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U N I V E R S I T Y O F M I C H I G A N CYSTIC FIBROSIS CENTER Cystic Fibrosis Center Department of Pediatrics C.S. Mott Children’s Hospital Ann Arbor, MI 48109-5212 734-764-4123 734-936-7635 (FAX) NEWS NOTES AND SPRING 2012, VOL. XXVI NEWS FROM THE FRONT NEW UNIVERSITY OF MICHIGAN C.S. MOTT CHILDREN’S HOSPITAL Same Infection Control Policy By Samya Nasr, MD We celebrated the opening of the new University of Michigan, C.S. Mott Children’s Hospital on December 4, 2011. The new hospital provides a major improvement in the facilities over the old hospital that is over 40 years old. The new hospital is a state-of-the-art hospital. It is designed with patients and their families as the center (patient and family centered care). It Samya Nasr, MD provides private rooms for all our Director, Cystic Fibrosis Center patients. The pulmonary floor is on the 12th floor of the building with a beautiful view from every room. The rooms are designed not only for patients comfort but also for their families comfort with input from the patient and family centered care committee. The clinic facility has moved to the new hospital building as well. The pulmonary clinic is located on the 6th floor of the outpatient clinic building. Among amenities that the new hospital provides is a cafeteria for patients’ and families’ convenience. With these changes, the infection control policy is in place to prevent transmission of infection between patients. It is as follows: INSIDE THIS ISSUE... FOR HOSPITALIZED PATIENTS: 1. CF patients must wash/sanitize their hands before leaving the room and upon returning. Frequent hand washing/sanitizing should be encouraged. 2. Masks should be worn by CF patients while outside of their rooms in the Hospital, due to potential contact with sick patients or other CF patients. 3. No visitation between CF patients, unless they are siblings. 4. Patients should not go to play area or any common area. Please see below for Child Life Guidelines for more details. With the infection control policy in place, we were able to reduce/ eliminate patient-topatient transmission of infection and improve quality of life for our patients. 5. A sign designating the specific type of precautions (i.e. Contact for BC or Droplet for viral infection shall be placed on the patient’s door). 6. CF patients should only be in the hallways for travel to and from tests, appointments, etc. 7. Visitors / sibling with CF should not use activity rooms, park areas or the lobby’s play areas. continued on page 6 News From the Front . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 1 Adult Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 5 What’s News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 3 Clinician’s Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 7 Parent to Parent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 4 CFC Staff and Donors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 8 NEWS AND NOTES | VOL. XXV | SPRING 2012 NEWS FROM THE FRONT Personalized Medicine for Cystic Fibrosis By Richard H. Simon, MD The Adult CF Care Program: Dr. Ojo, Dr. Sisson, Dr. Grum, Dr. Coffey and Dr. Simon More and more frequently, the phrase “personalized medicine” is being used to characterize a modern approach to medical care. The idea of personalized medicine is that treatments should be carefully selected to fit the special needs of a patient. In one sense this in not a new approach. Care providers have always paid attention to how a disease affects each patient and have designed treatments appropriate for that person. But what is different now is that increasingly, treatments are being selected based on a person’s genetic makeup. This practice is being used a lot in the area of cancer therapy. It is known that the genes within cancer cells have undergone mutations that cause the cells to grow and spread uncontrollably. Furthermore, even for cancers of a single type, there are differences between patients in what mutations their tumors carry. These differences turn out to be important because now we know that some cancer treatments work only on tumors that have certain mutations. So, practicing personalized medicine for cancer patients means analyzing the DNA of their tumors for specific mutations and choosing the therapies that will work best on their tumors. For cystic fibrosis, knowing a patient’s CF mutations has already helped doctors choose 2 treatments. We now know that some people with CF have mutations that allow them to digest their food without taking enzymes, so we don’t prescribe pancreatic enzymes for them. But now, cystic fibrosis care has taken a giant step forward in the area of personalized medicine. On January 31, 2012, the Food and Drug Administration (FDA) approved a drug for patients who have a specific mutation