Hospitals and doctors are not all alike_ they vary in quality due to differences in their training, experience and services. These differences in quality become greater and matter more when you need sophisticated medical care for a complex condition.
A surgeon who performs a complex procedure often, for example, has better success with it than a surgeon who does the same procedure only occasionally. The complication rate and death rate for the same procedure may be many times higher at one hospital than another.
Clearly, the doctor and hospital that you choose have a direct impact on how well you do _ especially when you need treatment for a condition potentially as serious as a heart rhythm disturbance.
Heart rhythm disorders (arrhythmias) affect an estimated one in 1,000 Americans. Arrhythmias are of many different types and degrees of severity. Some cause symptoms that are disturbing but not life-threatening. Others can cause death within minutes. There are between 200,000 and 400,000 sudden cardiac deaths annually _ most of which are caused by rhythm disorders.
The full picture, however, is far more hopeful. Advances in cardiac electrophysiology, the study of the heart's electrical activity, are making arrhythmias easier to detect and treat. Many arrhythmias can be cured today without using surgery. Arrhythmias that cannot be cured usually can be controlled by medication or advanced surgical techniques. With proper diagnosis and appropriate treatment, most people with rhythm abnormalities can live full, active lives.
However, to benefit from the advances that have been made, you face a difficult and important decision _ choosing a doctor and hospital for your treatment. No one has more at stake than you; it is one of the most important decisions of your life.
This brochure deals with the diagnosis and treatment of many types of arrhythmia. You may be reading this because you have been told you have an arrhythmia, because your doctor suspects you have one, or because you are considering treatment. Comparisons like those we talk about making are not possible in an emergency. If you make these comparisons early, you will be prepared should the need for treatment arise.
How Do You Judge Quality?
Most of us do more research when we buy a car or a television set than when we choose a doctor and hospital. That may be because we don't know what questions to ask or what to base our evaluation on. There are few consumer magazines that rate doctors and hospitals the way Consumer Reports rates air conditioners.
Quality of care can be measured in many different ways, and no universal agreement exists on which should be used. At The Cleveland Clinic Foundation, however, we believe that you can use the following six points, or quality indicators, to compare health care providers:
Choosing a doctor or hospital is often influenced by values. You may want to go to a hospital that is close to home. You may want a hospital with a specific religious affiliation. But when you need specialized medical care for an arrhythmia, you also should consider a doctor's qualifications and a hospital's outcome record. These quality indicators will help you make an informed evaluation should you require treatment for a cardiac arrhythmia.
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A Step-by-Step Guide
This guide helps you choose a doctor and hospital by:
Arrhythmia
The steady pumping of the heart is controlled by electrical impulses that signal the heart muscle to expand and contract. In a normal, healthy heart, a heartbeat begins with an electrical impulse in the sinus node, a group of cells in the right atrium, one of the heart's four chambers. In a healthy heart, contractions occur at a rate of 60 to 100 per minute when a person is at rest.
Some medical conditions _ such as heart disease, high blood pressure or heart attack _ can disrupt the heart's normal pattern and cause arrhythmia. Other causes of arrhythmia include stress, caffeine, tobacco, alcohol, diet pills and cough and cold medicines. Some types of arrhythmia are congenital _ present at birth _ and are not associated with other heart disease. In general, arrhythmia that is associated with other heart disease is more serious than arrhythmia that occurs in an otherwise healthy heart.
The three general types of arrhythmia are tachycardia (a rapid heartbeat), bradycardia (a slow heartbeat) and fibrillation (a chaotic, random, rapid heartbeat).
Arrhythmias that originate in the heart's upper chambers above the ventricles are supraventricular arrhythmias. Those that originate in the lower chambers are ventricular arrhythmias.
With a few exceptions, supraventricular tachycardia is not life-threatening. However, ventricular arrhythmia can cause cardiac arrest, a life-threatening situation in which the heart suspends its pumping action.
Symptoms of arrhythmia depend on the type, its severity, how long it lasts and how frequently it occurs. In some people, an arrhythmia goes unnoticed until a doctor discovers it during a routine physical exam. In other people, arrhythmia may be associated with symptoms of weakness, fatigue, chest discomfort, shortness of breath or fainting, or an episode of heart stoppage and resuscitation. Bradycardia often has no symptoms, but in more serious cases when the heart rate drops very low, it can cause the same symptoms as tachycardia.
