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The STITCH Procedure or micro ETS for Excessive Sweating
Monday, January 23, 2012

When the less invasive medical treatments have failed to provide adequate treatment, hyperhidrosis can be effectively treated through surgical intervention. This is an important point, as most insurers want documented failure of conservative therapy before endoscopic thoracic sympathectomy is approved.

 

Hyperhidrosis surgery has come a long way in the last decade. Traditionally, large incisions were made in the chest to surgically interrupt the sympathetic trunk.

Micro ETS

 

With the advent of minimally invasive techniques to work in the chest via endoscopes and surgical instruments, Dr. Karmanoukian and other leading cardiothoracic surgeons have evolved a procedure called Micro ETS which is very effective in treating patients with sweating of the hands, underarms, face, scalp as well as patients that have facial blushing.

 

Dr. Karamanoukian, Director of The Center for Excessive Sweating has pioneered a variant of Micro ETS (Endoscopic Thoracic Sympathectomy) coined STITCH, Sympathetic Trunk Interruption with Titanium Clips for Hyperhidrosis.

 

The STITCH procedure is a revolution in Micro ETS for excessive sweating. With the STITCH technique,  the incision is smaller and less invasive than traditional Micro ETS procedures.

 

This is the most durable treatment for hyperhidrosis when performed by experienced hands. Clipping the thoracic sympathetic trunk at the appropriate levels will immediately eliminate hyperhidrosis.

 

It is not uncommon for patients to wake up from anesthesia and almost immediately take note of a dry hand or underarm. With modification of the level of sympathectomy, compensatory hyperhidrosis is also minimized or eliminated.

 

Micro ETS or Sympathetic Trunk Interruption with Titanium Clips for Hyperhidrosis (STITCH) can be performed with minimal side effects and excellent outcomes. The procedure is performed in an outpatient setting and takes less than 45 minutes to complete, including anesthesia time. In most cases this procedure is covered by medical insurance.

 

To make an appointment for evaluation for hyperhidrosis, call 716-839-3638.

 

Dr. Karamanoukian has written 3 books about hyperhidrosis which are available on Kindle Books and Amazon.com for immediate download.

Treatment of Post Thrombotic Syndrome in Buffalo Niagara - Canadian Patients are welcome - www.PeaceBridgeHealthCare.com
Thursday, August 8, 2013

 

 

One of the most significant sequela of having had a deep vein thrombosis is postthrombotic syndrome.  It has been shown to that up to 50% of patients with proximal deep vein thrombosis (DVT) will develop post thrombotic syndrome.  Fifty per cent of patients with post thrombotic syndrome due to proximal DVT will develop symptoms and 10% will develop venous stasis ulcers.

 

Multiple studies have shown that patients with proximal deep vein thrombosis are at significant risk of developing this devastating complication (post thrombotic syndrome) and therefore it is highly recommended that patients with any type of deep vein thrombosis and especially those in the proximal deep veins continue to wear compression stockings even when the deep vein thrombosis resolves.

 

There are some studies recently which have suggested that early thrombolysis of the deep vein thrombosis results in preservation of the venous valvular system and prevention of the deep venous insufficiency. This will likely have less long term complications such as venous obstruction and will surely reduce the likelihood of developing post thrombotic syndrome.  As such, clinicians are advocating a more aggressive interventional approach with fibrinolysis of proximal deep vein thrombosis as opposed to the traditional approach of  anticoagulation alone.

 

Fro more information about deep vein thrombosis and post thrombotic syndrome,  contact Hratch Karamanoukian, MD FACS at the Vein Treatment Center in Williamsville, New York and Clarence, New York or go to www.VeinsVeinsVeins.com or call 716-839-3638.

 

You can also request a free copy of Dr. Karamanoukian’s book called Post Thrombotic Syndrome by calling of requesting it online through his website www.VeinsVeinsVeins.com

 

www.VeinsVeinsVeins.com, www.VeinGuide,com are partners with www.PeaceBridgeHealthCare.com

 

 

Is Polidochanol Painful for Sclerotherapy ? Asclera in Williamsville, NY
Friday, November 23, 2012

 

Asclera (Polidochanol) is FDA approved. It has advantages because it is painless on injection, has low likelihood of skin necrosis and is effective.

