Graves' disease

 

Overview

Thyroid gland

 

Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Although a number of disorders may result in hyperthyroidism, Graves' disease is a common cause.

 

Thyroid hormones affect many body systems, so signs and symptoms of Graves' disease can be wide ranging. Although Graves' disease may affect anyone, it's more common among women and in people younger than age 40.

 

The primary treatment goals are to reduce the amount of thyroid hormones that the body produces and lessen the severity of symptoms.

 

Symptoms

 

Common signs and symptoms of Graves' disease include:

 

Anxiety and irritability

A fine tremor of the hands or fingers

Heat sensitivity and an increase in perspiration or warm, moist skin

Weight loss, despite normal eating habits

Enlargement of the thyroid gland (goiter)

Change in menstrual cycles

Erectile dysfunction or reduced libido

Frequent bowel movements

Bulging eyes (Graves' ophthalmopathy) (discussed further below)

Fatigue

Thick, red skin usually on the shins or tops of the feet (Graves' dermopathy, discussed further below)

Rapid or irregular heartbeat (palpitations)

Sleep disturbance

 

Graves' ophthalmopathy

Eye complications associated with Graves' disease

About 30% of people with Graves' disease show some signs and symptoms of Graves' ophthalmopathy. In Graves' ophthalmopathy, inflammation and other immune system events affect muscles and other tissues around your eyes. Signs and symptoms may include:

 

Bulging eyes

Gritty sensation in the eyes

Pressure or pain in the eyes

Puffy or retracted eyelids

Reddened or inflamed eyes

Light sensitivity

Double vision

Vision loss

 

Graves' dermopathy

 

An uncommon manifestation of Graves' disease, called Graves' dermopathy, is the reddening and thickening of the skin, most often on your shins or the tops of your feet.

 

When to see a doctor

A number of medical conditions can cause the signs and symptoms associated with Graves' disease. See your doctor if you experience any potential problems related to Graves' disease to get a prompt and accurate diagnosis.

 

Seek emergency care if you're experiencing heart-related signs and symptoms, such as a rapid or irregular heartbeat, or if you develop vision loss.

 

More Information

Graves' disease care at Mayo Clinic

Graves' dermopathy: How is it treated?

Causes

Graves' disease is caused by a malfunction in the body's disease-fighting immune system. It's unknown why this happens.

 

The immune system normally produces antibodies designed to target a specific virus, bacterium or other foreign substance. In Graves' disease — for reasons that aren't well understood — the immune system produces an antibody to one part of the cells in the hormone-producing gland in the neck (thyroid gland).

 

Normally, thyroid function is regulated by a hormone released by a tiny gland at the base of the brain (pituitary gland). The antibody associated with Graves' disease — thyrotropin receptor antibody (TRAb) — acts like the regulatory pituitary hormone. That means that TRAb overrides the normal regulation of the thyroid, causing an overproduction of thyroid hormones (hyperthyroidism).

 

Cause of Graves' ophthalmopathy

Graves' ophthalmopathy results from a buildup of certain carbohydrates in the muscles and tissues behind the eyes — the cause of which also isn't known. It appears that the same antibody that can cause thyroid dysfunction may also have an "attraction" to tissues surrounding the eyes.

 

Graves' ophthalmopathy often appears at the same time as hyperthyroidism or several months later. But signs and symptoms of ophthalmopathy may appear years before or after the onset of hyperthyroidism. Graves' ophthalmopathy can also occur even if there's no hyperthyroidism.

                                                                   

 

Risk factors

Although anyone can develop Graves' disease, many factors can increase the risk of disease, including:

 

Family history. Because a family history of Graves' disease is a known risk factor, there is likely a gene or genes that can make a person more susceptible to the disorder.

Sex. Women are much more likely to develop Graves' disease than are men.

Age. Graves' disease usually develops in people before age 40.

Other autoimmune disorders. People with other disorders of the immune system, such as type 1 diabetes or rheumatoid arthritis, have an increased risk.

Emotional or physical stress. Stressful life events or illness may act as a trigger for the onset of Graves' disease among people who have genes that increase their risk.

Pregnancy. Pregnancy or recent childbirth may increase the risk of the disorder, particularly among women who have genes that increase their risk.

Smoking. Cigarette smoking, which can affect the immune system, increases the risk of Graves' disease. Smokers who have Graves' disease are also at increased risk of developing Graves' ophthalmopathy.

