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MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING
Cortical Visual Impairment as it
Relates to Seating & Mobility
Presented by:
Angie Kiger M.Ed., CTRS, ATP/SMS
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Content Disclosure
• The author and presenter of the Sunrise Training & Education Programs (STEPS) is a full-time employee of Sunrise Medical.
• The content for this webinar was created by:
– Angie Kiger, M.Ed., CTRS, ATP/SMS
• We do not intend to endorse any particular model, brand
of product or manufacturer.
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CEU Information
• All of the STEPS educational presentations have been certified for
Continuing Education Units (CEU) by The MED Group.
• The MED Group has been accredited as an authorized provider by
the International Association for Continuing Education and Training
(IACET).
• This seminar has been awarded 1 contact hours or .1 CEUs by The
MED Group.
• It is the participant’s responsibility to verify CEU validity for state
licensure and/or other entities.
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To Receive CEUs
• In order to be awarded CEUs, the participant must:
– Participate in the entire two hour seminar.
– Complete the entire demographics form, which includes contact
information and the last 4 digits of the participant’s social
security number (SSN).
– Complete the seminar evaluation form.
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Objectives
• Define cortical visual impairment.
• List the common characteristics individuals with CVI present.
• Identify at least 3 considerations to take into account when
conducting a seating and mobility evaluation on a client with CVI.
• List 3 strategies to utilize when teaching a client with CVI to propel a
wheelchair manual and drive a power wheelchair.
Upon completion of this one seminar participants will be able to:
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Words of Wisdom
“Alone we can do so little….together we can do so much.”
- Helen Keller
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What’s your why?
Rafael
• 17 y/o male
• Unrestrained driver in a MVA.
• Ejected from the vehicle.
• Initial presentation in rehab
program Rancho 2.
• No response to visual stimuli.
• Plateaued in therapy.
Maryn
• 2 y/o female
• Dx w/ CVI approximately 6
months-old
• Mitochondrial disease
• H/o seizures
• Moderate bilateral hearing loss
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What’s The Big Deal?
“The first time I saw her sitting in her KidKart I was shocked at how upright she was sitting and how much more engaged she was in her surroundings. It was a wake-up call to her dad and I about how important proper positioning is for Maryn.”
– Kim (Arlington, VA)
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A few things to consider…
• A child’s motor development can be significantly impacted in a
negative way if there is the presence of a visual impairment, because vision provides vital feedback to the vestibular and
proprioceptive systems (Prechtl et al. 2001).
• A common myth related to CVI is that the individual’s vision will
never improve (Tallent, Tallent, & Bush 2012).
• Caregivers and treatment teams may focus primarily on the conditions that are more readily noticed thus inadvertently
overlooking the presence and/or impact of CVI on the client as
related to seating and mobility (Chokron & Dutton 2016).
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A few things to consider…
• “Behaviors that are adaptive to enable the child to cope, or are
reactive owing to the stress caused by certain environments or conditions exceeding mental processing capacity, can resemble a
range of disorders such as ASD and ADHD.”
• “The presence of CVI will induce as a direct consequence, a delay
or a deficit in motor skills, motor coordination, and motor control.”
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(Chokron & Dutton 2016).
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Practical Understanding
• What’s involved in catching a ball?
– See it
– Identify it
– Distinguish from other objects
– Choose it
– Predict it’s vector
– Configure and move hand to catch it
• Computing process for vision multi-step process
• How might this relate to mobility?
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The Players
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Parent/ Guardian
Teacher/Aide
PT
OT
SLP
RTS
MD
Vision Teacher
Neuro-ophthalm
ologist
Rec. Therapist
Etc.
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General Flow Of The Evaluation
• Explain the purpose and process of the evaluation with the client and caregivers.
• Review goals of the evaluation and case history with the client and caregivers.
• Evaluate the client’s positioning in his/her current seating system and make adjustments/modifications as needed.
• Complete a mat evaluation.
• Equipment trials with the client.
• Review of recommendations
with the client and caregivers.
• Review follow-up plan (i.e.
funding process, dealer
contact information, potential delivery time, etc.)
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Additional Evaluation Considerations
• Screenings, reports, or formal consultation– Physicians (including
specialists)
– Speech Therapist– Teacher - classroom aide
– School therapists – IEP– Audiologist
• Cognition– Ability to following directions – Initiation of exploring the
environment independently
– Visual learner vs. auditory learner (supports needed?)
• Auditory status– Acuity vs. processing
• Communication Status– Verbal vs. non-verbal– Picture based vs. word based
• Vision Status
– Acuity vs. processing
– Field loss, field neglect, color blind, visual motor, etc.