Most people have felt dizzy, faint, out of breath, have experienced a fluttering in their chest, or noticed that their heart skipped a beat. For the majority of people, these experiences are harmless. If these symptoms occur only rarely and mildly, they probably are not symptoms of a rhythm problem. However, you should be evaluated by a doctor if symptoms persist, are severe or occur frequently.
How is arrhythmia diagnosed?
Because arrhythmias may occur sporadically, electrocardiograms (EKGs) that show the heart's electrical activity often are not effective in diagnosing these disorders. Even 24-hour EKG (Holter) monitoring may not detect the abnormal rhythm. In many cases, an electrophysiology study is the most accurate way to diagnose arrhythmias.
Cardiac electrophysiology studies provide detailed information about the heart's electrical activity and allow the physician to determine precisely where the arrhythmia originates in the heart and how serious it is. These studies also help the doctor to plan potential treatment to cure or control the arrhythmia. Advances in computer technology and electronics have improved the sensitivity and accuracy of electrophysiology studies and have reduced the risks of serious complications to less than 1 percent in the hands of an experienced cardiac electrophysiologist.
A cardiac electrophysiology study is performed under mild sedation. The cardiac electrophysiologist makes a small incision in a vein in the groin area. Next, a catheter (a long, thin line) with a tiny electrode on its tip is threaded through the vein and into the heart. The catheter is usually positioned on the heart's right side, where electrical impulses originate. Once in place, the electrodes transmit information to a computer about the heart's electrical activity and how that activity moves through the heart during each contraction. The pattern of electrical activity prints out on a rhythm strip similar in appearance to an EKG strip.
For more specific information, the cardiac electrophysiologist can deliberately elicit an arrhythmia using programmed electrical stimulation. To do this, the electrophysiologist moves the catheter to various locations in the heart and delivers a tiny pulse of electric current to the site to purposely create an arrhythmia. Because this procedure is done in a very controlled environment under continuous monitoring, the risks are small. The physician halts the abnormal rhythm almost immediately.
Once an arrhythmia is elicited, the patterns of electrical activation recorded by the catheter can help the physician identify the source and mechanism of the arrhythmia.
How is arrhythmia treated?
Many people with arrhythmia do not require treatment. Some arrhythmias can be prevented by avoiding caffeine or alcohol. Arrhythmia associated with underlying heart disease may be controlled by treating the heart disease. When the arrhythmia itself requires treatment, several options are available.
Drug therapy. Arrhythmia often can be controlled by antiarrhythmic drugs. With electrophysiology studies, the physician can test multiple drugs in a controlled manner to select the medication that is most effective in controlling the arrhythmia.
Radiofrequency ablation. Many types of heart rhythm disturbance can now be cured using this new, non-surgical procedure. Radiofrequency ablation uses precisely directed, high-frequency electrical energy to sear and eliminate tiny abnormal bundles of heart muscle responsible for the arrhythmia. Approximately 95 percent of patients who undergo this treatment are completely cured.
Implantable defibrillators. These devices are used to correct severe, potentially fatal ventricular arrhythmias. The defibrillator monitors the heart's rhythm and identifies arrhythmias as they occur. When it detects a deadly arrhythmia, the device disrupts it with a pacing impulse, or electrical shock, and restores a normal heartbeat.
Pacemakers. Pacemakers are the primary treatment for bradycardia, a heartbeat that is too slow. This small electrical device monitors the heartbeat and emits tiny electrical impulses which stimulate the heart when the heart rate falls below a critical rate. The impulses are sent to the heart by leads, or electrode wires, that go from the pacemaker to the heart. The newest pacemakers speed up or slow down the heart rate according to activity, allowing patients to be more active than with standard pacemakers.
Surgery. A small percentage of patients who have severe arrhythmias that cannot be controlled any other way require surgery.
Maze surgery is a new technique being used to treat atrial fibrillation. In this procedure, the surgeon creates a new pathway _ a maze _ for the electrical impulses to travel. This procedure can permanently restore the heart's natural rhythm.
