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Chamber of Commerce Uses Scare Tactics

Robert Blanchard — Fri, 04 Dec 2009 13:00:47 GMT

The title of a recent US Chamber of Commerce spam email says it all, "Terror by Trial Lawyer." Not only do they denigrate a profession with a long noble history that goes to the core of what it means to be American, the Chamber also feels it necessary to out and out lie. "LIARS at the U.S. Chamber of Commerce" should be the title. Their spam email is an attempt to undermine legislation, introduced by a Republican, that is designed to restore Notice Pleading in our federal courts after recent rulings left attorney and judges uncertain on the rule of law. The big companies profiteering do not like it (KBR, Blackwater, Halliburton) so the Chamber lies for them and tell you the legislation will allow terrorists to sue our Nave SEALS. This total fabrication assumes you are ignorant and that you do not want to know the true content or purpose of the legislation.

Don't let them get away with it. Go read the bill (the Notice Pleading Restoration Act of 2009) and then write your elected officials to denounce these scare tactics.

Originally posted at InjuryBoard by Robert Blanchard

Budget Office Misquoted on MalPractice Reform

Robert Blanchard — Wed, 14 Oct 2009 12:54:00 GMT

If you start seeing headlines that medical malpractice reforms could result in substantial savings to the health care system, don't beleive it. The Congreesional Budgret Office released a repot that savings could be acheived, but if also found that “imposing limits on [the right to sue for damages] might be expected to have a negative impact on health outcomes.” In other words, it would result in more seriously injured people, and the cost of providing care to those people is not included in the assessment of savings. Also, the CBO reprts admits that even if the most severe restrictions were put in place, the savings would be less than 5% of the total cost of health care. This report itself miquotes previous studies on the cost of the malpractice tort system which have always found the overall impact of lawsuits to be about 1.5% of total health care cost.

You decide, is this savings enough to do away with the responsiblity for the damages caused by negligent health care? Do we want a health care system that is unaccountable to the people it injures?

Originally posted at InjuryBoard by Robert Blanchard

Digitek Recall shows FDA Inept

Robert Blanchard — Mon, 19 May 2008 21:52:55 GMT

The FDA appears late to the party again. This time widely prescribed piolls were made too large and so they had, you guessed it, too much of the medication in each dose.

Digitek pills manufactured by Actavis Totowa, distributed by Mylan Pharmaceuticals and sold under the labels “Bertek” or “UDL” have been recalled because they may contain double the dose of the active ingredient. Digitek is used to treat heart failure and abnormal heart rhythms. Tablets with twice the appropriate dose pose a risk of digitalis toxicity, symptoms of which include nausea, vomiting, dizziness, abnormal vision, low blood pressure, cardiac instability, slow heart rate and even death. Individuals with poor renal function are particularly susceptible to digitalis toxicity.

It is not yet known how many lots may have been affected so all lots are subject to this recall. Those suffering from digitalis toxicity may experience severe flu-like symptoms and, depending on the severity, may require hospitalization and intensive medical intervention.

Originally posted at InjuryBoard by Robert Blanchard

Judge Decries Preemption

Robert Blanchard — Mon, 21 Apr 2008 11:04:58 GMT

Finally, a beautiful and succinct statement from a Federal Judge on the real nature of the move to preempt state courts from having pharmaceutical liability lawsuits.. The two page Order is making the rounds among plaintiffs' attorneys, reassuring us that someone understands that Federal Preemption in drug cases is nothing less that an outright power grab by the federal government, brought to us by the party that used to advocate, hypocritically it appears, for the expansion of states' right and the diminishment of Federal power. Judge Wilson's supplement to his previous order denying preemption in the Prempro litigation is direct and to the point: "It appears to me that the expansive reading of preemption is part of an "overall assault on the citadel of the right to trail by jury'" (Quoting Cardozo). The Order also refers to this assault as "backdoor federalization." This is clearly true in light of the fact that there is nothing in the FDA enacting legislation that says state action (including state jury trials) is preempted. There is extensive history and precedent that there is no such preemption, but the Bush packed FDA (haven't they have done a great job by the way) ignored all that and issued a preamble to recent regulations (they couldn't get it to pass through standard rule procedures) saying the FDA now wants preemption. They want no state to determine by jury trial or otherwise that a drug manufacturer was negligent in the marketing of its products. The powers that be seem intent on getting this piece of corporate payback through the courts, so unless we get a president who understands this injustice, the right to jury trial will no doubt be trampled by our U.S. Supreme Court.