– Cortical visual impairment?
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Visual Acuity
• Clarity and sharpness of vision.
• 20/20 Vision – Term used for normal visual acuity.
– Person can see clearly what should be
seen at 20 feet.
– Does NOT mean perfect vision
• Common Acuity Problems– Myopia - nearsightedness
– Hyperopia - farsightedness
– Astigmatism - can cause images to
appear blurry and stretched out
– Presbyopia – age-related condition in
which items close up become difficult to focus on.
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https://nei.nih.gov/healthyeyes/problems
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Vision & Brain Injuries
• Every person and TBI is unique
• 20-40% of individuals with a TBI experience related visual complications
• 40-50% of the brain is involved in vision
• Visual evaluations post injury– Comprehensive enough?
– Eyes are the collectors and brain is the interpreter
Brain Injuries: Potential Impact on Vision
• Tracking
• Fixation
• Focus Change
• Depth perception
• Peripheral vision
• Binocularity
• Visualization
• Near vision acuity
• Distance acuity
• Vision perception
• Blurred vision
• Sensitivity to light
• Reading difficulties; words
appear to move
• Comprehension difficulty
• Attention and concentration difficulty
• Memory difficulty
• Double vision
• Aching eyes
• Headaches with visual tasks
• Loss of visual field
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CVI Overview
• History
– Late 19th century emergence of the concept that the brain is
involved in vision.
– During WW1 increased knowledge of visual pathways
• Veterans with injuries to the visual cortex could perceive
motion in non-seeing visual fields.
• Became known as “blindsight”
• Blindsight is the awareness of moving targets, lights, and/or colors in the blind area.
– In the 1980’s transition from term cortical blindness to CVI
• Increase in research and dx in children
• Increase in prevalence directly related increase in survival
rate of children with increased survival rates of children who
sustained severe neurological conditions.
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CVI Overview
• CVI Defined
– Brain is unable to process information passed along the visual
pathways.
– Visual impairment due to the result of bilateral damage to the
occipital cortex.
– Can occur congenitally or be acquired.
– Impacts both the Dorsal (“where”) and Ventral (“what”) visual pathways
• CVI has become the primary cause of visual impairment and blindness in children in industrialized countries.
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CVI Evaluation & Diagnosis
• CVI is a brain dysfunction not eye dysfunction
• Often consider a diagnosis of exclusion.
• Cues for Evaluation
– Often have a normal or near normal eye exam
– History or presence of a neurological disorder
– Presence of behavioral responses to visual stimuli unique to CVI
– Sustained gaze may be difficult
– Common presentation: head tilted slightly forward and tilted to the side
• Neuro-ophthalmologist
– Vision problems that are related to the nervous system as opposed the
eyes
• Vision Teacher & Developmental Therapist Vision
– Specialization in CVICONFIDENTIAL AND PROPRIETARY Duplication or Distribution Prohibited 9/28/2017
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CVI Details & Statistics
• Recognized as the primary cause of visual impairment in children in first world countries.
• Largest and fastest growing visual diagnosis.
• Almost ½ of the children diagnosed with a visual impairment have CVI.
• 29% of individuals with CVI also have a cognitive impairment.
• 56% of individuals with CVI also have a additional disabilities
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Medical Conditions Associated With CVI
• O2 deficiency in the brain during or after birth
• Cerebral hemorrhage
• Shunt malfunction
• Hypoglycemia
• Meningitis
• Encephalitis
• Intrauterine infections
• Head injury
• Epilepsy
• Cerebral tumor
• Metabolic conditions
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CVI Common Comorbidities
• Cerebral Palsy
• Cognitive impairment
• Seizure disorder
• Microcephaly
• Hearing loss
• Memory dysfunction
• Hyper or hyposensitivity to sensory stimulation
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CVI Characteristics & Behaviors
• Color Preference
• Movement
• Latency
• Field Preference
• Difficulty with Visual Complexity
• Light Gazing
• Difficulty with Distance Viewing
• Visual Reflexes
• Novelty of Visual Stimuli
• Absence of Visual Reach
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- Dr. Christine Roman-Lantzy
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CVI Characteristics
• Color Preference
– Initially prefer one color
– Commonly red or yellow, but can be others
– High contrast
• Movement
– Movement alerts the brain, especially peripherally
– Attend movement better
– See better when they are moving or object is
moving
– Slight bounce draws attention
– Slow movements
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Roman-Lantzy, C. (2007)
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CVI Characteristics
• Latency
– Need for time to process
– Wait time provided in SILENCE
– Up to 20 seconds
• Field Differences
– Rarely visual fields are intact
– Field loss due to brain has potential to develop
– Dictates client position, how stimuli is presented, etc.
