R. William Stones, MD

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 "We're       at the meeting of the International Pelvic Pain Society here in       Connecticut, and I'd like to introduce my colleague, Dr. Jerome Weiss, who       is the Director of the Pacific Center for Pelvic Pain and Dysfunction at       San Francisco. I'm William Stones, I'm a British gynecologist in academic       practice at the University of Southampton, and I've come over to see what       my American colleagues are up to in the field of pelvic pain. So it's, as       you can imagine, quite an interesting experience for me because they do       have some very different perspectives on these things. One of the features       I'm really appreciating at this meeting, Dr. Weiss, is the       interdisciplinary nature of the meeting; we're hearing from colleagues       from different specialties that are giving a different angle, and also       really learning about some of the different patient groups that we get to       see. I wonder, if you could share with us what kind of patients tend to       make up your practice."
       
       

 "First,       I want to mention how the meeting has been developing over the years that       I've been coming, and how all the groups are coming together and starting       to see things a little bit more similarly. It's been very exciting to see       the blending of ideas, not just separate ideas, but people are really       blending them. I come from an area looking at pelvic floor dysfunction as       an underlying cause for many of the pelvic complaints that we see that are       many times looked at separately but I think can be tied together under one       underlying etiology of pelvic floor hypertonerism spasm. We see people in       my office that have interstitial cystitis or urinary urgency or frequency,       vaginal pain, vulvodynia, anal pain, low back pain, or suprapubic pain,       and they may all be treated separately because the shelf/shallow pelvic       floor muscle spasm trigger points behave in a very sound fashion. Instead       of speaking out, they send their increased tension or muscle and muscle       nerve reflexes to the various organs that penetrate them - such as the       urethra, vagina, and the rectum. Because they insert on the same route,       there can be low back problems, and because of trigger point referral       patterns, they can be felt in many other areas. So as a consequence,       patients could go to a gynecologist, urologist, and proctologist, and they       all seem to be looked at separately but rather not seeing the whole       picture."
       
       

 "Yes,       so you're a urologist. What was it that led you to start thinking in a       slightly wider way or how did this way, when you see patients with       primarily bladder symptoms - what was it that led you to start asking them       about their pelvic floor or examining their pelvic floor?"
       
       

 "There       have been studies - years of medical studies - that show that urine       urgency and frequency, severe urgency and frequency, was the cause of       increased tension of urinary sphincter. I was aware of that, and many       standard urologic procedures do not attend to give any long-term success       as urethra dilations, antispasmodics, and so on - because it's the muscles       surrounding the urethra that are involved and dilations can help. So as a       consequence, I started to investigate other means; I started doing       acupuncture, and I was doing acupuncture for, maybe, several years before       I realized that it really wasn't the answer either, and since acupuncture       currents and manufactured trigger points are one and the same - I started       to explore the possibility of working on those in another manner."
       
       

 "So       we're really talking about patients who've been through, perhaps, a       routine work-up with an absolute suppositive finding. Is that the sort of       patient group that we're really talking about?"
       
       

 "And       that's a suppositive findings or a finding that is thought to be the cause       but isn't and, therefore, receive surgical treatment and so on."
       
       

 "So       that would be individuals who've had medical or surgical treatments or       both or...?"
       
       

 "Yes,       they would have had medical treatments generally or surgical treatments. I       usually see them after they've failed the methods."
       
       

 "So       women who've been through that sort of process already, and they've had       failure treatment, they must be pretty angry and hostile individuals when       they get to your office."
       
       

 "I would       say in general, they're pretty agitated, upset, depressed, and pretty       hopeless a lot of times."
       
       

 "Yes,       are there any tips that you can give us as to how you would actually get       through and establish a rapport with somebody who's really had that       previous negative experience with investigation and treatments?"
       
       

 "I would       say - first of all listen, because most doctors will hear them, but not       really hear them. I think if you really listen to the patient and spend       time - I think that's how I usually get through the first day."
       
       

 "Right,       that sounds like going back to basics in medical practice. Were there any       very specific features that you would be looking for in the history that       would most take you in the direction of thinking about a pelvic floor       dysfunction or point you in the direction of wanting to identify trigger       points?"
       