Originally posted at InjuryBoard by Robert Blanchard

Nail Salon Infections - Hidden Dangers

Robert Blanchard — Thu, 03 May 2007 10:46:20 GMT

Inside sources at GoLeft TV report that incidences of uncontrollable infection being spread at nail salons is a growing concern. Soon they will separate the myths from the facts, but in the mean time, some consumers are taking their own instruments to the nail salons so that they are not exposed to shared items. Infection in the fingers and toes are reportedly harder to treat in some cases where circulation is limited. See the video.

Originally posted at InjuryBoard by Robert Blanchard

Breast Cancer Mis-Diagnosis and Late Diagnosis

Robert Blanchard — Fri, 22 Dec 2006 12:22:30 GMT

An international panel updated their standards on the diagnosis and treatment of breast cancer, as reported in the October 2006 issue of the Journal of the American College of Surgeons (JACS).

According to the American Cancer Society, invasive breast cancer will be diagnosed in 211,240 women and will cause more than 40,000 deaths in 2005. The updated statement reflects the conclusions of a panel of 23 expert surgeons, radiologists, pathologists, and oncologists based on their own research, clinical experiences, familiarity with the professional literature, and points of consensus reached through discussion at a conference. However, the panel cautions that their conclusions should not be considered inclusive of all appropriate treatments or exclusive of other treatments reasonably directed at achieving the same results or of interventions performed in the context of clinical trials.

The overall focus of the statement is that physicians should attempt to replace traditional, invasive procedures for diagnosing breast cancer with proven, less-invasive diagnostic methods, such as minimally invasive needle biopsies of the breasts and sentinel node biopsies.

Summary of Recommendations
Mammography is the only imaging modality that should be used routinely to screen women for breast cancer. However, MRI may be used to screen younger women with a high risk of breast cancer because of a strong family history or BRCA mutation. MRI findings should be combined with other imaging data or histologic results prior to surgical planning. Diagnostic ultrasonography can be helpful in characterizing known breast masses, as it is more sensitive than mammography in evaluating tumor size.
The panel agreed that minimally invasive breast biopsy is the optimal initial method for tissue acquisition for image-detected breast lesions, in large part because the determination of cancer prior to surgery improves outcomes of breast-conserving therapy. For microcalcifications without an obvious mass, the authors recommend vacuum-assisted devices with needle sizes of 11 gauge or larger. Fine- needle aspiration is suitable for lymph-node evaluation but less so for evaluation of breast lesions.
Biopsy specimens should be labeled by surgeons to preserve three-dimensional orientation. Radiography or ultrasonography of the surgical specimen can be useful in determining whether the target lesion was successfully removed. Two views should be used for specimen radiography.
Pathologic breast specimens should be evaluated using the Nottingham Combined Histologic Grade, which accounts for glandular differentiation, mitotic count, and nuclear grade. Ideally, these findings are combined with radiologic data at a treatment conference involving pathologists, radiologists, and surgeons.
Pathologists should read both prognostic size, determined by the extent of the largest invasive component of the tumor and helpful in predicting survival and distant metastasis, as well as the overall size of the breast tumor.
Intraoperative ultrasonography and bracketing localization wires can aid in defining the limits of resection in breast-conserving surgery, as can preoperative MRI and ultrasonography.
Sentinel lymph node biopsy is the preferred means of pathologic axillary nodal staging. However, patients should be made aware of the possibility of a false- negative result with such testing. When the sentinel lymph node reveals minimal involvement of 0.2 mm or smaller, complete axillary dissection is not necessarily indicated.
Regarding treatment of DCIS, adjunctive radiation therapy has been demonstrated to reduce rates of local failure but may not improve survival. Older age, smaller, widely excised DCIS, and low- or intermediate-grade histology mitigate against using radiation therapy following surgery for DCIS. The use of adjunctive tamoxifen for patients with DCIS is controversial, but it seems to be more helpful among patients with receptor-positive DCIS. Sentinel lymph node biopsy generally has no role in the staging of DCIS, but it should be performed in women receiving mastectomy for DCIS.
Hormonal therapy should be offered to all women with hormone-receptor-positive tumors, and the minimum period of treatment is 5 years. Patients receiving other chemotherapy should receive both an anthracycline and a taxane. However, chemotherapy in addition to hormonal therapy is less likely to provide an overall clinical benefit for women older than 60 years of age with hormone-receptor-positive tumors or for those older than the 70 years with any breast cancer.

