff
WASHINGTON - Senator Edward M. Kennedy, under treatment for brain cancer, made a brief, triumphant return to the Senate yesterday, stunning fellow lawmakers with a surprise appearance to vote on a critical Medicare bill that is central to the Massachusetts senator's healthcare agenda.
His Senate colleagues had not expected to see Kennedy, who is being treated with radiation and chemotherapy, for several more weeks or longer. Some feared that Kennedy, 76, would never be well enough to return to the chamber where he has served for nearly 46 years.
But with just minutes to go in a vote to protect Medicare payments to doctors, Kennedy, beaming and laughing, walked through the back doors of the Senate chamber and gave Democrats the vote they needed to stop a Republican filibuster and pass the bill.
The entire chamber erupted in cheers and applause as Kennedy - flanked by his son, his best friend, the Democrats' presidential nominee, and his fellow Massachusetts senator - strode into the well of the Senate floor. Lawmakers from both parties mobbed him; most shook Kennedy's hand and a few pecked him on the cheek.
Then, Kennedy gazed up at the Senate clerk to do what he has done many thousands of times since he arrived in Washington in 1963, but has been unable to do for more than a month: vote.
When the din had subsided, Kennedy raised his arms jubilantly and cast his first vote, signaling not only a victory for the legislation, but a temporary win over a deadly disease that has kept him from the job he loves since he was diagnosed May 20.
"Aye," he yelled, his arms high in the air.
Again, the packed chamber - filled with senators, staff, and spectators, including his wife, Victoria Reggie Kennedy, and his niece, Caroline Kennedy - exploded in celebration at the extraordinary moment.
"It was just a rush of emotion. We love the man," said Senator Richard J. Durbin, Democrat of Illinois and the majority whip. "The fact that he would make the sacrifice, and take the risk of coming here, means so much."
"It was so Ted Kennedy to decide to come, and to cast the deciding vote on an issue he cares so deeply about and that he identifies with," said Senator Susan M. Collins, Republican of Maine. "Everybody on both sides [of the aisle] had tears in their eyes," she said.
The bill would void a GOP effort to cut Medicare payments to doctors by 10.6 percent. It also would weaken subsidies to health maintenance, discouraging seniors from abandoning Medicare for private HMOs.
Kennedy, who left quickly after the vote, told reporters afterward that he flew down from Massachusetts yesterday afternoon because he did not want to miss such an important vote on Medicare, a program he has fought to protect for decades. Kennedy's face seemed slightly bloated but he appeared otherwise well, with his shock of white hair and broad smile intact.
"I'm feeling fine - a little fatigued once in a while," Kennedy said as he left the Capitol.
The visit was an unusually well-kept secret on gossipy Capitol Hill, with most lawmakers unaware Kennedy was en route until he actually arrived in the building.
The dramatic appearance kept Republicans from revamping their political strategy to defeat the bill; expecting Kennedy to be absent, the GOP leadership had no time to scrounge for an extra vote to kill the bill when he arrived at the last minute.
Until Kennedy showed up, Senate Democrats had not been able to muster the 60 votes needed to stop a Republican filibuster. With his vote, nine additional Republicans came on board, ending the filibuster, 69 to 30. The measure passed and was sent to President Bush's desk yesterday afternoon.
Senate Democrats say they have enough support to override a potential presidential veto.
Kennedy had been following the Medicare bill from Cape Cod, and was disappointed to see that Democrats failed to pass the measure by one vote late last month, sources close to the senator said. Kennedy began considering making the trip for a second effort to pass the bill, and had several conversations with Senator Harry Reid, the majority leader, in the past week.
The senator's doctors "weren't terribly pleased" with Kennedy's decision to make the trip down to Washington, said Senator Chris Dodd, a Connecticut Democrat and one of Kennedy's closest friends. "But Ted is not in the habit of listening to doctors, so he surprised us all and he came here."
"Ted Kennedy wasn't going to let Medicare be destroyed," said Reid, a Nevada Democrat. "So he rose to the challenge, came to work, and his vote made the difference."