– Difficulty noticing items in lower visual fields
– Fear of falling off a cliff
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Roman-Lantzy, C. (2007)
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CVI Characteristics
• Difficulty with Visual Complexity
– Complex patterns
– Complexity of visual array
• Visual crowding
• Busyness
– Complexity of sensory environment
• Touch
• Sound
• Strong olfactory inputs
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Roman-Lantzy, C. (2007)
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CVI Characteristics
• Light Gazing
– Non purposeful gazing
– Attracted to light sources
– Use light to attract visual attention
– Need more light to visually attend.
• Difficulty with Distance Viewing
– May present like nearsighted
– Closer the item is brought to eye less of a chance for visual clutter.
– Look & locate
– How might this impact w/c skills
training?
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Roman-Lantzy, C. (2007)
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CVI Characteristics
• Visual Reflexes
– Absent or delayed blink on response to non-
threatening stimuli
– Atypical response a visual threat - doesn't
blink or try to avoid a moving threat
• Novelty of Visual Stimuli
– Anti-novelty response when presented w/
something new
– Favorite toys or objects
– Decrease visual white noise
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Roman-Lantzy, C. (2007)
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CVI Characteristics
• Absence of Visual Reach
– Look toward an object.
– Look away.
– Then reach for the object
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Roman-Lantzy, C. (2007)
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Improvement/Resolution of Characteristics
• Best chance for resolution is within first 3 years
• Characteristics will not resolve without structured intervention
• Order of Resolution
– Early resolution: light gazing, and visual reflexive response of
blink
– Mid-Resolution: color, latency, visual novelty, visual reflexive response of blink to threat, and movement
– Later Resolution: visual fields, visual motor, complexity, and
distance vision
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CVI Ranges
• Range 1-2
– May localize
– No appropriate fixation on objects or faces
– Consistently attentive to lights or perhaps ceiling fans
– Prolonged periods of latency in visual tasks
– Responds only in strictly controlled environments
– Objects viewed are a single color
– Objects viewed have movement and/or shiny or reflective properties
– Visually attends in near space only
– No blink in response to touch or visual threat
– No regard of the human face
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Roman-Lantzy, C. (2007)
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CVI Ranges
• Ranges 3-4
– Visually fixates when the environment is controlled
– Less attracted to lights; can be redirected
– Latency slightly decreases after periods of consistent viewing
– May look at novel objects if they share characteristics of familiar objects
– Blinks in response to touch and/or visual threat, but the responses may
be latent and/or inconsistent
– Has a favorite color ‣ Shows strong visual field preferences
– May notice moving objects at 2 to 3 feet
– Look and touch completed as separate events
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Roman-Lantzy, C. (2007)
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CVI Ranges
• Range 5-6
– Objects viewed may have two to three colors
– Light is no longer a distracter
– Latency present only when the student is tired, stressed, or overstimulated
– Movement continues to be an important factor for
visual attention
– Student tolerates low levels of background noise
– Blink response to touch is consistently present
– Blink response to visual threat is intermittently present
– Visual attention now extents beyond near space, up to 4 to 6 feet
– May regard familiar faces when voice does not
compete
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Roman-Lantzy, C. (2007)
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CVI Ranges
• Range 7-8
– Selection of toys or objects is less restricted, requires 1 - 2 sessions of "warm up"
– Competing auditory stimuli tolerated during periods of viewing; student may now maintain visual attention on objects that produce music
– Blink response to visual threat consistently present
– Latency rarely present
– Visual attention extends to 10-feet with targets that produce movement
– Movement not required for attention at near distance
– Smiles at/regards familiar and new faces
– May enjoy regarding self in mirror
– Most high-contrast colors and/or familiar patterns regarded
– Simple books, picture cards, or symbols regarded
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Roman-Lantzy, C. (2007)
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CVI Ranges
• Ranges 9-10
– Selection of toys or objects not restricted
– Only the most complex environments affect visual response
– Latency resolved
– No color or pattern preferences
– Visual attention extends beyond 20 feet
– Views books or other two-dimensional materials, simple images
– Uses vision to imitate actions
– Demonstrates memory of visual events
– Displays typical visual-social responses
– Visual fields unrestricted
– Look and reach completed as a single action
– Attends to two-dimensional images against complex backgrounds
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Roman-Lantzy, C. (2007)
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CVI Phases Defined
• Phase 1: Building Visual Behavior
� Color – Will only look at one color items. Exhibits clear favorite
colors.