Originally posted at InjuryBoard by Robert Blanchard

Knee Injuries Are Common in PI Practice

Robert Blanchard — Wed, 20 Dec 2006 12:00:29 GMT

Anterior Cruciate Ligament Injury (ACLI) usually happen from low-velocity, noncontact, deceleration injuries or from contact injuries with a rotational component. Some sports may also produce injury to the anterior cruciate ligament (ACL) secondary to twisting, valgus stress, or hyperextension all directly related to contact or collision.

We have all seen the signigicance of the ACL in athletes who require stability in running, cutting, and kicking. The ACL injury has also been linked to an increased rate of degenerative changes and meniscal injuries. For these reasons, between 60,000-75,000 ACL reconstructions are performed annually in the United States.
An estimated 200,000 ACL-related injuries occur annually in the United States, with approximately 95,000 ACL ruptures. Approximately 100,000 ACL reconstructions are performed each year. The incidence of ACL injury is higher in people who participate in high-risk sports such as basketball, football, skiing, and soccer. When the frequency of participation is considered, a higher prevalence of injury is actually seen more in women than men, at a rate 2.4-9.7 times greater for females.

History:
Most ACL injuries may be diagnosed through a careful history emphasizing mechanism of injury coupled with a good physical examination. A previous ligamentous injury may be the cause of instability. An audible pop often accompanies this injury, which often occurs while changing direction, cutting, or landing from a jump (usually a hyperextension/ pivot combination). Within a few hours, a large hemarthrosis develops. Patients usually are unable to return to play, secondary to pain, swelling, and instability or giving way of the knee. High energy traumatic injuries are often associated with other ligamentous and meniscal injuries. The classic "terrible triad" (ACL, MCL, and medial meniscus tears) involves a valgus stress to the knee with resultant acute injury to the ACL and MCL; however, the medial meniscus tear is now thought to occur later, as a result of chronic ACL deficiency.
Physical:
An organized, systematic physical examination is imperative when examining any joint. Immediately after the acute injury, the physical examination may be very limited due to apprehension and guarding by the patient. The basic examination should include the following:
The examiner should begin with inspection, looking for any gross effusion or bony abnormality. An immediate effusion indicates significant intra-articular trauma. According to Noyes et al, in the absence of bony trauma, an immediate effusion is believed to have a 72% correlation with an ACL injury of some degree.
Assess the patient's range of motion (ROM), especially looking for lack of complete extension, secondary to a possible bucket-handle meniscus tear or associated loose fragment.
Palpation of bony structures may suggest an associated tibial plateau fracture.
Palpation of the joint lines to evaluate a possible associated meniscus tear. Palpation over the collateral ligaments to suggest any possible injury (sprain) of these structures. Up to 50% of ACL ruptures have associated meniscal injuries; acute injuries are likely to have associated injuries of the MCL and meniscus.
Ligamentous laxity may be difficult to detect in the acute situation. The Lachman test is the most sensitive test for acute ACL rupture. Since the Lachman test must be performed when the patient is relaxed, it is often better to conduct this test prior to manipulating the painful knee.
Lab and Imaging Studies:
Arthrocentesis is performed less frequently today because of the advent of other less invasive and more specific diagnostic tests, especially MRI. MRI has a sensitivity of 90-98% for ACL tears. MRI also may identify bone bruising, which is present in approximately 90% of ACL injuries.
Treatment:
Before surgical treatment strengthening of the quadriceps and hamstrings, as well as ROM (range of motion) exercises is undertaken. Performance of ROM helps reduce the amount of effusion and regain motion and strength.
Generally, the recommendation is that surgical intervention be delayed at least 3 weeks following injury to prevent the complication of arthrofibrosis. The methods of surgical repair may be categorized into 3 groups, primary repair, extra- articular repair, and intra-articular repair. Primary repair is not recommended except for bony avulsions, which are mostly seen in adolescents. Because the ACL is intra- articular, the ligamentous ends are subjected to synovial fluid, which does not support ligamentous healing. Extra- articular repair generally involves a tenodesis of the iliotibial tract. This may prevent a pivot shift but has not been shown to decrease anterior tibial translation.
Intra-articular reconstruction of the ACL has become the criterion standard for treating ACL tears. Bone-patella-bone autografts are currently popular because they yield a significantly higher percentage of stable knees with a higher rate of return to preinjury sports. The major pitfall of these grafts is their association with postoperative anterior knee pain (10-40%). Hamstring tendon grafts are associated with a faster recovery and less anterior knee pain. Critics believe that these are more susceptible to graft elongation. Recent literature has supported a greater tensile strength with the use of braided quadruple hamstring grafts. However, this finding has not been confirmed in vivo, and the graft may be limited by the type of fixation.
