Twitter Facebook RSS Feed Print
Your Child

40% of Children 3 to 11 Are Exposed to Secondhand Smoke

2:00

The good news is that exposure to secondhand smoke dropped by half in the United States between 1999 and 2012. While more and more people are giving up the unhealthy habit, the amount of children being exposed to secondhand smoke is still significant – particularly in the African-American population. 

In a recent report, The Centers for Disease Control and Prevention (CDC) estimated that 58 million American nonsmokers are exposed to secondhand smoke.

In that group, the CDC suggests that 40 percent of children aged 3 to 11 are breathing in secondhand smoke and among black children, the number is much higher at 70 percent.

"Secondhand smoke can kill, and too many Americans -- and particularly too many children -- are still exposed to secondhand smoke," Dr. Tom Frieden, director of the CDC, said during a midday press conference.

Frieden, citing the U.S. Surgeon General, said, "There is no safe level of exposure to secondhand smoke." Tobacco smoke contains over 7,000 chemicals including about 70 that can cause cancer, he added.

The connection of secondhand smoke and illnesses in children has been widely studied and reported. In infants and children, secondhand smoke has been linked to sudden infant death syndrome (SIDS), respiratory infections, ear infections and asthma attacks.

In adult nonsmokers, passive smoke has been tied to heart disease, stroke and lung cancer, according to Frieden.

Each year, secondhand smoke kills more than 41,000 Americans from lung cancer and heart disease, and causes 400 deaths from SIDS, Frieden said. "These deaths are entirely preventable," he added.

Susan Liss, executive director of the Campaign for Tobacco-Free Kids, said in a statement: "The high level of child exposure to secondhand smoke also underscores the need for parents to take additional steps to protect children, such as ensuring that homes, cars and other places frequented by children are smoke-free. For parents who smoke, the best step to protect children is to quit smoking."

Smoking can become such a mindless habit that parents and caregivers forget that their children are breathing in the smoke they exhale. In nonsmoking homes, it can be difficult when friends or other family members want to light up when visiting. Asking people to either step outside or not smoke in the house has caused many a friends and family rift. But, standing your ground will protect your child from the influence of smoking and the polluted air that flows from a smoker.

Most restaurants, bars and workplaces have issued smoke-free policies but one's home and auto are open to personal choice. The number of U.S. households that are now smoke-free has increased in the past 20 years from 43 percent to 83 percent and that’s truly amazing considering our long love affair with cigarettes and cigars!

However, when 1 in 4 nonsmokers – including many children-are still being exposed, it’s going to take more parents, friends and family members to put down their cigarettes for good to finally stop children and adults from suffering the disastrous effects of breathing in secondhand smoke.

Source: Steven Reinberg, http://consumer.healthday.com/kids-health-information-23/adolescents-and-teen-health-news-719/58-million-americans-exposed-to-secondhand-smoke-cdc-696149.html

Your Teen

Teen Athletes Leading the Nation in Tommy John Surgeries

2:00

Teen athletes accounted for more than half of the Tommy John surgeries performed in the U.S. from 2007 to 2011 according to a new study. The surgery is actually an ulnar collateral ligament reconstruction (UCLR) graft procedure in which the ulnar collateral ligament in the elbow is replaced with a tendon from elsewhere in the body. Tommy John was the first Major League baseball pitcher to have the surgery and the nickname has now become common use.

 “Our results showed that 15- to 19-year-olds accounted for 56.7 percent of the Ulnar Collateral Ligament Reconstruction (UCLR) or Tommy John surgeries performed in the US between 2007 to 2011," said lead study author Brandon Erickson, MD, of Rush University Medical Center in Chicago, in a press release. "This is a significant increase over time with an average increase of 9.12 percent per year.”

Once a player has the surgery, he or she needs a good 12 to 15 months of recovery time before they are able to return to a high level of sport activity. Oftentimes, a second surgery may be required as the athlete continues to strain the ligament.

Baseball pitchers are the athletes that most often require the surgery because of the way they pitch; overhanded instead of underhanded. Many believe that the problems start in the teenage years with players who throw harder than ever and don't ever take a month off.

Dr. Erickson and his team looked at a private insurance database to identify patients who received UCLR surgeries throughout the US.