Ventricular resection is a major open-heart operation that involves removing the specific site in the heart muscle where an arrhythmia originates. It is used only when no other treatment is effective or possible.
Where Do You Begin?
Measuring quality in ways that are useful to consumers is a new idea in health care. Because of that, it may not be possible to get complete information for each of these quality indicators. But the willingness of providers to give you as much information as possible is a good sign. It shows that they are dedicated to maintaining and improving their quality, responsive to patients, and confident of their capabilities.
If you are diagnosed with a heart rhythm disorder, ask your doctor about seeing a cardiac electrophysiologist, a physician who specializes in cardiac arrhythmia.
Get the names of several doctors and hospitals that offer the newest, most effective treatments and have the most experience in treating arrhythmia. Ask the questions we suggest. Make comparisons. Then make your decision. Be an informed consumer for yourself and your family.
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Second Opinions
If you have been told you have arrhythmia, you may want to seek a second opinion. A second opinion can confirm the diagnosis and ensure that the treatment planned for you is the most advanced with the best chance of effectively treating your type of arrhythmia.
How to Use Quality Indicators
How can you use these indicators to judge if one doctor or hospital is better for you than another? By combining information from more than one quality indicator, according to a report, "The Quality of Medical Care: Information for Consumers," produced by the U.S. Congress, Office of Technology Assessment.
According to the report, patients about to have surgery can be confident if the hospital performs a high number of surgeries, has a low mortality (death) rate, and if the surgeon has extensive training and experience in the procedure.
On the other hand, the report states "...if a hospital has a high mortality rate and a low volume of procedures, the patient might wish to question the surgeon about that hospital and about alternatives, even if other hospitals require longer travel."
1. Credentials
Do the doctor and hospital measure up?
Credentials have been set by nationally recognized medical professional organizations to verify that doctors and hospitals meet certain standards in health care delivery.
Doctors:
Board certification, or the international equivalent, is a sign that doctors are highly trained in their fields. Doctors who specialize, such as cardiologists, should be board certified in the specialty in which they are practicing. Each specialty has a national board that is responsible for setting standards doctors must meet in order to be certified. Doctors who are board certified in their specialties have completed the amount of training that the specialty board requires, have practiced for a specified number of years in that specialty and have passed a difficult examination in their specialty areas. Some excellent doctors are not board certified. Board certification, however, is generally a good indicator of competence and experience.
To become board certified in the sub-subspecialty of cardiac electrophysiology, physicians must first be certified in the primary specialty of internal medicine. Next, they must be certified in the subspecialty of cardiology. Then they must be certified in the sub-subspecialty of cardiac electrophysiology.
Other specialty boards _ such as the board that certifies pediatricians and pediatric cardiologists _ do not offer board certification in cardiac electrophysiology. Therefore, only physicians trained and board certified in internal medicine and cardiology can become certified as cardiac electrophysiologists. In the absence of sub-subspecialty certification, ask what training physicians have received and how long they have been practicing in that sub-subspecialty.
Hospitals:
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the nationwide authority that surveys hospitals. The JCAHO decides whether a hospital gets, keeps or loses accreditation based on its meeting certain criteria for staffing, equipment and facility safety requirements. Although accreditation is voluntary, most hospitals go through the process. If the hospital that you are considering is not accredited, it is important to know why.
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One of America's Best
· In U.S. News & World Report's 1995 ranking of hospitals, the Cleveland Clinic was rated the best in the country for cardiac care.
This is the sixth year that U.S. News has named the Cleveland Clinic one of "America's Ten Best Hospitals" and has recognized the Clinic for excellence in cardiology.
Q&A
Are the cardiac electrophysiologists board certified?
All Cleveland Clinic staff cardiac electrophysiologists are board certified in the primary specialty of internal medicine and the subspecialty of cardiology.* They have the sub-subspecialty certification appropriate to their fields at the highest level possible given their previous board certification and training.
Are the cardiothoracic surgeons board certified?
All Cleveland Clinic staff cardiothoracic surgeons are board certified in surgery and thoracic surgery.
Is the hospital accredited by JCAHO?