Kennedy arrived surreptitiously through a side entrance of the Capitol, waiting in Reid's office until the vote. He was escorted into the chamber by Dodd; US Representative Patrick Kennedy of Rhode Island, the senator's son; Senator Barack Obama of Illinois, the presumptive Democratic presidential nominee; and Senator John F. Kerry.
Obama was so distracted by Kennedy's presence that Durbin had to nudge him, reminding him to vote on the Medicare bill.
Kennedy stopped first to shake the hand of Senator Robert C. Byrd, Democrat of West Virginia and the oldest and longest-serving member of the Senate. Byrd, who was in a wheelchair, had staked out the chamber door to greet his good friend.
Overwhelmed with emotion, Senator Patrick J. Leahy, Democrat of Vermont, approached Kennedy.
"We miss you, Ted," Leahy said. He noted later that Kennedy had replied with characteristic determination: "I'll be back," he said.
|
Return to 2008 News Archive Page
|
July 22: Memory Problems Tied to Sound Processing Disorder, HealthDay News
Inability to filter out background noise may be indicator of mild impairment, study says
Mild memory impairment may be associated with a sound processing disorder called central auditory processing dysfunction, say U.S. researchers.
People with the disorder have difficulty hearing in complex situations with competing noise, such as making out what one person is saying while many people in a group are talking at the same time.
"Central auditory processing dysfunction is a general term that is applied to persons whose hearing in quiet settings is normal or near normal yet who have substantial hearing difficulty in the presence of auditory stressors such as competing noise and other difficult listening situations," according to background information in the study. "Central auditory testing is important in evaluating individuals with hearing difficulty, because poor central auditory ability, per se, is not helped by amplification and requires alternative rehabilitation strategies."
Previous research has found that people with Alzheimer's disease and other types of dementia have central auditory processing dysfunction.
This new study by Dr. George A. Gates, of the University of Washington, Seattle, and colleagues included 313 people, average age 80, taking part in a dementia surveillance program that began in 1994. Of the participants, 17 had been diagnosed with dementia, 64 had mild memory impairment, and 232 had no memory problems.
Three tests were used to assess the participants' central auditory processing. In one test, nonsense sentences were read over the background of an interesting narrative. In the other two tests, separate sentences or numbers were read into each ear simultaneously.
"These central auditory processing test paradigms evaluate how well an individual manages competing signals, a task that requires adequate short-term memory and the ability to shift attention rapidly," the researchers noted.
Participants with dementia and mild memory impairment scored significantly lower on the tests than those without memory problems. The findings were published in the July issue of the Archives of Otolaryngology -- Head & Neck Surgery.
"Central auditory function was affected by even mild memory impairment," the researchers wrote. "We recommend that central auditory testing be considered in the evaluation of older persons with hearing complaints as part of a comprehensive, individualized program to assist their needs in both the aural rehabilitative and the cognitive domains."
|
Return to 2008 News Archive Page
|
July 24: Gates, Bloomberg Pledge $500 Million For Antismoking Programs, The Wall Street Journal
By ROBERT A. GUTH
The Bill and Melinda Gates Foundation and New York Mayor Michael Bloomberg pledged to invest $500 million in antismoking programs in developing countries, building on a continuing effort by Mr. Bloomberg to end what he called on Wednesday "the global tobacco epidemic."
Microsoft founder Bill Gates and New York City Mayor Michael Bloomberg announce a partnership to get people to quit smoking.
The effort gives Mr. Bloomberg a powerful ally in his tobacco fight, which started in 2002 in New York City. That effort, which includes smoking bans in restaurants and workplaces, has led to 300,000 fewer smokers in New York City than in 2006, Mr. Bloomberg said at an announcement of the funding in New York.
Success in New York "helped convince me to take on the global initiative," Mr. Bloomberg said.
Under the plan, Mr. Bloomberg's philanthropy over the next four years will increase by $250 million his earlier pledge of $125 million to fund antismoking and tobacco-control efforts world-wide.