       

 "Many       times, as I mentioned, there's a whole complex that goes together with the       pelvic floor 

       They complain of urinary symptoms, some difficulty starting a stream or       some other dysfunction of voiding, frequency or urgency, or they'll have       the vulvar symptoms etc., or they'll have back problems. What I start       doing is going over their history to find out what might have set off some       of these problems because myofascial trigger points, active points, are       usually the result of accumulation of traumas, not necessarily one trauma.       When we look at this…."
       
       

 "So       you'll be delving into the history of specific episodes that could have       led to an inacerbation"
       
       

       "Exactly, and if we go way back into childhood, and we're going to       try to because you can find early in childhood there can be issues that       have set off a tension holding pattern and maintained through life that       have been added to the other traumas."
       
       

 "Would       those most prominently be issues of the family life or issues like sexual       abuse?"
       
       

 "There       could be sexual abuse, but there could be problems even with dance and       gymnastics. Children that are taught ballet are taught to hold their       center core very tight and to keep their pelvic floor tight, and in       gymnastics the same. It could be abnormal problems with bad training,       there's a lot of problems occasionally that surround that, or could simply       be a lot of stress during childhood, and that's an area that they hold       their stress. It could be urinary infections as children, and so on -       there's a whole list of things that could occur."
       
       

 "In       your own practice, do you find that sometimes this can be difficult in a       consultation to really start to uncover these issues or is this kind of       information that patients are, in a way, waiting to share with you?"
       
       

 "It's a       variable thing, some people share immediately, and other people with tears       in their eyes - they don't have to say anything, you can just mention some       of the possibilities. I don't say - "did you" - I just mention -       "these are some of the things" - and you can tell sometimes what       the story is."
       
       

 "That       why it's good. Could you take us through your approach of the physical       examination in one of these patients who has a chronic condition with a       number of organ systems involved, some bladder symptoms, perhaps some       vulva pain. How would you approach this examination?"
       
       

 "Because       some of the surrounding muscles groups can affect the pelvic floor, I       first look at the way they walk and their posture just taking them into       the examining room, have them stand up, look at their back, look for a       lordotic position or tilt, pelvis tilt, or weaknesses of abdominal wall.       Then I will lie them down and check the abdominal wall muscles, the rectus       abdominis for trigger points, the ileococcygeus muscle, the gluteal       muscles, the abductors, the piriformis, and so on, and just look for any       areas that might be abnormal with tenderness or trigger points. Then we'll       usually put them in a lithotomy position and inspect the pelvic floor -       usually by compression - externally to see if there's any tenderness and       many times it's real tight and tender just on external compression. I'll       look at the vulvar area and the vestibule, and generally I use the Q-tip       test to check for sensitivity developed in the vestibular area and see if       there's any other abnormalities. I check the strength of pubococcygeus       muscle, though it can contract or relax many times; if they've lost       complete control of that there is so much pain or weakness from trigger       points that they have no connection at all. Then I'll assess various       muscles groups internally with my finger, looking at the levator groups,       the coccygeus, piriformis, the urinary sphincter etc.; the obturator       internus is a very important one as well. Once I've established the       pattern, then I'll go ahead and start working on these muscles to try to       relax them using standard manufobic       techniques."
       
       

 "In       terms of your diagnostic findings on examination, do you tend to find that       one particular muscle group is involved or do your patients tend to have       some degree of tenderness or spasm associated with many of the       muscles?"
       
       

 "Yes,       muscles will kind of work together, when there's a lot of tension most of       the muscles will get tense, but there are specific areas that I find will       relate to the complaint. If they have urinary symptoms there usually will       be tightness around the urinary sphincter, the puborectalis. If they have       clitoral pain behind that same area to be involved, you constantly nick       the pudendal extension if you tend to work into that area into the       clitoris, so when they come in complaining about that, I find that's       really a very tender area. I also find that priformis muscle to be       extremely important, vaginal symptoms, and then so on, around the anus,       and so on for symptoms back there."
       
       

 "Then       your findings on examination do tend to relate quite reasonably to a       particular pattern of complaint?"
       
       

 "In       general, but many times I'm surprised that the referral can be quite so       erratic, but in general, I suppose."
       
       

"So can       you outline the main approaches to treatment when you've identified the       muscle groups that you think are mainly the problem?"
       
       

 "What I       do with treatment would be using manual therapy techniques of stretching,       compression, and sometimes injections - trigger point injections using an       anesthetic agent. We'll try to eradicate the tender spots, but we also       need to re-educate the muscles to be sure the muscles are stretched to the       full range and contracted. It's a re-training process because these       muscles have not known full range of motion for a long time."
       