About 4 out of every 100,000 patients who had surgery between 2007 and 2011 had a UCLR surgery. These patients were overwhelmingly male, with 32 percent coming from the 15- to 17-year-old age group and 22 percent coming from the 20- to 24-year-old age group.

These surgeries grew at a rate of 4.2 percent each year between 2007 and 2011. And more than half were performed in the southern region of the US.

Another reason many teen athletes are susceptible to injury is that they play only one sport and play year-round, never giving their immature bodies enough time to rest and repair.

According to Dr. Erickson, more attention should be given to prevention because overuse injuries tend to occur in intensive training and high-performance games.

"The research numbers suggest that more young athletes believe that having an UCLR procedure performed earlier in their career may lead to the big leagues or a scholarship, even though only 1 in 200 kids who play high school baseball will make it to the MLB," Dr. Erickson said. "This paradigm shift needs to be evaluated further to help prevent overuse injuries in kids from the beginning of the season when most issues arise."

Some teens simply play through the pain without considering the possible long-term physical problems that could quickly end the career they worked so hard to attain. It’s up to the adults in their lives to watch over and give them the guidance they need to stay healthy. Parents and coaches need to make sure that their kids and students are following the safety rules established by the sport associations and organizations.

This study was presented at the American Orthopaedic Society for Sports Medicine's annual meeting. Research presented at conferences may not have been peer- reviewed.

Source: Beth Greenwood, http://www.dailyrx.com/tommy-john-surgeries-elbow-overuse-injuries-were-common-teen-athletes

 

 

 

 

Your Teen

FDA Proposes Ban on Tanning Beds for Minors

1:30

When warm summer days give way to cold gray skies, tanning beds can become the go-to alternative for a continuous tan. A 2014 study found that 59% of college students and 17% of teens use indoor tanning beds and a 2011 study reported that 32% of 12th graders had used a tanning bed.

Researchers have also found that people who use tanning devices before age 20 were twice as likely to develop a form of skin cancer called basal cell carcinoma by age 50, than those who had never used a tanning bed. Tanning beds are known to contribute to other skin cancers as well, including melanoma, the deadliest form of the disease.

Several studies from Europe have suggested that the radiation from a tanning bed can be up to 15 times more intense than the radiation from the midday sun.

After years of studies, the U.S. Food And Drug Administration (FDA) is proposing a ban on tanning beds for people under the age of 18, along with new preventive measures that reduce the risks from tanning to adults.

Using tanning beds at a young age can be particularly harmful, according to a statement from the FDA. The effects of UV radiation exposure add up over a lifetime, so exposure in children and teenagers puts them at greater risk for skin and eye damage later in life, according to the statement.

How many minors are using tanning beds? According to a 2013 National Youth Risk Behavior Study, about 1.6 million adolescents.

The "action is intended to help protect young people from a known and preventable cause of skin cancer and other harms," Dr. Stephen Ostroff, the acting FDA commissioner, said in the statement.

The American Academy of Pediatrics responded to the FDA's proposal with a statement of support.

"The FDA's action today is part of ensuring a safe environment for every child and adolescent, and sends a loud and clear message: Tanning beds are dangerous and should not be used by anyone under age 18," said the academy. "Pediatricians welcome FDA's action and will continue to urge parents and our young patients to protect their skin from ultraviolet radiation and to avoid tanning beds altogether."

In addition to restricting minors, the FDA is proposing that before a person's first tanning bed session and every six months thereafter, they sign a "risk acknowledge certification" that states they have been informed of the health risks that may result from indoor tanning. The hope is that people will think twice about using a tanning bed of they are reminded and have to sign off on the health dangers.

The FDA is also proposing a second rule that would require sunlamp manufacturers and tanning facilities take extra steps to improve the overall safety of the devices. Some of the proposed measures would include making warnings more prominent on the devices, requiring an emergency off switch or "panic button" and improving eye safety equipment, according to the statement.

"The FDA understands that some adults may continue to use [tanning beds]," Ostroff said in the statement. "These proposed rules are meant to help adults make their decisions based on truthful information," he said.

The new proposed rules are available for public comment for 90 days. The rules were recommended on December 21, 2015.  To comment you can log onto http://www.fda.gov/forconsumers/consumerupdates/ucm350790.htm#Proposed

Source: Sara G. Miller, http://www.livescience.com/53159-fda-proposes-tanning-bed-restrictions.html

 

 

 

 

Parenting

Backyard Chickens and Salmonella Bacteria

1:45

Chicken coops are springing up in backyards around the country. People are into raising chickens for fresh eggs and some are even developing close bonds with their feathered producers.  Unfortunately, many of the new chicken owners don’t have any experience with safely handling and keeping fowl.