Yes. The Cleveland Clinic has JCAHO accreditation. For information about a hospital's status, call the Joint Commission on Accreditation of Healthcare Organizations at 708/916-5800.
Has the hospital been positively and consistently recognized for medical excellence and leadership?
Hospitals that measure up are often in the public spotlight for their medical advances and the quality of their care. Information about a hospital's reputation is widely available through the mass media, the government, consumer groups, and books and magazines such as U.S. News & World Report. The Cleveland Clinic is often named among the top medical centers in the country. Some of the publications that have recognized the Clinic for excellence include those in the box at the left.
*Board certification or its international equivalent became a requirement at the Cleveland Clinic in 1989 for doctors being appointed to the medical full staff.
One senior staff member has the equivalent of board certification in many years of experience, recognition by his peers and accomplishments in his field.
2. Experience
Does practice make perfect?
In the case of complex medical and surgical care for arrhythmia, the more experience the doctors and hospital have, the better the results usually will be.
An experienced electrophysiologist has an in-depth understanding of the causes, diagnosis and treatment of arrhythmia gained from diagnosing and treating many patients. Years of experience give the electrophysiologist the professional judgment necessary to quickly and accurately determine the origin of an arrhythmia and the best treatment for it.
An experienced electrophysiologist or cardiac surgeon who performs many procedures and treats many arrhythmia patients generally has a higher level of expertise than a physician who treats arrhythmia patients only occasionally. An experienced physician who has handled many cases also is prepared for the most difficult situations and potential complications that may arise during treatment.
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How many children with arrhythmia are treated?
Each year Heart Center pediatric cardiologists care for more than 100 children with arrhythmia and perform more than 50 radiofrequency ablations.
The Cleveland Clinic has the most experience in Ohio and one of the largest experiences in the country in diagnosing and treating arrhythmia in children from birth to age 21.
Q&A
How many people with arrhythmia are treated at the hospital each year?
Cleveland Clinic electrophysiologists annually provide for nearly 5,000 adult and pediatric patient visits each year.
How many radiofrequency ablations are done?
Heart Center electrophysiologists were the first in Ohio to perform radiofrequency ablation and now treat nearly 300 patients annually with this technology. They perform about 1,000 electrophysiology studies and catheter procedures each year.
How many pacemakers are implanted?
Heart Center specialists implant nearly 500 pacemakers annually, more than any other center in Ohio and one of the highest volumes in the country.
How many defibrillators are implanted?
Clinic electrophysiologists were the first in Ohio to implant cardiac defibrillator systems for treatment of arrhythmia, and now implant more than 140 each year. Clinic cardiac electrophysiologists have Ohio's largest and longest experience with implantable defibrillation systems.
How many surgical procedures to treat arrhythmia are performed at the hospital?
Heart Center cardiothoracic surgeons have done over 50 Maze procedures for atrial fibrillation, and have one of the country's largest experiences with this procedure.
How many pacemakers and implantable defibrillators are regularly monitored?
Heart Center cardiologists monitor pacemakers and defibrillators for patients either during office visits or electronically over telephone lines. Approximately 10,000 monitoring events take place each year.
Does the physician have experience in extracting pacemaker infected or damaged leads?
Heart Center electrophysiologists have extracted 487 pacemaker leads from 286 patients; the second highest volume in the United States.
3. Range of Services
What services are available?
Hospitals with a broad range of services can treat more complex medical conditions and better handle complications that may occur.
Range of specialty departments
Patients with arrhythmia often have other related medical problems such as high blood pressure, heart disease or other heart or lung problems that also require treatment. Therefore, immediate access to a full range of specialty departments within a facility is critical.
Range of treatment options
Appropriate treatment of an arrhythmia depends on the cause, but treatment that is effective for one person with a specific rhythm disorder may not work for another person with the same problem. For these reasons, it is important to choose a facility that can treat arrhythmia in a variety of ways. That way you will get the most effective, appropriate and cost-effective treatment available.
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Range of Services
Q&A
Is help available from a full range of specialty departments?
The Cleveland Clinic's 600 physicians _ all on staff full time _ provide care in more than 100 specialties and subspecialties. All of these specialties are present in one facility, so multidisciplinary consultation, diagnosis and treatment are readily available.