       

 "So in       practical terms, is this something that you would need to repeat on a -       what sort of frequency?"
       
       

 "I would       need to repeat it ideally twice a week but generally on patients, how       difficult is it coming in that often, so I do it once a week. That depends       upon the condition on how long it's lasted, we may have to do with, maybe,       10 or 12 treatments fairly close together then start spreading them out       according to their improvement. This is only part of the treatment because       we have to work on the external muscle groups as well, so a physical       therapist will use stretching, manual therapy and instructions as well,       and then we do biofeedback, re-education, pelvic form for strengthening,       relaxation, so that's many arms of it."
       
       

 "Just       recently I've had some experience of using biofeedback. It does seem to be       encouraging - is that your perception that that's a useful modality?"
       
       

 "I think       it's essential, it gives the patients a connecture       of the pelvic floor. A lot of times they just don't know what to do with       it, they just have no energy, and they just completely don't want to have       anything to do with the tightening or relaxing. It's a matter of       re-training them and reprocessing them so they can connect. I think it's       extremely important that they say it's a help that can be done on a daily       basis at home, and it reinforces what we've been doing. In addition to the       biofeedback, we also many times teach the spouse how to do some of the work       internally because that also will be a more constant, even penile, will be       a more constant therapy."
       
       

 "In a       patient who is responding to this sort of personal treatment, over what       sort of time frame will you get a response? Is it fairly immediately or do       you fail to see a particular individual is going to benefit or is it       something that will only become apparent later on in a series of       treatment?"
       
       

 "There's       a variation on that too, again, depending on how long it is and what other       elements there are. Many patients will feel better when they get off the       table for the first time because everything feels lighter and it feels       different. I think to get sustained improvement, it may take months, it       could even take up to a year depending on what circumstances there are, to       really get sustained improvement. Vestibulitis patients, I'd say, take a       good eight-to-nine months or so; interstitial cystatic patients may take       one or two years, but it's an ongoing process of re-education."
       
       

 "Do you       think that the approach that you are taking in this group of women - do       you think this is something that all gynecologists or urologists should be       trying to extend to their practice or is this something which is really       quite specialized and applies to a very definite group of, if you like,       difficult patients that really should be seen by somebody with a very       special interest in that area?"
       
       

 "I think       that all gynecologists and urologists should be aware of this because I       think as we discussed in the meeting today, it's better to try to head off       something in the early stages than to let it go too long for central       sensitization to occur. I think that it should be a preliminary to any       kind of surgical or invasive procedures. I think from that standpoint,       they should be aware of it, and I think it could be learned; it's not that       hard basically."
       
       

"So you       feel this is something that every gynecologist or urologist should be       having in their mind during their initial assessment of patients with       pain?"
       
       

 "I       definitely think so, it's very important."
       
       

 "Do you       have any pearls of wisdom that you can share with us in this field with       regards to diagnosis or treatment approaches?"
       
       

 "I think       basically, as what you said, a pearl is a sudden awareness realizing that       this does exist as an entity, that through various nerve reflexes it can       create all kinds of symptoms. And that if it's not brought up and       examined, a lot of future patients will treat it improperly. What we       really need to do is just pay attention."
       
       

 "Dr.       Weiss, thank you very much."
       
       

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OBGYN.net Conference CoverageFrom IPPS - Simsbury, Connecticut - April/May, 1999

Pelvic Pain and the Pelvic Floor - Diagnosis and Treatment

 "Hello,       I'm Dr. Jim Carter, and I'm here in Connecticut at the International       Pelvic Pain Society meeting. With me I have R. William Stones, physician       from England, specifically University of Southampton, who has been very       busy working in this area of pelvic pain for many years and has a number       of insights into how we should approach women with chronic pelvic pain.       Welcome to Connecticut, it was a long trip, and I'm sure happy you're       here."
       
       

 "Thank       you very much Jim, it's a pleasure to be here. It's particularly       interesting to get the American angle on pelvic pain and see how it       compares to the way that things happen in Britain and Europe. I think that       some of our perspectives have been somewhat different over the years, and       it's very interesting to exchange views with colleagues."
       