While fresh eggs from the backyard may make breakfast more satisfying, there’s also a downside to raising chickens; salmonella bacteria.

The Centers for Disease Control and Prevention (CDC) says eight ongoing outbreaks of salmonella are linked to backyard chickens. These outbreaks have sickened 611 people, including 195 children under the age of 5, across 45 states since Jan. 4. Because most cases go unreported, the actual number of illnesses may be as high as 10,000, according to the CDC.

“Direct contact with chicks, chickens, ducklings, ducks, geese, and turkeys or contact with their environment can make people sick with salmonella infections,” says Megin Nichols, DVM, a veterinarian with the CDC. “Poultry can have salmonella in their droppings and on their feathers, feet, and beak, even though they appear healthy and clean.”

Salmonella can make you very ill. Symptoms include diarrhea, stomach cramps and fever. If you’re basically healthy, you’ll most likely get better without treatment.  However, children under the age of 5, adults over 65, people with chronic illnesses, people with weakened immune systems, and pregnant women have a higher risk of severe salmonella infections.

Experts say salmonella cases are increasing. The CDC says the 2016 outbreaks "involve the largest number of sick people linked to live poultry that we've seen."

The CDC is trying to pinpoint what types of contact caused the most illnesses in the recent outbreaks. In the past, baby chicks have been the source. Keeping baby chicks in the house, snuggling them, and kissing them are no-nos.

Experts say since you can’t be sure that your flock does not harbor salmonella, you should treat it as if it does.

Salmonella is part of chicken and other live poultry’s gut bacteria.  They shed it in droppings as well as onto their feathers and feet. It’s going to be anywhere you keep your birds.

Washing your hands is one of the top ways experts suggest to protect yourself.

After you handle live poultry, feed live poultry, or touch its backyard coop or living space, wash your hands vigorously for 20 seconds or more with soap and water, then dry them with a clean towel. Have an alcohol-based hand sanitizer handy in case you can’t get to a sink right away, says Elizabeth Scott, PhD, co-director of the Center for Hygiene and Health at Simmons College in Boston.

“If possible, wash your hands outdoors, not at the kitchen sink,” Scott says. “You do not want to be rinsing salmonella off your hands and into the kitchen sink, and you don’t want to use the kitchen sponge or dishrag either. The salmonella can proliferate in both.”

You should also clean any feeding dishes or other equipment outside. Do not bring them indoors.

Experts also offer these tips to prevent infection:

Wear proper clothes: Pick out clothing and a pair of boots or shoes that you will wear only when tending your flock, advises Scott, who grew up on a farm. Keep it outside. After cleaning your coop, separately wash the clothes you wore in your machine’s hot water cycle. (Wash yourself as well! A hot shower will do the trick.)

Set barriers: Chickens and other live poultry belong in the yard, not in the house, and especially not in the kitchen or any room where you store, prepare, and serve food, Scott says.

Says Nichols: “The poultry have their area, you have your area, and you keep it that way. That will definitely help prevent infection.”

Supervise your children: Children under the age of 5 should not have any direct contact with live poultry, Nichols says. Their immune systems cannot protect them enough from infection. Also, they are much more likely to put their fingers in their mouths.

Keep a close eye on older children to be sure that they don’t put their fingers in their mouths and that they wash their hands thoroughly after handling poultry.

No kissing: Don’t let a baby chick’s cuteness fool you into thinking it’s free of disease, Scott warns. “It’s better not to kiss them.”

Handle eggs properly: When you collect your flock’s eggs, which you should do at least once a day, rinse them in water that’s warmer than the eggs themselves. The warm water causes the shell to expand slightly, which helps push dirt out of pores on the shell. Don’t let them sit in the water. Use a detergent made for egg washing if your eggs are dirty. Dry them and store large side up in the refrigerator.

When you’re ready to eat, make sure to cook your eggs thoroughly. “The salmonella bacteria are actually in the yolk,” Scott says. “That’s why we shouldn’t eat raw or undercooked eggs.”