in their cystic fibrosis genes, namely the G551D mutation. [The designation “G551D” means that a change has occurred in the 551st amino acid of the CF protein. The 551st amino acid should be a glycine (G) but the mutation causes it to be replaced by an aspartate (D).] This single amino acid change causes the CF protein not to function correctly and leads to many of the problems that occur in people with CF. Now, with heavy financial support from the Cystic Fibrosis Foundation, Vertex Pharmaceuticals has developed a drug that can be truly considered a personalized medicine. It was designed specifically for CF patients who have the G551D mutation. The drug, which was originally called VX-770 during its early testing, has now been given the generic name “ivacaftor” and the brand name “Kalydeco” (pronounced kuh-LYE-deh-koh). The drug corrects most of the problems caused by the G551D mutation. People with CF who participated in the clinical trials of ivacaftor have seen their sweat tests return toward normal. They also had large improvements in pulmonary function test results and increased body weight. We are recommending that all people with CF should have their CF mutations analyzed to see if they have the G551D mutation. This mutation was first identified in 1990, so anyone tested after then would know if they have a G551D mutation. Vertex is now planning on studying whether there are other CF mutations that may be helped by ivacaftor. Unfortunately, when used alone, ivacaftor does not help patients with deltaF508, the most common CF mutation. However, it may help when combined with other research drugs that are undergoing clinical study. Another example of personalized medicine for CF is ataluren (PTC124), a drug designed for people with CF who have a “stop” mutation in their CF genes. Stop mutations cause only part of the CF protein to be made. [Any mutation whose name ends with an X is a stop mutation, for example G542X.] Ataluren allows the full length CF protein to be made, so it can work properly. Ataluren is currently undergoing phase III clinical trials. In conclusion, the expansion of personalized medicine into CF treatment is an important milestone. If ivacaftor is any indication of the future, there is good reason for optimism. Personalizing medicine will allow doctors to select for each patient those treatments that will have the greatest chance to help them. WHAT’S NEWS NEW STAFF IN SOCIAL WORK In July 2010, we welcomed Elsa Larson Weber to our Social Work team. She has been a part of the University of Michigan development community for the past three years and has experience volunteering over the past year with St. Joseph Mercy Hospital. She worked closely with the clinical bereavement staff from the Home Care and Hospice Elsa Larson Weber team. She also has worked closely with SOS Community Services in Ypsilanti, Michigan as a Children’s Services Case Manager. She is excited to work with the families, staff and Family Advisory Board at the UM CF Center. We are very excited to have Elsa join the Social Work team. ADHERENCE STUDY UPDATE Our CF Center has been involved in the I Change Adherence & Raise Expectations (iCARE) Study (developed through John Hopkins and the University of Miami), with patient participation since June 2010. This is one of the largest randomized-control trials that has been done with CF, focusing on patients ages 11 – 21. At our center, we have 36 patients involved, with a total of 635 patients across the country. So far, this study has helped show gaps in knowledge across the country that can help all of us improve in CF education and treatment. The study mainly consists of annual assessments (completing baseline assessments, and then tracking progress and increasing knowledge over the next 2 years plus), as well as problem solving sessions during regular clinic visits. It is from this study that the PFT lab staff recognized the value of every patient having an annual assessment/review. During the problem solving sessions that Social Work facilitates, families have helped prove that more heads are better than one, and thinking outside of the box has helped come up with many different fun and creative solutions – that seem to actually work! Problem solving sessions focus on breaking down goals into smaller more manageable steps and brainstorming creative solutions to help have success in adherence. The idea of the study is to have the patient in the driver’s seat with the parent/ caregiver(s) and siblings/other family members supporting and assisting the patient. We have received feedback that some families have used these same techniques for other areas of their lives (i.e. helping with homework, chores, other expectations). And, better yet, families have helped teach us ideas that we’ve shared with many families outside of the study, and