 

Complications

Complications of Graves' disease can include:

 

Pregnancy issues. Possible complications of Graves' disease during pregnancy include miscarriage, preterm birth, fetal thyroid dysfunction, poor fetal growth, maternal heart failure and preeclampsia. Preeclampsia is a maternal condition that results in high blood pressure and other serious signs and symptoms.

sHeart disorder. If left untreated, Graves' disease can lead to heart rhythm disorders, changes in the structure and function of the heart muscles, and the inability of the heart to pump enough blood to the body (heart failure).

Thyroid storm. A rare but life-threatening complication of Graves' disease is thyroid storm, also known as accelerated hyperthyroidism or thyrotoxic crisis. It's more likely when severe hyperthyroidism is untreated or treated inadequately.

 

The sudden and drastic increase in thyroid hormones can produce many effects, including fever, sweating, vomiting, diarrhea, delirium, severe weakness, seizures, irregular heartbeat, yellow skin and eyes (jaundice), severe low blood pressure, and coma. Thyroid storm requires immediate emergency care.

 

Brittle bones. Untreated hyperthyroidism also can lead to weak, brittle bones (osteoporosis). The strength of your bones depends, in part, on the amount of calcium and other minerals they contain. Too much thyroid hormone interferes with your body's ability to incorporate calcium into your bones.

 

 

 

Jan Ricks Jennings, MHA, LFACHE

Senior Consultant

Senior Management Resources, LLC

 

Jan.Jennings@EagleTalons.net

JanJenningsBlog.Blotspot.com

 

412.913.0636 Cell

724.733.0509 Office

 

June 23, 2022

 

                                                                                    

Amyotrophic lateral sclerosis (ALS) . . . Lou Gehrig’s Disease

 

 

Overview

Amyotrophic lateral sclerosis (a-my-o-TROE-fik LAT-ur-ul skluh-ROE-sis), or ALS, is a progressive nervous system disease that affects nerve cells in the brain and spinal cord, causing loss of muscle control.

 

ALS is often called Lou Gehrig's disease, and he died from it, after the baseball player who was diagnosed with it. Doctors usually don't know why ALS occurs. Some cases are inherited.

 

ALS often begins with muscle twitching and weakness in a limb, or slurred speech. Eventually, ALS affects control of the muscles needed to move, speak, eat and breathe. There is no cure for this fatal disease.

 

Symptoms

Signs and symptoms of ALS vary greatly from person to person, depending on which neurons are affected. It generally begins with muscle weakness that spreads and gets worse over time. Signs and symptoms might include:

 

Difficulty walking or doing normal daily activities

Tripping and falling

Weakness in your legs, feet or ankles

Hand weakness or clumsiness

Slurred speech or trouble swallowing

Muscle cramps and twitching in your arms, shoulders or tongue

Inappropriate crying, laughing or yawning

Cognitive and behavioral changes

ALS often starts in the hands, feet or limbs, and then spreads to other parts of your body. As the disease advances and nerve cells are destroyed, your muscles get weaker. This eventually affects chewing, swallowing, speaking and breathing.

 

There's generally no pain in the early stages of ALS, and pain is uncommon in the later stages. ALS doesn't usually affect your bladder control or your senses.

Causes

ALS affects the nerve cells that control voluntary muscle movements such as walking and talking (motor neurons). ALS causes the motor neurons to gradually deteriorate, and then die. Motor neurons extend from the brain to the spinal cord to muscles throughout the body. When motor neurons are damaged, they stop sending messages to the muscles, so the muscles can't function.

 

ALS is inherited in 5% to 10% of people. For the rest, the cause isn't known.

 

Researchers continue to study possible causes of ALS. Most theories center on a complex interaction between genetic and environmental factors.

 

Risk factors

Established risk factors for ALS include:

 

Heredity. Five to 10 percent of the people with ALS inherited it (familial ALS). In most people with familial ALS, their children have a 50-50 chance of developing the disease.

Age. ALS risk increases with age, and is most common between the ages of 40 and the mid-60s.

Sex. Before the age of 65, slightly more men than women develop ALS. This sex difference disappears after age 70.

Genetics. Some studies examining the entire human genome found many similarities in the genetic variations of people with familial ALS and some people with noninherited ALS. These genetic variations might make people more susceptible to ALS.