Story source: Matt McMillen, http://www.webmd.com/food-recipes/food-poisoning/20160719/backyard-chicken-salmonella

Your Toddler

Toddlers Lack of Sleep Tied to Behavior Problems

2:00

Sleep is vital to survival and while we may appear to be doing nothing, our brains are very active. Sleep deprivation can make us grumpy and unable to make good decisions or concentrate. Not only do adults need sufficient amounts of sleep- so do children.

 A new study looks at the affects not enough sleep can have on toddlers and found that those little ones that slept less than 10 hours a night or woke up frequently were more inclined to have emotional and behavioral problems at age five.

Researchers were surprised that the “risks were so strong and consistent” said lead author Borge Sivertsen of Uni Research Health and the Norwegian Institute of Public Health in Bergen.

“While only an experimental study can determine causality, our study does suggest that there is an increased risk of developing such problems, also after accounting for a range of other possible factors,” Sivertsen told Reuters Health by email.

The results were from a long-term study of 32,662 pairs of mothers and children in Norway. The mothers filled out questionnaires when they were 17 weeks pregnant, when the child was 18 months old and again when the child was five years old.

Mothers rated 99 child behaviors on a scale from “not true” to “very true” and reported how long the child slept in a 24-hour period and how often he or she woke up during the night.

At 18 months, almost 60 percent of toddlers were sleeping for 13 to 14 hours per night and about two percent were sleeping for less than ten hours per night. About 3 percent of toddlers woke three or more times per night. Most kids woke a few times per week or less.

Toddlers who slept less than 13 hours per night often had emotional or behavioral problems at the same age, the authors write in JAMA Pediatrics.

They also had a higher risk of internalizing problems such as being emotionally mercurial, anxious and depressed.

While the study doesn’t prove causation, it does lend a lot of credibility to there being a link between too little sleep in toddlers and later emotional and social problems.

“Although it is difficult to tease out causality from observational studies, this longitudinal study does suggest that inadequate sleep in early childhood increases the risks for later emotional and behavioral problems,” said Michelle M. Garrison of Seattle Children’s Research Institute in Washington, who wrote an editorial about the research.

Not all of these children will necessarily develop mental health problems later in life. Other factors also play important roles like the child’s temperament and his or her parent’s emotional health.

If your child seems to have difficulty sleeping well or getting to sleep, talk with your pediatrician about tips to help your little one get the rest he or she needs. 

Source: Kathryn Doyle, http://www.reuters.com/article/2015/04/13/us-toddlers-sleep-behavior-idUSKBN0N41U920150413

 

Your Baby

Higher ADHD Risks Linked to Premature Births

2:00

The risk that a child will have Attention Deficit Hyperactivity Disorder (ADHD) is relatively low among the general population. However, a new study suggests that the more premature a baby is when born; the risk for ADHD increases significantly.

Finnish researchers led by Dr. Minna Sucksdorff of the University of Turku compared more than 10,000 children with ADHD against more than 38,000 children without ADHD but similar in terms of gender, birth date and place of birth.

The researchers used birth medical records to see how far along in the pregnancy the mother was when the child was born. They also looked at whether the children were underweight or overweight for what is expected at that gestational age.

The study results showed that the risk of ADHD increased for each week earlier that a child was born. A full-term pregnancy is considered to be 40 weeks.

The odds of children with ADHD were 10 times greater when they were born during the 23rd to 24th week of pregnancy. Children born between the 27th and 33rd week of pregnancy were twice as likely to have ADHD compared to those without ADHD.

Other factors that affect gestational age and ADHD were also taken in account such as the mother’s age and whether she smoked or used drugs or alcohol. After these considerations, the findings remained the same.

In regards to birth weight, researchers found that infants born at very low or very high weight percentages were also at a higher risk for ADHD.

These findings imply that the pathways in the fetal brain may develop differently in children who are not adequately nourished, or are over-nourished, in the womb, or once a child is delivered prematurely, said Dr. Glen Elliott, chief psychiatrist and medical director of Children's Health Council in Palo Alto, Calif.

However, he added, this type of study cannot show that premature birth or growth rate in the womb actually causes ADHD. Symptoms of the common brain disorder include inattention, impulsive behavior and hyperactivity, which can affect a child's ability to learn and make friends.