of all ages. THE ANNUAL RESPIRATORY ASSESSMENT In the past year, you may have been contacted by Kim in the pulmonary lab to schedule an “annual respiratory assessment” and wondered what this is and why you are being asked to do it. We’d like to give you a bit of background about the assessments and why they are such a valuable tool. Part of the iCARE study required that participating families take part in an assessment. From the information we gathered, we determined that this kind of assessment would be most beneficial to all of our families. At the same time we were networking with other CF centers and learned that assessments have become a standard of care in most CF centers in the United States. We developed a questionnaire regarding airway clearance, equipment care, cleaning techniques, medication knowledge, and other things that are a part of your day-to-day life. We ask that you bring in your vest compressor, your vest, your nebulizer compressor, spacers, Acapella, nebulizer cups, and anything else that you use for your child’s respiratory care. At the evaluation we will look at all of your equipment, evaluate your airway clearance techniques, adjust vest settings and check the size. We will talk about proper cleaning of equipment, be sure that you are using the best nebulizer for the medications your child is taking, help you get new supplies if you need them, and make sure that you have everything you need to provide the best care for your child. CYSTIC FIBROSIS FAMILY ADVISORY BOARD We are excited to announce the U-M Cystic Fibrosis Center Family Advisory Board was restarted at the end of January. The Family Advisory Board is instrumental in the improvement in CF Center Programs using the patient’s and their family’s experiences to drive quality improvements at the CF Center. The U-M CF center is committed to patient and family centered care and wants to ensure our Family Advisory Board serves as an advisory resource for the center, providing constructive input and assistance to continually improve our CF center. 3 NEWS AND NOTES | VOL. XXV | SPRING 2012 PARENT TO PARENT Lessons learned: A Parent’s Perspective at the North American Cystic Fibrosis Conference By Carole McGillen As a parent advisor attending the North American Cystic Fibrosis (NACF)conference for the first time, my reactions ranged from feeling overwhelmed, amazed, grateful and inspired. Overwhelmed – The wealth of resources and education available from the speakers, exhibitors and online was amazing. The challenge we have in follow-up to the conference is to work with Connor (10 ½) with CF, Brennan (6 ½) and Rory (13) with mom Carole our advisory group and care teams to determine how we can and dad Tim integrate best practices and lessons learned. There is a fine I saw how many different While for some parents this might be ‘old line that we do not want to disciplines across the world are cross with providing too much working to improve the lives of news’; for others, reinforcing and improving information when parents and those with cystic fibrosis. the role and relationship as ‘partners’ with children are not ready. all members of the health care team can have Grateful – I was not only a significant impact on the health of our One area where this is thankful for the opportunity children. Patients and families need to take an somewhat sensitive surrounds to attend this conference but the issue of advanced care extended this gratitude when I active role to continue to improve care. Our planning. As a parent, if anyone fully recognized how broad the active involvement can have a positive impact, addressed the issue of end of support is in finding a cure for whatever role we are able to take…. whether it life care planning, it can be this disease. It truly takes more is as patient advisor, working on a committee, perceived extremely negative than ‘a village’ for a cure and I (giving up hope). As difficult am convinced that the combined participating in clinical trials, or closely as it was to sit through this efforts of the Cystic Fibrosis tracking responses to treatments. We all can session as a parent, I recognized Foundation (CFF) with our care make a difference by recognizing we are not that all programs across the team at UMHS, we are receiving alone in our efforts to provide the highest country struggle with this issue. the best care for our children. Current recommendations from quality life for those with cystic fibrosis. the experts at the conference Inspired – The best care feel these discussions should be involves informed decision part of routine care with annual visits, hospitalizations and new making with our care team..