The Gates Foundation said it will spend $125 million on similar efforts over the next five years, with $24 million of that going into Mr. Bloomberg's three-year-old antismoking program, the Initiative to Reduce Tobacco Use.
The funds will be used to promote tobacco-control programs, including media and education campaigns, as well as programs to help people quit smoking and efforts to promote higher taxes on tobacco products.
The pledge is the Gates Foundation's first funding of antismoking programs and fits into its broader global-health programs. The Gates Foundation, the world's largest private philanthropy, with an endowment of nearly $40 billion, is a major backer of programs to combat AIDS, tuberculosis and malaria.
The funds are a huge addition to the relatively small sums spent thus far on tobacco-control programs in developing countries, where smoking is on the rise. In China, per-capita cigarette consumption rose 11% from 2001 to 2006, and the country is home to a third of the world's 1.3 billion smokers, according to researcher Euromonitor International.
The funding could rankle tobacco companies, which count on developing countries for much of their growth.
British American Tobacco PLC isn't opposed to the funding and believes people should have an "informed view of the potential dangers" of smoking, said Catherine Armstrong, a spokeswoman for London-based BAT. "We have consistently supported the harm-reduction goals of governments and many in the public health community," said Marija Sepic, a spokeswoman at Philip Morris International Inc.
The Gates funding will largely be focused in Africa, which foundation officials say has relatively low tobacco use compared with Asia. "We can catch it at an early stage" in Africa, Mr. Gates said.
|
Return to 2008 News Archive Page
|
July 24: Head And Neck Cancer: Quick Way To Determine If Cancer Has Spread, ScienceDaily
For patients with head and neck cancer, accurately determining how advanced the cancer is and detecting secondary cancers usually means undergoing numerous tests - until now. New Saint Louis University research has found that the PET-CT scanner can be used as a stand-alone tool to detect secondary cancers, which occur in 5 to 10 percent of head and neck cancer patients.
The study findings, which were presented on July 22, at the 7th International Conference on Head and Neck Cancer in San Francisco, Calif., will streamline care for head and neck cancer patients allowing them to begin treatment earlier, says Michael Odell, M.D., assistant professor of otolaryngology at Saint Louis University School of Medicine.
"There has been a lot of confusion about the best ways to evaluate head and neck cancer patients to see if their cancer has spread," said Odell, the study's primary author.
"Traditionally, doctors used many different tests, such as chest X-rays, CT scans, ultrasounds, bone scans and blood work. Patients went through too many unnecessary procedures because there was no real consensus on the best way to evaluate them."
According to Odell, when choosing the appropriate treatment plan for head and neck cancer patients, it is critical to accurately stage the primary cancer and detect secondary cancers. Odell's research shows PET-CT scanning can replace all the other traditional tests.
Using the PET-CT scanner is not just a time saver, though; it also can be a life-saver.
"We all know that the time from when your doctor sees you to the time when you initiate treatment is important to outcomes," Odell explained. "So minimizing the number of tests is definitely important from an outcome standpoint."
To determine if PET-CT scans were as effective as the tradition tests, Odell and his colleagues evaluated the scans of 77 patients and found four to contain secondary cancers and one to have an additional primary cancer. The study's rate of detection - 7 percent - was inline with the results of previous studies, which range from 5 to 10 percent.
The PET-CT, which is an acronym for position emission tomography/computed tomography, combines two the benefits of both tests to offer unsurpassed diagnostic capabilities in pinpointing cancer. The PET scan is a highly sensitive scan that detects the growth of cancer cells, while the CT scan provides a detailed picture of the internal anatomy and the location of the growth.
While the current study focused exclusively on head and neck cancer patients, Odell says that it is likely that it will be applicable to other cancers.
|
Return to 2008 News Archive Page
|
|
|
|
|
|
|
|
100 South Ellsworth Avenue, Suite 308, San Mateo CA 94401
tel 650/344 6896 fax 650/344 2794
|
|
805 Veterans Boulevard, Suite 115, Redwood City CA 94063
tel 650/369 1619 fax 650/474 2997
|
|
|
|
|
|
|