Most early cesarean births happen because a mother and / or her infant are in distress and surgery is needed to protect one or the other or both of their health. Planned cesareans are typically scheduled close to the original due date and are unlikely to be associated to ADHD risk. However, the findings may give doctors something to consider when making a decision about cesarean birth.

"Since both gestational weight and gestational age have marked effects, clinicians may face difficult choices if a fetus is not thriving in the womb at an early gestational age," Elliott said. "Does one deliver the child early to enhance nutrition or delay to minimize the effects of premature delivery?"

The risk is still low overall that a child will have ADHD, and these findings are based on a child's relative risk of having the condition compared to others, Elliott added. The study suggests that the chance for ADHD appears to be greatest among the very premature babies.

The findings were published in the August 24th online edition of  the journal Pediatrics.

Source: Tara Haelle, http://www.webmd.com/baby/news/20150824/adhd-risk-rises-for-each-week-a-preemie-is-born-early

Daily Dose

Staying Heart Healthy

1:30 to read

With it being heart month it seems like an appropriate time to discuss sudden cardiac death (SCD) in children. Thankfully, sudden cardiac death is rare in children with estimates somewhere between 0.6-6.2 deaths /100,000 in children in the U.S.  

SCD is defined as “a death that is abrupt, unexpected, and due to a cardiovascular cause”. It is also defined as a death that occurs within 1 hour from the onset of cardiovascular symptoms, and in the pediatric population death typically occurs within a few minutes of symptoms.  The majority of these tragic sudden deaths occur during sports (20-25%), and in many cases there have been no previous warning signs.

While congenital heart disease is the most common cause of SCD, there continues to be a great deal of research into this subject.  It is now known that there are genetic risk factors involved for many of the disorders that lead to heart disease, arrhythmias and SCD.  Hypertrophic cardiomyopathy ( enlargement of the heart) is the most common cause of SCD in children and adolescents and is due to a genetic abnormality as is prolonged QT syndrome.

Since sport participation has been associated with an increased risk of SCD in children, it is now recommended that athletes are pre-screened for risk factors associated with SCD. A good history is always important, with questions directed towards the heart - including chest pain with exertion, recurrent syncope (fainting) or syncope with exertion.  While many children may not be symptomatic a detailed family history of sudden early unexplained death may be a clue to provoke a further work . The physical exam is equally important including blood pressure readings with the patient both supine, sitting and standing. A good cardiac exam is necessary to listen for murmurs as well as any physical findings suggestive of Marfan’s syndrome. 

Routine ECG (electrocardiogram) screening for all athletes is currently not recommended, although this is the recommendation in several other countries ( Italy has a lot of data on this topic). Unfortunately, an ECG alone does not diagnose all abnormalities and there are frequent false positive results as well, which may lead to unnecessary testing.  An echocardiogram is also necessary to diagnose some abnormalities, and again is not routinely recommended and requires a pediatric cardiologist to read it. 

The most important treatment for SCD is early cardiopulmonary resuscitation (CPR) and to have an AED (automatic external defibrillator) available.  It is estimated that early CPR/AED use could prevent about 25% of pediatric sudden deaths.  If we increase the number of people ( including older children)  who have been instructed in CPR and feel comfortable knowing the correct way to use an AED the statistics for survival may even become more favorable.  There have been anecdotal reports of children performing CPR successfully simply due to the fact that they had seen CPR performed on TV shows or the internet.  Taking CPR/AED training into middle and high schools may be one way to insure this. For children that have been found to have a genetic abnormality which puts them at risk for SCD, or for those who have survived a sudden cardiac event, there are treatments available including medications and in some cases implantation of an internal cardioverter and defibrillator ( almost like your own AED).  Evaluation and treatment by a pediatric cardiologist with expertise in this area is preferred.  

So…with it being heart month a good family activity might be CPR training…who knows when you just might save a life!

Daily Dose

Exercise Can Maintain Heart Health

1.30 to read

Moms and dads...you have an exercise plan but what about your kids? Your child's heart health is important too! Heart health is based on genetics, diet and lastly exercise. (For adults and my teen patients as well, need to add smoking and drinking to the discussion).  

While I start talking about healthy eating during infancy the discussion about exercise comes a bit later.  If you have a toddler you know they “exercise”.....all day long, and never stop except to sleep! But as our children get older, once again it is up to the parents to model behavior, including exercise. 