       

 "Let's       start with the views from England and the area that you are in;       approaching women with chronic pelvic pain - would you describe some of       your work?"
       
       

 "Yes, I       think, probably in common with practice in the U.S., most women probably       have a laparoscopy looking for specific pathology at an early, early stage       in their investigation. But one of the problems arises when we don't find       specific pathology, and I'm sure that's your experience as well. The       question then arises - how do we explain the condition in women who have       pain but don't have specific obvious laparoscopic pathology? I think one       of the answers may well be that we haven't looked hard enough, that we       haven't done a laparoscopic evaluation that hasn't been systematic as it       should have been. But I think on the other hand, there are people even       when we do our laparoscopy very carefully that clearly don't have specific       pathology. The condition that we've really focused on quite a lot over the       last few years, and particularly under the influence of my own teacher,       Richard Beard, has been pelvic congestion syndrome - i.e. pain related to       congestion of veins in the uterus and the ovarian circulation."
       
       

 "Could       you describe what you might find on a physical examination, a radiologic       study, and a laparoscopy for your patients with pelvic pain and       congestion?"
       
       

 "Sure,       I think the classic clinical features that Richard Beard has highlighted       are really a variable nature of the pain, that symptoms are typically not       confined to one specific location, they may well shift. There's the       posture effect, particularly, that the patient's symptoms will be       exacerbated by their standing for a long time, perhaps relief by rest. I       know that Richard describes the classic occupation of the patient with       pelvic congestion as a hairdresser whose occupation makes her stand all       day attending to her clients."
       
       

 "So one       first thing to look for is in the history. A real important feature is the       occupation; a person that's standing a long time can develop this type of       pelvic congestion, kind of a venous stasis-type picture."
       
       

       "Absolutely. I suspect it's probably not the primary cause but in       somebody who has that predisposition, it's certainly an acerbating       factor."
       
       

 "And       then physical exam…"
       
       

 "Just       finishing on the symptom thing. I think the other very interesting symptom       which we don't always get unless we inquire for it specifically, is in       women who have pain with intercourse, there's pain going on after       post-coital aching. Those are symptoms that women may not volunteer during       their consultation unless we ask them specifically about it. I think that       seems to be a particular feature with pelvic congestion."
       
       

 "So       those women who have pain afterward…."
       
       

 "Going       on after intercourse."
       
       

 "That's       a common complaint that we'll hear and that may be related to this issue       of pelvic congestion."
       
       

       "Absolutely. Going on to the physical exam, I think, perhaps       tenderness typically related to the ovaries rather than the uterus or       uterine - I call ligament tenderness, but adnexal palpation by manual       palpation of the ovaries, perhaps exquisitely tender."
       
       

 "So on       the deep palpation, the physical exam, the ovarian tenderness…"
       
       

 "Yes,       the tenderness seems to be more prominent and related to the ovaries than       the uterus itself."
       
       

 "And       then your radiologic studies, could you describe those?"
       
       

 "Yes,       the technique of venography to demonstrate pelvic venous congestion is an       old technique, it's been around, I think, since the 1940's, that recently       has been used more systematically, perhaps, to try to evaluate that pelvic       congestion. The technique is actually surprisingly simple for those who       are familiar with doing hysterosalpingograms. It's really not too much       more troublesome for the patient than a hysterosalpingogram. But the       trans-myogram where a needle is inserted - just penetrating a couple of       millimeters into the myometrium, and then contrast medium injected under       fluoroscopic screening into the myometrium with some vigor. Then we can       see on the imaging the contrast medium dispersing into the pelvic veins,       and get that impression not only of the venous diameters but also of the       clearance - the venous clearance - which I think is one of the key       features of pelvic congestion - that it's dilated veins that would reduce       the rate of clearance from the pelvic veins."
       
       

 "You       inject the dye just a couple of millimeters deep into the myometrium, the       veins are dilated but they clear very slowly."
       
       

 "That's       right, you get pools of contrast medium sitting there for several minutes,       even up to ten minutes. One really wonders why those veins don't clot, the       contrast just seems to be sitting there. I think it's obviously desirable       not to be minimizing one's use of radiation, even diagnostic radiation, in       women in their reproductive years. Of course, we're talking about a       condition which is a relative feature of reproductive years, and obviously       it would be better if we could primarily rely on ultrasound."
       
       

 "Are       there ultrasound findings that can help you with this diagnosis?"
       