Allografts have also been very popular because of their efficiency, their ability to provide bony fixation, and the lack of associated patella morbidity. However, they are associated with a risk of viral transmission. Allografts are best used in revisions. These have also fallen out of favor by some because several deaths linked to clostridial infections from inadequate sterilization techniques have been reported, which led to increased research into sterilization techniques to ensure safety. In addition, concerns exist regarding what effects the immunologic response and delayed revascularization and remodeling may have on clinical outcomes. Although allografts are generally accepted as having less associated morbidity, no proof of this is present in the literature.
Synthetic grafts and ligament augmentation devices have also been used. Synthetic grafts are no longer acceptable, because of their high rate of complications, including failure and aseptic effusions. Intra-articular reconstruction may be performed through a 2-incision technique or a single-incision endoscopic technique; the latter is currently more popular. This procedure requires graft stabilization with some type of fixation hardware for all of the graft options. The stabilization may be performed with metal interference screws, bioabsorbable screws, endobuttons, and cross pins. Each device has its own benefits.
Rehabilitation follows operative management. One special point is that the use of knee braces remains a highly controversial topic; braces are well accepted by patients, but most biomechanical studies do not support their use. Studies have shown that functional bracing can limit anterior translation of the tibia at low loads. Furthermore, most braces have been found to decrease the reaction time of the hamstring muscles.
Other Treatment:
Nonoperative treatment may be considered in elderly patients or in less active athletes who may not be participating in any pivoting type of sports (e.g.: running, cycling). The goal is to obtain a full ROM and strength compared with the uninjured knee. This modality of treatment requires modification of activity levels and avoidance of physically demanding occupations. Arthroscopy may also be considered for persons who are poor candidates for reconstruction but have a mechanical block to ROM. The goal of this procedure is to debride the remaining stump to increase motion. Patients with significant arthritis are also thought to be poor candidates unless they are experiencing recurrent instability.
Complications:
The current failure rate for ACL reconstruction is approximately 8%. The 3 major categories of failure in an ACL reconstruction are (1) arthrofibrosis (due to inflammation of the synovium and fat pad), (2) pain that limits motion, and (3) recurrent instability, secondary to significant laxity in the reconstructed ligament. These factors may be related to the surgical procedure (e.g.: malpositioned tibial or femoral tunnels, misplaced hardware, inadequate notchplasty).
Anterior placement of a tibial tunnel may result in graft impingement. If a tunnel is placed too posteriorly on the femoral side, the posterior cortex of the femur may be violated.
A graft also may fail due to a lack of incorporation, secondary to rejection or stress shielding.
Trauma from re-injury or aggressive rehabilitation also may cause graft failure. The incidence of graft re-rupture is approximately 2.5%.
Other complications include patella fractures and patella-tendon ruptures. Reflex sympathetic dystrophy, postoperative infection, and neurovascular complications are rare (each accounting for less than 1% of complications). The rate of postoperative deep venous thrombosis is approximately 0.12%.
Prognosis:
Patients treated with surgical reconstruction of the ACL have long-term success rates of 82-95%. Recurrent instability and graft failure is seen in approximately 8% of patients. Knee scores of those treated nonoperatively have fair/poor results up to 50% of the time. As many as 40% of patients treated nonoperatively had no episodes of giving way. The knee scores in this group may be too sensitive, not accurately representing the clinical situation. Patients with ACL ruptures, even after successful reconstruction, are at risk for osteoarthrosis. The goal of surgery is to stabilize the knee, decrease the chance of future meniscal injury, and delay the arthritic process.
Medical/Legal Concerns:
Medical/legal issues from ACL injury and graft replacement generally arise from complications during surgery. Initial misdiagnosis of ACL injury also can be a source of potential litigation. Obtain a complete history from the patient.
The mechanism of injury for ACL tear is fairly consistent. A thorough physical examination helps the physician confirm the diagnosis, and an MRI identifies additional possible injuries to other ligaments or cartilage.
Potential for a lawsuit arising from improper physical therapy also exists. If the therapist is too aggressive in rehabilitation exercises and rupture of the ACL graft occurs, some patients might consider litigation.