… treatment regimens are very interventions. We as parents need to be open and help with these complicated and we need to work together to provide the best conversations. outcomes. Amazed – While I have been able to attend conferences in my own profession, I was still taken aback by the wealth of information and industry support for cystic fibrosis. Visiting the poster sessions, 4 ADULT PERSPECTIVES TIPS FOR COLLEGE BOUND CFERS By Anna DiPirro Hi! My name is Anna DiPirro and I am a 20 year old college student. Being diagnosed with CF as an infant I have learned to live with the disease. Life is always slightly more difficult than the average person. However, overall adherence with treatments and exercise has been key to staying healthier, longer. Now as a college student I know firsthand that this isn’t always easy! My college transition as far as healthcare was at first fairly simple. As time went on though, homework became my priority. Exercise, my vest, sleep and spending time with friends fell by the wayside. School work was my priority and although I wouldn’t call myself a perfectionist, I do have high standards when it comes to something that is being graded. During the time of my transition I still made sure to do my breathing treatments, I could do them while doing my homework. However, I no longer did my vest or exercised much at all. Any exercise was a weekly game or two of co-ed softball or some tennis a few times a week in the Fall. Once it started getting colder those irregular exercises turned into an even Anna DiPirro more irregular “weekly” volleyball. And this quickly turned into an “if I’m not too busy” volleyball game every other week or once a month. Instead of my vest I became content with just doing my acapella. I quickly learned that not only was I being graded by my teachers, but my body too. My decrease in treatment and exercise adherence along with previous problems with lower lung functions took its toll. My next year and a half in college were filled with hospital visits and IV meds. My body was giving me an “F,” the worst “F” I could ever get. Not only was my body failing, but I couldn’t function for school. I wasn’t always able to drive myself to school, do my homework, or sometimes, even attend class. However, I had joined an adherence study this previous summer. This study helped me get my healthcare back to where it needed to be. It became a priority for me again and with much help I was able to find time in my already busy schedule for the treatments and exercise that I had been neglecting. It has been hard trying to fit in treatments, school, and a job into a working schedule. I’m slowly making it work and hope to reach this goal my first month back to school. Oh, and my friends! During school I don’t have much time to spend with friends, but I use the time I do have. At the beginning of the semester I sit down and make a schedule that allows me to spend time with friends on the weekends. My friends are all in college too and understand how hectic college life can be. They’ve also known from early on that I have things I have to do with my health that makes my schedule even more crazy. In order to hang out they know it will probably have to be a movie on a Saturday night at my house while I do my treatments. They understand this though and we make the most of it. Okay, so now to my tips for college-bound CFers: (1) Work out a schedule at the beginning that will make doing treatments and exercise easier to fit in everyday. This is a must or everything else will fail. Also, it may seem obvious, but I have learned the hard way that you can’t just get up and run out the door in the morning without sacrificing your treatments. You must learn to adjust your schedule without omitting treatments. (2) Know your limits. If a paper usually takes you a day or so to complete, don’t try to fit it into an hour or two. Don’t procrastinate! You’ll only become stressed and frustrated, and (3) If you find it hard to exercise in the winter because of the cold, invest in a gaming station and get interactive games that will get your heart beating. I challenge all CF patients (myself included) to fight this disease with exercise and treatment adherence. There are many resources to fight this disease and to create a better and healthier life. 5 NEWS AND NOTES | VOL. XXV | SPRING 2012 Great Strides Walk Fundraising Events Same Infection Control Policy continued from page 1 Looking for more ways to make a difference in the CF community? Join the Cystic Fibrosis Foundation at one of their annual Great Strides walks. Great Strides is the Foundation’s largest, national, fundraising endeavor and offers individuals a chance to raise vital funds and much needed awareness for cystic fibrosis. Whether you join members of the U-M Care Center staff at the Ann Arbor walk site or choose one of our other 13 sites, you’re sure to make a difference. This year we’ll be walking towards a cure in: Ann Arbor Lansing/ Tri-City Birch Run DeWitt (Midland- Charlotte