I regularly ask, “how much time does your child play outside?” (I know it is much harder in winter months), “what does your child do for exercise outside of school?” and “do you exercise as a family?’”.  Once a child is older, say 5 or so, I include them in the questioning as well as they are a wealth of information. I ask them “if they ride a bike”....they love to tell me about taking off their training wheels. Then I ask “who they ride with and where do they go?”.  I also ask about bike helmets, you would be amazed at how many children tell me that they wear a helmet, but their parents don’t! (HINT HINT to parents). 

I find that most children under the age of 10 or so do get a fair amount of exercise, but as they get older many have stopped playing sports outside of school and have chosen to spend more time being sedentary.  They are not just watching TV, but have found other interests like music, art, drama, chess and even computer programming.  All of that is great, but children still need exercise and many schools have cut PE programs especially once you get to middle school and high school. This means that parents once again may have to encourage exercise, for the whole family. Walking the dog, family bike rides, tennis matches, front yard kickball or badminton.  Get the family exercising together....they may not even realize. 

The hardest group I have to encourage to exercise are my teens who are just not athletes (I can sympathize).  We all have our talents, but for some sports are not it.  I find myself asking my teenage patients, how much exercise they get and so many say, “None”.  Many say, “walking between classes” is all of their exercise, and the idea of walking to school is long gone for most.  Many of my teens start to gain weight after puberty and have to be reminded that we all stop growing....so you can’t keep gaining weight. Exercise has to be done on a regular basis...again it is about lifestyle. 

So, heart health and exercise should be a focus for families year round, see if you can get your family moving as we head into spring!

Parenting

Any Benefits From Eating Your Own Placenta?

2:00

Here’s a medical study I never thought I’d read –“Are there health benefits associated with eating your own placenta after giving birth”?

Well…no, according to a research team from Northwestern University in Chicago. In fact, there may be a few health risks associated with ingesting placenta.

As I read the study’s findings, I began to wonder; who thought this was a good idea in the first place?

It turns out that throughout history there have been some cultures in which women ate the placenta after giving birth. It’s called placentophagy.

Some animals are known to also eat their afterbirth.

Apparently its’ also become the thing among a few celebrity mothers. While some believe that fresh placenta provides the most benefits, others elect to make a smoothie or have it dried, processed and made into pills.

However, the question still remains – is there any real benefit from eating placenta whether it’s raw, processed, made into a smoothie or pill, grilled or baked?

Scientists from Northwestern University pored over accumulated research that has been done on the topic.  The bottom line is that they could not find any evidence that there are any health benefits to placentophagy and that there may be unknown risks to mothers and their infants.

"Our sense is that women choosing placentophagy, who may otherwise be very careful about what they are putting into their bodies during pregnancy and nursing, are willing to ingest something without evidence of its benefits and, more importantly, of its potential risks to themselves and their nursing infants," study lead author and psychologist Cynthia Coyle said in a Northwestern news release.

In the study, Coyle's team reviewed data from 10 published studies. They found no data to support that eating the placenta -- either raw, cooked or in pill form -- protects against postpartum depression, reduces pain after childbirth, increases a woman's energy, helps with lactation, improves mother-child bonding, replenishes iron in the body, or improves skin elasticity. All touted as reasons many of the celebrity moms chose to give it a try.

The researchers also said that there are no studies examining the risks associated with eating the placenta, which acts as a filter to absorb and protect fetuses from toxins and pollutants.

Coyle noted that "there are no regulations as to how the placenta is stored and prepared, and the dosing is inconsistent. Women really don't know what they are ingesting."

If placentophagy appeals to you, be sure and check with your hospital or birthing center first. Many hospitals dispose of the placenta as bio-hazardous waste along with the other medical waste that occurs during birth (needles, blood, gloves etc.). You’ll most likely have to make arrangements ahead of time or find a more accommodating provider.

Source: Robert Preidt, http://www.webmd.com/baby/news/20150604/new-moms-gain-no-benefit-from-eating-placenta-studies-show

Pages

Please fill in your e-mail address to be included in our newsletter.
You may opt out at any time.

 

DR SUE'S DAILY DOSE

Why you should never use a kitchen spoon to measure medicine.

Please fill in your e-mail address to be included in our newsletter.
You may opt out at any time.

 

Please fill in your e-mail address to be included in our newsletter.
You may opt out at any time.