Environmental factors, such as the following, might trigger ALS.

 

Smoking. Smoking is the only likely environmental risk factor for ALS. The risk seems to be greatest for women, particularly after menopause.

Environmental toxin exposure. Some evidence suggests that exposure to lead or other substances in the workplace or at home might be linked to ALS. Much study has been done, but no single agent or chemical has been consistently associated with ALS.

Military service. Studies indicate that people who have served in the military are at higher risk of ALS. It's unclear what about military service might trigger the development of ALS. It might include exposure to certain metals or chemicals, traumatic injuries, viral infections, and intense exertion.

 

Complications

As the disease progresses, ALS causes complications, such as:

 

Breathing problems

Over time, ALS paralyzes the muscles you use to breathe. You might need a device to help you breathe at night, similar to what someone with sleep apnea might wear. For example, you may be given a bilevel positive airway pressure (BiPAP) device to help with your breathing at night. This type of device supports your breathing through a mask worn over your nose, your mouth or both.

 

Some people with advanced ALS choose to have a tracheostomy — a surgically created hole at the front of the neck leading to the windpipe (trachea) — for full-time use of a respirator that inflates and deflates their lungs.

 

The most common cause of death for people with ALS is respiratory failure. On average, death occurs within 3 to 5 years after symptoms begin. However, some people with ALS live 10 or more years.

 

Speaking problems

Most people with ALS develop trouble speaking. This usually starts as occasional, mild slurring of words, but becomes more severe. Speech eventually becomes difficult for others to understand, and people with ALS often rely on other communication technologies to communicate.

 

Eating problems

People with ALS can develop malnutrition and dehydration from damage to the muscles that control swallowing. They are also at higher risk of getting food, liquids or saliva into the lungs, which can cause pneumonia. A feeding tube can reduce these risks and ensure proper hydration and nutrition.

 

Dementia

Some people with ALS have problems with memory and decision-making, and some are eventually diagnosed with a form of dementia called frontotemporal dementia.

                                                                                    

 

 

Jan Ricks Jennings, MHA, LFACHE

Senior Consultant

Senior Management Services, LLC

 

Jan.Jennings@EagleTalons.net

JanJenningsBlog.Blogspot.com

 

412.913.0636 Cell

724.733.0509  Office

 

June 21,2022

                                                                                        

Cosmetic surgery

 

 

Overview

The goal of cosmetic surgery is to improve a person's appearance, self-esteem and self-confidence. Cosmetic surgery can be performed on any part of the face and body.

 

Types of cosmetic surgery

For the face

Botox

Cheek lift

Chemical peel

Chin surgery

Cosmetic dentistry

Dermabrasion

Eyebrow/forehead rejuvenation (brow lift)

Blepharoplasty (eyelid surgery)

Face-lift

Facial contouring

Facial fillers

Facial wrinkles

Laser hair removal

Laser resurfacing

Neck lift

Otoplasty (ear surgery)

Rhinoplasty (nose surgery)

Skin problems (blemishes, spider veins, scar revisions, tattoo removal)

Wrinkle treatment

 

For the body

Abdomen reduction (tummy tuck)

Arm lift

Liposuction

Breast augmentation

Breast lift

Breast reduction surgery

Buttock lift (belt lipectomy)

Circumferential body lift

Inner thigh lift

Laser hair removal

Why it's done

Because cosmetic surgery can bring lasting and dramatic changes to your outside appearance, it is important to understand how these changes might affect you on the inside. Before making an appointment to see a cosmetic surgeon, consider your motives for wanting to change how you look.

 

Many physical characteristics can be successfully changed through cosmetic surgery; others cannot. Good candidates for cosmetic surgery:

 

Have realistic expectations about what can be accomplished

Understand the medical risks, physical effects during healing, how the surgery will affect them personally and professionally, what lifestyle changes may accompany the recovery period, and the expenses involved

Have chronic medical conditions under control

Have no history of smoking or commit to abstain from smoking and nicotine products, including chewing tobacco and nicotine patches, gums, or lozenges for four to six weeks before and after surgery

Have had a stable weight for six to 12 months, for certain procedures

Risks

All surgeries, including cosmetic procedures, carry risk. If your body mass index is 30 or higher (obesity) or you have diabetes, you might be at higher risk of developing complications such as blood clots in the legs or lungs. Smoking also increases risks and interferes with healing.