       

 "Yes,       we can certainly identify dilated pelvic veins, particularly, I think the       transvaginal ultrasound. I think the possible problem with transabdominal       scanning is that the full bladder that we use for our artistic window may       possibly contract some of the pelvic veins and alter their appearance, so       transvaginal is probably the ideal modality. One can easily assess       diameters using transvaginal but unfortunately it's less easy to really       assess venous clearance or venous flow because, I think, the Doppler       possibilities are really still under evaluation. So the venous flow rates       tend to be rather low, and it's difficult to get a decent Doppler shift in       order to get meaningful data."
       
       

 "Then       your findings of laparoscopy, are there any specific pearls that we could       give to the laparoscopist on what to evaluate?"
       
       

 "Anyone       who undertakes laparoscopy certainly will have seen very dilated pelvic       veins, and in the appropriate context that could be very useful. I think       the practical problem for diagnostic laparoscopy as the modality for       diagnosing pelvic congestion is, of course, we have the patient in the       head-down-tilt, and we've also distended the abdomen with gas for the       procedure which in both procedures will tend to collapse pelvic veins. I       think as some people have advocated, carrying out laparoscopy with some       degree of head-up-tilt and perhaps using a minimum of gas. But I think the       bottom line is - it's probably unrealistic to rely entirely on laparoscopy       for the diagnosis of pelvic congestion. I think we'd probably be better       off with ultrasound."
       
       

 "So if       a physician sees pelvic congestion at laparoscopy, they can pretty well       say, "That's pelvic congestion." But then if they don't see it,       it still could be a significant factor. They need to look at their history       of a standing position with occupation, with the complaint of pain after       intercourse, the discomfort after intercourse, and also the physical       examination findings of tenderness in the ovarian focil area rather than       on the ovaries. Then they do the laparoscopy, if they've done the       procedure to look for the dilated veins or even at ultrasound if they see       the dilated veins, perhaps, they should simply be ready to treat."
       
       

 "What       treatment approaches are you using?"
       
       

 "I       think if we're going up the scale of invasive treatments, one would start       obviously with simply discussing the diagnosis with the patients. I tend       to discuss the diagnosis very much as one might with the diagnosis of       cerebral migraine. In other words, this is a pain of vascular origin,       which as in the case of cerebral migraine isn't associated with any       ongoing or serious progressive pathology but it does, of course, cause       pain. Thinking in terms of a migraine-like condition, I think that's a       conceptual model that patients find very useful, and that type of       explanation sometimes lead women to say, "Thank you very much, now       I've got an explanation for my pain." It helps remove the anxiety,       and they perhaps don't necessarily need specific treatments. Moving up the       scale then, of course, to people who do need specific treatment. I think       the women fully evaluated in our practice are certainly under the       leadership of Richard Beard, our treatments with ovarian suppression. One       that we know most about is using a high dose of medroxyprogesterone with a       dose for endometriosis of around 30 milligrams daily taken continuously.       That seems to be effective in reducing pain symptoms."
       
       

 "I've       also seen good reports on norethindrone of 20 milligrams, a similar       approach."
       
       

 "I       suspect there isn't any one specific route of the choice of ovarian       suppression, and similarly, the analogues will obviously will be       potentially useful."
       
       

 "The       GNRH analogues are appropriate ?."
       
       

 "Of       course, they'll be limited by each individual's side effects and the use       of addback which will obviate side effects. Then the limiting factor, of       course, becomes practicality and costs."
       
       

 "Yes,       the addback meaning the addback of .3 milligrams, say of an estradiol       agent?"
       
       

 "Yes,       and that doesn't seem to render the ovarian suppression less effective in       terms of pain relief."
       
       

 "Then       if you go into a surgical modality for treatment - what approaches are you       using?"
       
       

 "Again       the extreme, of course, would be hysterectomy and oophorectomy. I think in       women with this condition, if they have reached the end of the line, if       they are in extreme pain, and other treatments haven't been successful, it       does seem to me that treatment by hysterectomy with ovarian conservation       is not a good idea. Removing the ovaries and then continuing long-term       estrogen replacement is probably much more appropriate. If one does a       hysterectomy and conserves the ovaries, that is likely to be associated       with unknown symptoms. Of course, we are talking about young women with       this condition, and therefore, early recourse to that kind of mutilating       treatment is clearly inappropriate. This is really reserved for those with       very extreme symptoms where other treatments have failed."
       