� Movement – Looks at movement or shiny items. Does not seem interested in non-moving visual stimuli.
� Latency – Long delay before turning to visual stimuli.
� Field Preference – Primarily see stimuli in the peripheral fields.
Little to no response to when stimuli is in central vision position.
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CVI Phases Defined
• Phase I: Building Visual Behavior
� Field Complexity – Rarely looks at faces, sees best in quiet and
uncluttered places.
� Light Gazing – Briefly fixates on lights.
� Distance Viewing – Visually attends to near shapes only.
� Reflexes – Little to no response to visual threat.
� Novelty – Only looks at familiar objects.
� Visual Reach – Look and touch occur separately.
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CVI Phases Defined
• Phase II: Integrating Vision with Function
� Color – Objects can be 2-3 colors with favorite included.
� Movement – Continues to benefit from movement for visual
attention.
� Latency – Delay in looking decreases unless fatigued or ill.
� Field Preference – Visual fields gradually increasing.
� Field Complexity – Emerging attention to faces, patterns, and simple pictures.
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CVI Phases Defined
• Phase III: Resolution of CVI Characteristics
� Light Gazing – No longer fixates on lights.
� Distance Viewing – Visually attends to near shapes only.
� Reflexes – Threat and touch reflex in tact.
� Novelty – Visually explores new items.
� Visual Reach – Intact
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CVI & Wheelchair Provision Thoughts
• Vision is involved in approximately 90% of the learning
process.
• Allowing an individual to be positioned in a seating system best that accommodates visual needs is critical.
• The vision system does not fully develop without
movement.
• Providing independent mobility may help with improving
vision.
• Skills such as depth perception and object avoidance are primarily developed through experience.
• Obtaining the most appropriate seating and wheeled
mobility equipment begins with the evaluation process…
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Evaluation Toolbox
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Outside of the Evaluation Toolbox
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Evaluation Process Strategies
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• Setting
– Quiet environment
– Low visual stimulation
– Limited number of teammates in the room at a time
– Familiar caregivers present if possible
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Evaluation Process Strategies
• Personal presentation
– Muted colors and no patterns
– Avoid overpowering scents (perfume, cologne, fabric softener,
cigarettes, mints, etc.)
– Silence phones (not vibrate, silent)
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Vs.
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Evaluation Process Strategies
• Approach/Observation
– Prior to approach
• Stand back and watch
• Posture
• Response to stimuli
• Functional activities
– Initial approach
– Transition with caregiver
• Position for vision
• Allow for movement
• Reproducibility
• Familiar toys/activities
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Overall Goals of Wheelchair Seating & Positioning
• Support postural alignment
– Provide balance for function
– Provide base of support for
stability
– Slow down or correct flexible
deformity
– Accommodate fixed deformity
– Optimize functional tone
– Inhibit non functional tone
• Facilitate function
– Activity related functions
– Physiological functions
– Independence
• Increase sitting tolerance
– Consider comfort over time
• Skin care
– Protect skin integrity
– Decrease moisture
– Consider shearing
– Repositioning
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What role does vision play in wheelchair seating & positioning?
Seating Equipment: Examples & Considerations
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Out of the box or standard cushions and backs
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Seating Equipment: Examples & Considerations
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Custom fabricated seating
Seating Equipment: Examples & Considerations
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Positioning Belts
Lateral Supports
Headrests
Trays
Seating Equipment: Examples & Considerations
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Dynamic Components
Wheelchair: Examples & Considerations
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Manual Mobility
Wheelchair: Examples & Considerations
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Power Mobility
Skills Training Ideas
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Resources
• https://strategytosee.com/
• http://www.perkinselearning.org/videos/webcast/cortical-visual-impairment-and-evaluation-functional-vision
• https://cviteacher.wordpress.com/
• http://wvde.state.wv.us/osp/vi/cvi/
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CVI Resources
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Dr. Christine Roman-Lantzy
www.littlebearsees.org
Resources
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www.littlebearsees.org
CRT Industry Resources
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www.resna.org
www.nrrts.orgwww.ncart.us
Final Thoughts
• Evaluation setting
• Inquire about vision – eyes & brain
• Silence is golden
• Observe
• Allow for movements
• Position for vision
• Familiar objects/toys
• Inquire about CVI range
• Involve the team
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MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING
Thank You For Participating!
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