 

You'll meet with your surgeon to discuss these risks and others related to your health history.

 

Possible complications for any surgical procedure include:

 

Complications related to anesthesia, including pneumonia, blood clots and, rarely, death

Infection at the incision site, which may worsen scarring and require additional surgery

Fluid buildup under the skin

Mild bleeding, which may require another surgical procedure, or bleeding significant enough to require a transfusion

Abnormal scarring due to skin breakdown

Separation of the surgical wound, which sometimes requires additional procedures

Numbness and tingling from nerve damage, which may be permanent

 

How you prepare

Questions to consider before pursuing cosmetic surgery:

 

What are my motives for wanting to change how I look?

What are the specific parts of my appearance that I want to change?

Do I have realistic expectations about the results of the surgery?

What aspects of my life will be affected, such as family, work, travel and social obligations?

Is this a good time in my life to have cosmetic surgery?

Have I talked about my concerns and questions openly with my doctor?

Questions to ask the cosmetic surgeon:

It is a good idea to bring a notepad to write down answers.

 

What are your qualifications?

How long have you been board-certified?

How many procedures have you done similar to the one I'm considering?

What other health care professionals will be involved in my care?

What results can I expect?

Will I need a physical examination prior to surgery?

Are there risks unique to my health history?

Questions to ask about a procedure:

What does the procedure do? What does it not do?

Is this the right treatment for me? Are there other procedures I should consider?

What are the risks and complications associated with this procedure?

How long is the recovery period?

Can I expect much discomfort? What are my pain management options?

Will I have any scars and if yes, what will they look like?

If my procedure requires stitches, when will they be removed?

What kind of activity restrictions will I have following surgery?

How long before I can go back to my regular routine?

How long before I see the final results of my surgery?

How long will the results last?

How much does the procedure cost?

What you can expect

It's important to have a clear understanding of what will happen before, during and after the procedure, and what results to expect. Many physical characteristics can be successfully changed, while others cannot. The more realistic your expectations, the more likely you will be satisfied with the results.

 

Before the procedure

Your surgeon will explain how cosmetic surgery can change your body and what you can expect as a result. This is an opportunity for you to explain what you hope to achieve with surgery. Understanding the options and possible outcomes will help you make the best decision.

 

You will be informed about specific procedures, what to expect, the benefits, risks and possible complications, as well as other alternatives. The doctor might recommend additional procedures to enhance your overall result.

 

The concept of asymmetry will be explained. The human body is asymmetric, meaning one side of the body looks naturally different from the other. Consider the image reflected in the mirror — a photographic image is a true image, the opposite of the mirror image. The surgeon helps patients understand this so they can fully appreciate their true appearance and how this may change with cosmetic surgery.

 

The surgeon also will explain the concept of balance — how changing one part of the body may affect overall appearance and how additional surgical procedures may bring greater balance.

 

Nurse review

You will also meet with a nurse, who reviews general questions about health, current medications — including aspirin, vitamin E, over-the-counter medications and supplements — and lifestyle issues, such as smoking history.

 

The nurse will review what you can expect following surgery, including pain, medications, diet, activity and work restrictions, and details such as the need to arrange for a ride home following the procedure.

 

By listening and following instructions from the surgeon and health care team, you can minimize the risks and complications of surgery.

Consent form

You'll likely be asked to sign a consent form so that photographs can be taken before and after surgery. Photographs serve as a reference for the surgeon during the procedure and become a part of your medical record.

 

Estimate of costs

You'll be given an estimate of surgical fees. Insurance typically doesn't cover cosmetic surgery procedures. Payment is generally required before surgery.

 

Preoperative examination

You might be scheduled for a preoperative examination to check your general health prior to surgery.

 

During the procedure

Cosmetic surgery procedures requiring general anesthesia or IV (intravenous) sedation are performed in the hospital under the care of an anesthesiologist/nurse anesthetist team. Other procedures, such as injections of facial fillers, may be performed in an outpatient setting or physician's office under local anesthesia. Prior to surgery, you will see the surgeon (or a member of your health care team) one more time to answer any remaining questions.