Originally posted at InjuryBoard by Robert Blanchard

Old Surgeons Not a Problem

Robert Blanchard — Mon, 04 Dec 2006 10:05:47 GMT

When you need complex cardiovascular or cancer surgery, you have to choose a surgeon and many patients may select an older physician, assuming his experience may be needed. New research says they are right - experience helps. A study designed to address this issue used approximately 461,000 Medicare records to assess the association between age of the listed operator and surgical mortality. For some operations, such as pancreatectomy, coronary artery surgery, and carotid endarterectomy, surgeons aged 60 or older had higher mortality rates than younger surgeons. However, for other equally complex operations, such as esophagectomy, effects of the age of the surgeon were not observed. Surgical volume must also be taken into account when considering the impact of the age of the surgeon.
The conclusion of the study is that the age of the surgeon is not a major factor to surgical complications. It is unusual that an age effect was observed for a few difficult procedures but not for others of equal complexity. However, if you have to chooose a surgeon, the conclusions are reassuring: The results after surgery performed by an older surgeon are comparable to outcomes of similar procedures performed by a younger surgeon.

But, older surgeons - those over age 60 - who do not maintain a high surgical volume as they age are more likely to have high patient mortality rate than younger surgeons.
The researchers at the University of Michigan Health System say patients should be less concerned about the age of their surgeon and more focused on other factors that really count - like surgical volume.
These findings, published in the September issue of the Annals of Surgery, reveal that for some complex cardiovascular and cancer surgical procedures, older surgeons who continued to maintain higher surgical case loads were found to have comparable outcomes to peers ages 41 to 50.
The study also dispels the belief that younger, less experienced surgeons are more likely to have poor surgical outcomes. Instead, the researchers say young surgeons, ages 40 and under, had similar patient mortality rates to those of their more experienced peers for the eight surgical procedures studied.
"This study's results should be very encouraging not only for patients, but also for younger and older surgeons whose operative skills may previously have been the subject of scrutiny," says lead author Jennifer F. Waljee, M.D., M.P.H., general surgery resident in the Department of Surgery at the U-M Medical School.
"The bottom line is that for most procedures the age of the surgeon is not an important predictor of operative risk for a patient. The effect of surgeon age was largely limited to those surgeons with lower procedure volumes."
Previous studies that focused on primary care have suggested an inverse relationship between a surgeon's age and his or her clinical performance. They've found that older physicians are less likely to know about new treatments and medications, and tend to perform poorly on recertification exams.
Based on these recent studies, Waljee and her colleagues wondered if some of the common mental and physical affects of aging might affect older surgeons' performance in the operating room, as well.
Using data from the National Medicare Inpatient Files, the team reviewed eight major cardiovascular procedures and cancer surgical resections that were performed from 1998 to 1999 on patients between the ages 65 to 99.
For the study, surgeons were placed into three age groups: 40 years and younger, ages 41-50, and 60 years and older.
A total of 460,738 Medicare patients who underwent one of the eight surgical procedures - coronary artery bypass grafting; elective abdominal aortic aneurysm repair, aortic valve replacement, carotid endarterectomy, pancreatectomy, esophagectomy, lung resection and cystectomy - were used for this study. These procedures were chosen because they are some of the more commonly-performed procedures among Medicare patients, says Waljee.
Patient operative mortality - death before discharge or within 30 days of surgery - was reviewed for each patient. Additionally, factors such as surgeon procedure volume, hospital surgery volume and the hospital's teaching status were evaluated.
Overall, surgeons over age 60 were found to have higher patient mortality rates when compared against the rates of surgeons ages 41-50, for three of the eight procedures: pancreatectomy, coronary artery bypass grafting, and carotid endarterectomy. Surgeon age was not related to mortality for elective abdominal aortic aneurysm repair, aortic valve replacement, exophagectomy, lung resection or cystectomy.
More surprising to researchers, however, was that the younger surgeons - those under age 40 - had comparable mortality to surgeons between the ages of 41 and 50, for all eight procedures.
"We expected to see a significant difference in patient mortality at the extremes of surgeon age, but instead found very little variation among younger and older surgeons," says Waljee, a Robert Wood Johnson Clinical Scholar. "Based on these finding, we'd encourage patients not to focus on age when selecting a surgeon. Instead, other characteristics of the provider and practice setting, such as operative volume, are likely better predictors of patient outcome than surgeon age."
Waljee hopes to further explore this topic through future research to determine if specific mechanisms of aging (physical and mental stamina, vision and motor skills) affect low-volume surgeons' performance in the OR.