Does the hospital offer a variety of options for diagnosing and treating arrhythmia?
The Cleveland Clinic Heart Center offers the complete range of interventions for life-threatening arrhythmias, as well as arrhythmias that are chronic and do not require emergency treatment. The full range of services is listed to the left.
Are special services available to treat children?
The Heart Center offers a full range of diagnosis and treatment options for children with heart rhythm disorders. When children must be hospitalized, treatment is provided in the Cleveland Clinic Children's Hospital, which includes a Pediatric Intensive Care Unit for seriously ill infants and children.
Does the hospital have a dedicated laboratory for electrophysiology studies and procedures?
The Cleveland Clinic has three dedicated, state-of-the-art electrophysiology laboratories equipped with the latest instruments to aid in the improved diagnosis of arrhythmia, including experimental devices being developed here in cooperation with industry. The advanced imaging capabilities in these laboratories improve the accuracy of diagnosis, drug testing and ablation, and allow Heart Center electrophysiologists to perform radiofrequency ablation for a wider range of problems.
4. Participation in Research and Education
What type of hospital is it?
Selecting a hospital that combines patient care with research and education offers many advantages.
Ideally, the individuals engaged in patient care, research and teaching are organized around a given disease or class of patients, facilitating the sharing of knowledge, research and clinical findings. This approach results in the most rapid transfer of basic scientific knowledge from the laboratory to care delivered at the patient's bedside.
Those individuals on the staff of such a hospital are exposed to an important interchange of ideas. They are also exposed to the newest treatments and technology. At teaching hospitals, physicians are available 24 hours a day.
Choosing a teaching hospital for your care may offer other advantages as well. Private, not-for-profit teaching hospitals had lower mortality rates than other types of hospitals, according to a study in the December 1989 issue of the New England Journal of Medicine.
Q&A
Is the hospital associated with a teaching program?
Yes. The Cleveland Clinic sponsors one of the nation's largest physician postgraduate training programs and is affiliated with The Ohio State University College of Medicine.
Does the hospital have fully accredited residency training programs in heart disease?
The Accreditation Council on Graduate Medical Education has accredited our residency training programs in cardiology, cardiothoracic anesthesiology, and thoracic and cardiovascular surgery. Presently, 72 physicians are being trained in these programs.
Does the hospital have an advanced residency training program in electrophysiology?
Yes. The Cleveland Clinic offers advanced training in electrophysiology to physicians who have completed the three-year cardiology residency training program.
Does the hospital conduct research or clinical trials related to arrhythmia?
Clinic electrophysiologists are involved in basic laboratory and clinical research projects which include:
5. Patient Satisfaction
Is everybody happy?
If you ask one person about his or her experience with a doctor or hospital, you get one person's point of view. Patient satisfaction surveys allow you to judge quality based on the experience of many previous patients. This provides you with a more objective measure to use.
Most hospitals routinely use surveys to learn if patients are satisfied with their medical experiences. The hospital can use these results to improve its services.
Patient satisfaction often reflects the personal side of care. Surveys ask questions such as, How willing are the doctors and nurses to listen? Do they answer questions and explain treatments? How much time does the doctor spend with the patient? Is the hospital clean? Is the food good?
Patient satisfaction information can predict what your experience in a particular hospital is likely to be.
Q&A
How satisfied are hospitalized patients with their experience at this facility?
93% of patients with heart problems who are hospitalized at the Cleveland Clinic are satisfied with their hospital care.
93% said they would return.
How satisfied are outpatients with their experience at this facility?
96% of patients with heart problems who come to the Cleveland Clinic as outpatients are satisfied with their experience.
95% said they would recommend the Cleveland Clinic to their family and friends.
Is there a program to help patients and their families with the difficulties that may arise during a hospital stay?
Cleveland Clinic patients may call an ombudsman _ another name for a patient-relations representative _ if they have concerns about their care.
Patients in the Cleveland Clinic hospital may dial a 24-hour Helpline from their hospital rooms if they have any problems, questions, suggestions or concerns related to service.
6. Outcome Indicators
What are the risks?
All risks of death and complications associated with a procedure cannot be eliminated, especially for seriously ill patients. However, your risk can be reduced by choosing a hospital with a low mortality (death) rate.