 

After the procedure

Prior to outpatient surgery or before discharge from the hospital, you will receive:

 

Instructions for post-surgical care specific to your procedure

Medication instructions and prescriptions, such as for pain medications and antibiotics

Contact information if you have questions

 

Results

Despite being informed and prepared, you might be surprised by the bruising and swelling that follow cosmetic surgery and how long they last. Bruising might take a minimum of three weeks to lessen; swelling might take even longer.

 

You might experience a brief period of "the blues" or low spirits during recovery. Prematurely judging the results of your surgery or waiting to return to normal activities may contribute to feelings of disappointment and frustration.

 

Realistic expectations are key — the goal is improvement, not perfection. Each person will have a different result. Keep in mind that:

 

Bruising and swelling are temporary. Surgical scars are permanent.

Recovery times vary by person and procedure, but a minimum of six to 12 weeks is typical for many cosmetic surgeries.

Follow-up surgeries may be needed to achieve your goals

 

Jan Ricks Jennings, MHA, FACHE

Senior Consultant

Senior Management Resources, LlC

 

Jan.Jennings@EagleTalons.net

JanJenningsBlog.Blogsport.com

 

412.9130636 Cell

724.733.0509 Office

 

June 20, 2022

                                                                                   

Cystitis

 

 

Overview

Cystitis (sis-TIE-tis) is the medical term for inflammation of the bladder. Most of the time, the inflammation is caused by a bacterial infection, and it's called a urinary tract infection (UTI). A bladder infection can be painful and annoying, and it can become a serious health problem if the infection spreads to your kidneys.

 

Less commonly, cystitis may occur as a reaction to certain drugs, radiation therapy or potential irritants, such as feminine hygiene spray, spermicidal jellies or long-term use of a catheter. Cystitis may also occur as a complication of another illness.

 

The usual treatment for bacterial cystitis is antibiotics. Treatment for other types of cystitis depends on the underlying cause.

 

Symptoms

                                                           

Cystitis signs and symptoms often include:

 

A strong, persistent urge to urinate

A burning sensation when urinating

Passing frequent, small amounts of urine

Blood in the urine (hematuria)

Passing cloudy or strong-smelling urine

Pelvic discomfort

A feeling of pressure in the lower abdomen

Low-grade fever

In young children, new episodes of accidental daytime wetting also may be a sign of a urinary tract infection (UTI). Nighttime bed-wetting on its own isn't likely to be associated with a UTI.

 

When to see a doctor

Seek immediate medical help if you have signs and symptoms common to a kidney infection, including:

 

Back or side pain

Fever and chills

Nausea and vomiting

If you develop urgent, frequent or painful urination that lasts for several hours or longer or if you notice blood in your urine, call your doctor. If you've been diagnosed with a UTI in the past and you develop symptoms that mimic a previous UTI, call your doctor.

 

Also call your doctor if cystitis symptoms return after you've finished a course of antibiotics. You may need a different type of medication.

 

If your child starts having daytime wetting accidents, call your pediatrician.

 

In otherwise healthy men, cystitis is rare and should be investigated by your doctor.

 

Causes

Female urinary system

 

Your urinary system includes your kidneys, ureters, bladder and urethra. All play a role in removing waste from your body. Your kidneys — a pair of bean-shaped organs located toward the back of your upper abdomen — filter waste from your blood and regulate the concentrations of many substances. Tubes called ureters carry urine from your kidneys to the bladder, where it's stored until it exits your body through the urethra.

 

Bacterial cystitis

UTIs typically occur when bacteria outside the body enter the urinary tract through the urethra and begin to multiply. Most cases of cystitis are caused by a type of Escherichia coli (E. coli) bacteria.

 

Bacterial bladder infections may occur in women as a result of sexual intercourse. But even sexually inactive girls and women are susceptible to lower urinary tract infections because the female genital area often harbors bacteria that can cause cystitis.

 

Noninfectious cystitis

Although bacterial infections are the most common cause of cystitis, a number of noninfectious factors also may cause the bladder to become inflamed. Some examples include:

 

Interstitial cystitis. The cause of this chronic bladder inflammation, also called painful bladder syndrome, is unclear. Most cases are diagnosed in women. The condition can be difficult to diagnose and treat.

Drug-induced cystitis. Certain medications, particularly the chemotherapy drugs cyclophosphamide and ifosfamide, can cause inflammation of your bladder as the broken-down components of the drugs exit your body.