       

 "I've       had physicians report to me that uterine suspension or uterine positioning       procedures have also been performed in those patients who are preserving       fertility and gives them a relief for a period of time until their       pregnancy. Then of course, if this condition recurs and becomes a terribly       severe condition, I know Dr. Beard demonstrated an 80% success with the       extirpation procedure, which of course you want to reserve, but it does       have to be considered in some of the worst cases. Do you have any pearls       on the diagnostic area for this rather underdiagnosed condition, because       when we're looking at laparoscopy we don't see the dilated veins       generally. So we probably missed this at our laparoscopy, our "gold       standard" of laparoscopy somewhat fails us because the positions       people are in. Could you give a pearl to the physicians who are watching       that will help alert them to being a little more open to this?"
       
       

 "The       key thing is to be aware of that diagnostic possibility from the outset.       The clinical evaluation is the diagnosis that perhaps should be formed       early on in the process of diagnosis rather than at the end when all the       investigations have proved to be negative. If we're considering if we're       asking the right questions, I think, the pearl really is to focus on the       history and the physical exam, and in a way we're half expecting our       negative laparoscopy or our observation of dilated pelvic veins."
       
       

 "So       truly, this is a place where history and physical examination, and one       additional small pearl would be as I picked up from your discussion - ask       if you send your patients to a radiologist or to an ultrasound center, and       you're not doing your ultrasound yourself, ask them to measure the caliber       of the veins. How often do we actually get a report back where they've       told us the caliber of the veins - I think very rarely."
       
       

 "Jim, I       think that's a very important point, and it's something that when one is       carrying out ultrasound scans one would assume somebody has mentioned the       possibility of looking for a vein but suddenly become obvious and       sonographers then sometimes say, "I've never seen them." Then       one says, "Well, just go and look for them." And then having       pointed them out - it's obvious. But as you say, if we don't ask about       information from our sonographers, then we won't get it."
       
       

 "Is       there a particular diameter of these veins, just to comment that they       should be looking at when they do this caliber measurement?"
       
       

 "Yes, I       think the variables to look at, perhaps, are the number of veins. I think       in some individuals would be one or two quite large veins, perhaps, more       than a centimeter in diameter but others will have very large numbers of       smaller vessels in say, the 3-5 millimeter range but they'll be very       widely distributed around both adnexa. It's really the number of vessels       and their caliber."
       
       

 "So       you're looking at ovarian veins, and you're looking at caliber, and if       it's greater than a centimeter you should be concerned. If there's one or       two that are greater than a centimeter or if you see this plexus of       ovarian veins, that's just a mass of 3-4 millimeters veins that are all       distributed - that would give you a very good hint."
       
       

 "Yes,       exactly. I think it's important to bear in mind the limitations of       ultrasound compared to venography in that it is more difficult to evaluate       venous flow and venous clearance - ultrasound can't do that. If we really       want the gold standard and that still remains transvaginal sonography."
       
       

 "I am       very thankful that you've taken the time to travel from England to the       States to give us a perspective. By the way, I'd like you to tell the       audience the opportunity they have to come to London to England to your       conference. Do you want to give us some information on that?"
       
       

       "Certainly do, Jim, thank you. On Saturday, May the 13th in the year       2000, we're having the millennial meeting of the International Pelvic Pain       Society in London in England. That's going to be a meeting held the day       before the start of the World Congress of Endometriosis. Maybe many who       are planning to come to that World Congress which starts on Sunday, the       14th of May, might like to add that to their schedule, perhaps come a day       or two earlier and can join in. We've got a very pleasant venue for the       meeting in Central London at the Royal Society of Medicine, and I'm sure       that's going to be very exciting meeting."
       
       

 "I'd       like to add - we're working out the details of this program. Dr. Stone,       I'd be very appreciative myself if you would run a work shop prior to that       on your work on the venography and the techniques that are used. Also,       we're hopeful that he's going to put together a very nice party the night       before for all of you, and a little plenary lecture, and perhaps, a       reception. So come in early, don't just plan to come in for the 13th,       we're going to have him give us a little party in London. So the 12th       would be a good day to plan for it. Thank you very much."
       
       

 "Thank       you very much, Jim."
       
       

Author | R. William Stones, MD

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