Originally posted at InjuryBoard by Robert Blanchard

Florida Worker's Compensation Overview

Staff Writer — Wed, 09 Nov 2005 14:24:46 GMT

In Florida, as in most states there is a separate body of law addressing Workerâ€™s Compensation (formerly Workmanâ€™s Compensation). Generally, Workerâ€™s Comp. deals with an employer or the employerâ€™s insurance company obligations regarding wages and medical bills when an employee is injured on the job.

In Florida, as in most states there is a separate body of law addressing Worker's Compensation (formerly Workman's Compensation). Generally, Worker's Comp. deals with an employer or the employer's insurance company obligations regarding wages and medical bills when an employee is injured on the job. These laws are created to protect both the employer and employee. They insure that an injured employee will receive compensation both for the time that they are not able to work, and for all medical expenses arising from the injury, without that employee having to file a lawsuit against their employer. The employer is protected in 2 ways. First they are limited in the amount that they will have to pay, and second it protects them from being sued. These laws prevent an employee from filing a lawsuit against their employer for any injury incurred in the scope of their employment.

There are specific rules about which employers must carry workers compensation insurance. Employers in a non-construction business with 4 of more employees must carry insurance, while those involved in a construction business need only 1 employee for it to be mandatory. The state and local governments are also required to have coverage, and it is deemed necessary for farmers with 5 or more regular employees or 12 or more seasonal employees This insurance should cover an employee for all occupational diseases and injuries arising out of and in the scope of employment (FL St. 440.02(17), 440.16). This mandatory insurance will not include coverage for mental conditions, nor will it cover pain and suffering.

An injured employee should report their claim as soon as possible but no later than 30 days from the date of the injury. An employer should do the same only their report should be no longer than 7 days from the date of the injury. Upon receiving the employers report the insurance company should, within 3 days, provide the injured employee with a brochure explaining the employeeâ€™s rights and obligations and outlining the whole process. The first check should be received within 21 days.

While a direct action against an employer may not be possible a person may not be without remedy. It may be possible to file a third party claim. This is a lawsuit that brings in a party that is not directly involved, yet may be liable to the party. An example of this would be an employee who is injured at work by a machine that was defective. The machine may have malfunctioned and caused that employeeâ€™s injury. While in this case the employee may not sue the employer for his injury, there is nothing barring them from bringing a suit against the manufacturer of the machine.

Originally posted at InjuryBoard by Staff Writer

Broker Problems

Robert Blanchard — Tue, 13 Oct 2009 12:26:29 GMT

Everyday my firm sees new cases of people having lost too much money in the stock market. While those who were speculating in the market deserve to suffer the ups and downs of the market, many are just people who believed what the industry had told them. We have been told that to not invest you money in stocks is a waste of your money, because the value of you cash will go down with inflation. We have been told that over the long haul, the stock market averages better than other forms of investment. We have been told to just put in the money and just let it sit and grow for 20 years or more, so that it will be there for retirement. I agree that retirement planning is important, but the brokerage houses don't just invest money and let it sit. They not only buy and sell furiously every day, they now how computers systems programmed to buy and sell vast quantities in the blink of an eye. All of this is to the detriment of the average investor. The markets don't create wealth, they only create wealthy people by taking your money and rewarding those who control or game the system.

Proper handling of your stock account requires investments that are suitable for YOUR needs, If your investments have lost too much as you were about to retire, that is not suitable investing, and you should call a lawyer.

Originally posted at InjuryBoard by Robert Blanchard