The mortality rate associated with a procedure, as well as complication and survival rates, are important measures of your risk and sensitive measures of quality. The potential complications associated with treatment of arrhythmia include infection, bleeding, compression of the heart, and having the space between the lungs and the chest wall fill with air, a life-threatening condition called pneumothorax.
Although the greatest period of risk is during the hospital stay, your risks are also affected by the type of patient you are. Mortality rates generally will be higher for patients who are over age 65, or for patients with medical problems in addition to arrhythmia.
Ask the doctor and the hospital for their mortality and complication rates. Try to compare rates for patients most like yourself. It is important to try to compare apples to apples so that you know what your risks really are. This may be difficult, however, because mortality and complication rates may be reported differently. If a doctor or hospital cannot give you mortality rates or is reluctant to give information, look at alternatives.
On the following page, we provide our mortality and complication rates for arrhythmia treatment at the Cleveland Clinic. We have also provided, whenever possible, the most comparable national benchmarks available.
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Pacemaker Lead Extraction Requires Skill
A small percentage of pacemaker wires, known as leads, may become infected or damaged over time. When that happens, these wires, which connect the pacemaker to the heart, must be removed. If a wire is not properly removed, it could tear the heart, a valve or a vein.
Cleveland Clinic physicians are experienced and highly successful in extracting leads without complications, using modern techniques developed only at the Cleveland Clinic and a few other centers.
Q&A
What is the mortality rate for radiofrequency ablation?
The Clinic's mortality rate for 284 radiofrequency ablation procedures in 1994 was 0.4%.
By comparison, the June 1991 issue of Circulation cited a 1.9% mortality rate for ablation procedures in 800 patients.
What is the radiofrequency ablation success rate?
Heart Center success rates for radiofrequency ablation are among the best in the nation, ranging from 90% to 99% for most types of arrhythmia.
By comparison, the average success rate at the five medical centers that perform the most procedures was 93.6%, according to a 1992 article in the Journal of Interventional Cardiology. Success rates ranged from 85% to 98%, depending on the center and the procedure.
What is the mortality rate and complication rate for defibrillator implantation?
For 146 cases in 1994, the Cleveland Clinic had a 0.0% mortality rate and a 2% complication rate for defibrillator implantation.
By comparison, an article in the Nov. 1, 1991 issue of the Journal of the American College of Cardiology reported a 2% to 3% mortality rate. Although not reported, complications would be expected to be higher than mortality.
What is the pacemaker implantation complication rate?
The Cleveland Clinic's complication rate for 485 pacemaker implantations in 1994 was 2%.
By comparison, a 1994 article in the Annals of Thoracic Surgery cited an overall complication rate of 5.2%.
What is the mortality rate for pacemaker lead extraction?
The Clinic has a 0.0% mortality rate for pacemaker lead extraction, based on 487 extractions from 286 patients.
This compares to a multicenter mortality rate of 0.6% cited in the November 1994 issue of PACE.
Pioneering Work in Arrhythmia Treatment
The Cleveland Clinic Foundation is recognized nationwide for its comprehensive commitment to understanding, diagnosing and treating rhythm disturbances in children and adults. Doctors here have pioneered many advances in the diagnosis and treatment of arrhythmia:
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For Information
If you need more information or want to make an appointment with a Cleveland Clinic electrophysiologist, please call one of the numbers below:
216/444-6697 (in Cleveland)
800/CCF-CARE (223-2273), Ext. 46697 (toll-free outside Cleveland)
If you would like to receive any other guides in our series "How to Choose a Doctor and Hospital for Your Treatment," you may call one of these numbers:
216/444-8919 (in Cleveland)
800/545-7718 (toll-free outside Cleveland)
Cleveland Clinic Florida
Through such activities The Cleveland Clinic Foundation seeks to maintain its international reputation for excellence and innovation in the diagnosis and treatment of cardiac arrhythmia. Its affiliated Cleveland Clinic Florida is drawing upon this experience and expertise to establish corresponding state-of-the-art programs in arrhythmia treatment. For more information or to make an appointment at Cleveland Clinic Florida, call 800/359-5101.
Reprinted with permission by: Med Help International