Port Huron Bay City) Detroit Rochester Toledo, OH Fremont, OH Sterling West Grand Blanc Heights Bloomfield Hartland For more information or to register your team please visit http://detroit.cff.org/ greatstrides or call (248) 269-8759. Other CF resources: Josh from Minnesota (an adult who has CF) has created a terrific website that may help educate your children. He has a “muppet” named Moganko who sings songs about doing therapy and having CF. Check it out: www.mogankoforcf.org/p/musicvideos.html For adults, he also has a blog where he writes about coping with CF: www.welcometojoshland.com 6 CHILD LIFE GUIDELINES FOR HOSPITALIZED PATIENTS: 1. School No more than one pediatric CF patient at a time may attend the school room. A mask and hand washing/sanitization are required for the patient. Tables in the school room should be disinfected prior to and after use by a CF patient. 2. Activity rooms, park areas, lobby play areas, and outdoor play area Pediatric CF patients should not play in park areas or in lobby play areas in Mott Hospital. Child Life staff are available to provide bedside activities. 3. Toys It is suggested that CF patients bring toys and games from home. However, CF patients may use toys, games and art supplies provided by Child Life staff if the items are disinfected before and after use. Items such as board games or cards that are not easy to disinfect, may be brought to a CF patients room by child life. They should be discarded or sent home with the patient. 4. Books and magazines CF patients should bring books and magazines from home. Child Life may provide new/never used books or magazines that will be discarded after use or taken home by the patient. 5. Special events Mott Hospital CF patients may participate in special events with Physician’s approval and with monitoring of infection control practices by a volunteer or staff member. Patients must wear a mask and perform hand washing/ sanitization prior to and following attendance at an event. FOR OUTPATIENT CLINICS: 1. Because of the limited space in the waiting area in the new clinic, we recommend that all patients continue to wear masks as soon as they arrive to the clinic area [masks will be provided by the front desk] to protect them from other sick contact. 2. To reduce the time spend in the waiting area, patients will be placed in exam or consult rooms as soon as possible. Siblings may be placed in the same room. 3. All CF patients will have their diagnosis listed in the comments section of the appointment scheduling screen for prompt identification. 4. Children with CF can bring toys from home to avoid playing with communal toys. With the infection control policy in place for the last 18 years, we were able to reduce/eliminate patient to patient transmission of infection and improve quality of life for our patients. Currently, the CF Foundation formed a committee to review and revise the CFF infection control policy. Once the new recommendation is available, we will revise our policy accordingly. CLINICIAN’S CORNER UPDATE ON BMI PROJECT By Amy Filbrun, MD In addition to working on our goals, we have been tracking our progress. At the start of our project, we set a specific aim to improve the median BMI by 20% for those who had BMI less than the 25th percentile. We actually saw a 32% increase in median BMI in the group that started out below the 25th percentile, in the first year of The Pediatric CF Care Team: Back row from left to right: Dr. Saba, Dr. Popova, Dr. Arteta, Dr. Filbrun, Dr. Keaton, our project. As seen in the graph Dr. Hershenson, Dr. Hassan; Front row left to right: Dr. Lumeng, Cathy Boehle, RN, Dr. Nasr, Dr. Ramirez, Dr. from our CF Foundation Patient Lewis, Sue Critz, RN, and Donna Genyk, LMSW Registry Report below, we have improved the overall BMI in This past year we continued to work hard on our project to improve our center over the past two years, but we seem to have leveled our center’s body mass index (BMI). However, we did so in a more off. We are now above the national average, with a mean BMI of formalized fashion, as part of the CF Foundation’s Learning and 53.6 percent for our center as a whole. We will continue to work to Leadership Collaborative: Self Study Action Guide Program. This improve the nutritional status of our center to hopefully reduce the program provided us with a coach and a study guide with the goal percentage of our population with low BMI, and to strive to be the of accelerating improvement in CF care. We got our whole team very best we can be. Much as we needed a whole team to participate involved, including the doctors, nurses, dietician, social workers, in this program, we consider all our patients and families part of psychologist, and a parent representative. For some of us, it was like the team, and we look forward to continuing to work