Radiation cystitis. Radiation treatment of the pelvic area can cause inflammatory changes in bladder tissue.

Foreign-body cystitis. Long-term use of a catheter can predispose you to bacterial infections and to tissue damage, both of which can cause inflammation.

Chemical cystitis. Some people may be hypersensitive to chemicals contained in certain products, such as bubble bath, feminine hygiene sprays or spermicidal jellies, and may develop an allergic-type reaction within the bladder, causing inflammation.

Cystitis associated with other conditions. Cystitis may sometimes occur as a complication of other disorders, such as diabetes, kidney stones, an enlarged prostate or spinal cord injuries.

Risk factors

Some people are more likely than others to develop bladder infections or recurrent urinary tract infections. Women are one such group. A key reason is physical anatomy. Women have a shorter urethra, which cuts down on the distance bacteria must travel to reach the bladder.

 

Women at greatest risk of UTIs include those who:

 

Are sexually active. Sexual intercourse can result in bacteria being pushed into the urethra.

Use certain types of birth control. Women who use diaphragms are at increased risk of a UTI. Diaphragms that contain spermicidal agents further increase your risk.

Are pregnant. Hormonal changes during pregnancy may increase the risk of a bladder infection.

Have experienced menopause. Altered hormone levels in postmenopausal women are often associated with UTIs.

Other risk factors in both men and women include:

 

Interference with the flow of urine. This can occur in conditions such as a stone in the bladder or, in men, an enlarged prostate.

Changes in the immune system. This can happen with certain conditions, such as diabetes, HIV infection and cancer treatment. A depressed immune system increases the risk of bacterial and, in some cases, viral bladder infections.

Prolonged use of bladder catheters. These tubes may be needed in people with chronic illnesses or in older adults. Prolonged use can result in increased vulnerability to bacterial infections as well as bladder tissue damage.

In men without any predisposing health issues, cystitis is rare.

 

Complications

When treated promptly and properly, bladder infections rarely lead to complications. But left untreated, they can become something more serious. Complications may include:

 

Kidney infection. An untreated bladder infection can lead to kidney infection, also called pyelonephritis (pie-uh-low-nuh-FRY-tis). Kidney infections may permanently damage your kidneys.

 

Young children and older adults are at the greatest risk of kidney damage from bladder infections because their symptoms are often overlooked or mistaken for other conditions.

 

Blood in the urine. With cystitis, you may have blood cells in your urine that can be seen only with a microscope (microscopic hematuria) and that usually resolves with treatment. If blood cells remain after treatment, your doctor may recommend a specialist to determine the cause.

 

Blood in the urine that you can see (gross hematuria) is rare with typical, bacterial cystitis, but this sign is more common with chemotherapy- or radiation-induced cystitis.

 

Prevention

Cranberry juice or tablets containing proanthocyanidin are often recommended to help reduce the risk of recurrent bladder infections for some women. But research in this area is conflicting. Some smaller studies demonstrated a slight benefit, but larger studies found no significant benefit.

 

As a home remedy, avoid cranberry juice if you're taking the blood-thinning medication warfarin (Coumadin). Possible interactions between cranberry juice and warfarin can lead to bleeding.

 

Although these preventive self-care measures aren't well-studied, doctors sometimes recommend the following for repeated bladder infections:

 

Drink plenty of liquids, especially water. Drinking lots of fluids is especially important if you're getting chemotherapy or radiation therapy, particularly on treatment days.

Urinate frequently. If you feel the urge to urinate, don't delay using the toilet.

Wipe from front to back after a bowel movement. This prevents bacteria in the anal region from spreading to the vagina and urethra.

Take showers rather than tub baths. If you're susceptible to infections, showering rather than bathing may help prevent them.

Gently wash the skin around the vagina and anus. Do this daily, but don't use harsh soaps or wash too vigorously. The delicate skin around these areas can become irritated.

Empty your bladder as soon as possible after intercourse. Drink a full glass of water to help flush bacteria.

Avoid using deodorant sprays or feminine products in the genital area. These products can irritate the urethra and bladder.

 

Jan Ricks Jennings, MHA, LFACHE

Senior Consultant

Senior Management Resources, LLC

 

Jan.Jennings@EagleTalons.net

JanJennigsBlog.Blogspot.com

724.733.9509 Office

412.913.0636 Cell

 

June 15, 2022