together to learning a foreign language at first, as we learned about macro- and achieve these goals. microsystems, fish-bones, PDSA cycles, etc. Fortunately we had our coach that helped us. Also, some team members were more familiar with the concepts and they helped guide our team. We created a large story board to track our progress through the program, met regularly as a team, and had regular conference calls with our coach. During the past year, we were able to achieve several goals. We determined that there were access issues with supplements. Some of them were not covered by insurance. We were able to address these issues, and now have expanded the patient group who qualifies for supplements. Next we worked on providing written care plans at each visit. We felt that if we provided a care plan with recommendations regarding enzymes and supplements, it would be easier for families to follow those recommendations. We made this a priority, and saw a dramatic improvement over the course of the year. Finally, we are working on making sure everyone receives information about energy needs (how many calories are needed per day) as well as weight gain goals for the next visit. The weight gain goal was added to the plan. 7 NON-PROFIT U.S. POSTAGE PAID ANN ARBOR, MI PERMIT NO. 144 Cystic Fibrosis Center Department of Pediatrics L2201 Women’s 1500 E. Medical Center Dr. SPC 5212 Ann Arbor, MI 48109-5212 734-764-4123 734-936-7635 (FAX) T H E M I C H I G A N D I F F E R E N C E CFC STAFF Personnel Samya Z. Nasr, MD, Director, CF Center Richard H. Simon, MD, Director, Adult CF Center Amy Filbrun, MD, Associate Director, CF Center Mary Ball, MS, RN, Adult Program Coordinator Donna Genyk, LMSW, Pediatric Program Coordinator Julie Merz, LMSW, Clinical Social Worker Elsa Weber, LLMSW, Clinical Social Worker Manuel Arteta, MD, Pediatric Pulmonology Fauziya Hassan, MD, Pediatric Pulmonary Marc Hershenson, MD, Pediatric Pulmonology Toby Lewis, MD, MPH, Pediatric Pulmonology Carey Lumeng, MD, PhD, Pediatric Pulmonology Antonia Popova, MD, Pediatric Pulmonology Meghan Keaton, MD, Pediatric Pulmonary Fellow Ixsy Ramirez, MD, Pediatric Pulmonary Fellow Thomas Saba, MD, Pediatric Pulmonary Fellow Michael Coffey, MD, Adult Pulmonology Cyril Grum, MD, Adult Pulmonology Tammy Ojo, MD, Adult Pulmonology Thomas Sisson, MD, Adult Pulmonology Hope O’Leary, MS, RD, Nutrition Specialist Cathy Boehl, RN, Pediatric Pulmonary Nurse Kristen Cauchon, RN, Pediatric Pulmonary Nurse Nancy McIntosh, PhD, RN, Pediatric Pulmonary Nurse Tanya Emch, Pediatric Pulmonary Barbara Slattery, RN, BC, Coordinator, Pediatric Liz Baron, RN, BSN, CPN Theresa Kennedy, RN, BSN, BC Alison Wilson, BSN, RN, CCM, Practice Management Barb Butler, MS, PT Betsy Howell, MS, PT, Pediatric PT Chris Tapley, MS, PT, Pediatric PT Paulette Ratkiewicz, RRT, Respiratory Therapist Mary Britt, RRT, RPFT, Respiratory Therapist Suzanne Eyer, RRT, Respiratory Therapist Kathy Faber-Pitts, RRT, RPFT, BA, Respiratory Therapist Mark Waltrip, RRT, RPFT, Respiratory Therapist Kim Shaffer, PFT Lab Stephanie Reid, PFT Lab Ronnie Downer, RN, Coordinator, Adult Inpatient Barbara Carpenter, BSN, RN, Adult Pulmonary Nurse Karri Looker, RN, Adult Pulmonary Nurse Kristin Keith, MS, PT, Adult PT Geeta Peethambaran, MS, PT, Adult PT Rachel Wilken, BSN, RN, Practice Management Karen Carskadon, Pediatric Pulmonary Angie Adams-Stephens, Pediatric Pulmonology Kathy Parrish, Pediatric Clinic Kelly Smutek, Pediatric Pulmonary Kim Casto, BFA, Pediatric Pulmonology Nicole Cheesman, Pediatric Pulmonology Research Division Personnel Amy Filbrun, Assistant Professor Dawn Kruse, CCRC, Research Coordinator John LiPuma, Professor Kelley Bentley, PhD, Research Assistant Professor Marc Hershenson, MD, Pediatric Pulmonology Marisa Linn, Research Lab Specialist Associate Samya Nasr, Professor Uma Sajjan, PhD, Research Assistant Professo DONORS The following families and organizations have made donations to the CFC in the past year: Axcan Scandipharm, Inc. • Digestive Care, Inc. • Electromed • Genentech • Solvay Pharmaceuticals Executive Officers of the University of Michigan Health System Ora Hirsch Pescovitz, Executive Vice President for Medical Affairs; James O. Woolliscroft, Dean, U-M Medical School; Douglas Strong, Chief Executive Officer, U-M Hospitals and Health Centers; Kathleen Potempa, Dean, School of Nursing The Regents of the University of Michigan Julia Donovan Darlow, Laurence B. Deitch, Denise Ilitch, Olivia P. Maynard, Andrea Fischer Newman, Andrew C. Richner, S. Martin Taylor, Katherine E. White, Mary Sue Coleman, ex officio The University of Michigan is an equal opportunity/affirmative action employer. The University of Michigan Health System is committed to Total Quality. Copyright © 2012 The Regents of the University of Michigan, Ann Arbor, Michigan, 48109 MMD 120043