 

It is commonly used for feeder veins, reticular veins and some individuals use it for varicose veins. Its concentration when used is 0.5% to 1 %.

 

Asclera is a wonderful product for cosmetic sclerotherapy, foam sclerotherapy and ultrasound guided foam sclerotherapy.

 

For expertise in treating all telangiectasias in the lower extremities, contact www.VeinsVeinsVeins.com or 716-839-3638.

 

Hratch Karamanoukian, MD FACS is a Board Certified Phlebologist.

 

In Los Angeles, contact the Santa Monica Vein Center or www.SantaMonicaVeinCenter.com or 310-998-5535.

 

Raffy Karamanoukian, MD FACS is a Board Certified Phlebologist and has been featured on The Doctors TV show.

How prevalent is venous disease in the United States ?
Saturday, November 24, 2012

 

Vein disease is ten times more common than peripheral arterial disease (PAD). Peripheral arterial disease is due to atherosclerosis where there is insufficient oxygenated blood flow causing leg cramping and tissue loss. Although PAD generates a lot of publicity on television ads and in the news, vein disorders have been neglected until NOW!

 

An estimated 27 percent of the adult population of the United States has some form of venous  disease of the legs. Vein problems become more prevalent with age and can progress to the point of being disabling. As such, they should not be ignored.

 

The most common problems involving the venous system of the legs include varicose veins, chronic venous insufficiency and deep vein thrombosis (deep vein clots).

 

Market research indicates that over 2 million workdays are lost annually in the United States and $1.4 billion is spent each year on treating venous disorders. 

 

Of the 25 million Americans with venous insufficiency, approximately 7 million exhibit serious symptoms such as leg swelling, skin changes and venous leg ulcers.

 

It is estimated that in America, 72% of women and 42% of men will develop varicose veins by the age of 65. Prevalence is highly correlated to age and sex with women having an increased likelihood of having vein problems in each age group category.

 

For expertise in treating all telangiectasias in the lower extremities, contact www.VeinsVeinsVeins.com or 716-839-3638.

Hratch Karamanoukian, MD FACS is a Board Certified Phlebologist.

 

In Los Angeles, contact the Santa Monica Vein Center or www.SantaMonicaVeinCenter.com or 310-998-5535.

 

Raffy Karamanoukian, MD FACS is a Board Certified Phlebologist and has been featured on The Doctors TV show.

Management of Post Thrombotic Syndrome at Vein Treatment Center in Buffalo Niagara - Canadian Patients are Welcome
Monday, August 12, 2013

 

 

The management of post thrombotic syndrome (PTS) is multimodal and includes the use of elastic compression stockings, pneumatic compression stockings, the use of pharmacologic agents, and wound care.

 

Medical elastic compression stockings that provide at least 20-30 mmHg compression reduce lower extremity swelling and improve symptoms associated with post thrombotic syndrome.  Symptoms include pain, leg swelling, lower extremity cramps, heaviness, pruritus and paresthesias.

 

Use of intermittent pneumatic compression units is effective for patients who have severe symptoms of post thrombotic syndrome.  These devices are used during the day for symptoms relief or at night on a routine and regular basis.

 

The use venoactive agents such as of Aescin which is derived from horse chestnut extract or bioflavonoids such as Rutosides may offer symptom improvement in patients with post thrombotic syndrome and has been shown toalso promote venous valvular health.  They can be used on a long term basis in patients who have developed venous valvular incompetence or symptoms of post thrombotic syndrome.

 

Compression therapy including skin care and topical dressings are used to treat venous stasis ulceration in patients with postthrombotic syndrome.

 

For more information about Veinamin AM and Veinamin PM, which are horse chestnut extract products for venous insufficiency, go to www.MyVeinStore.com .

 

For a bioflavonoid formula, read about Varicosamin on www.MyVeinStore.com. Dr Karamanoukian has written a book about bioflavonoids.

 

The Health Benefits of Citrus Bioflavonoids and Diosmin

 

 To get a free copy of Dr. Karamanoukian’s book post thrombotic syndrome contact him directly by calling 716-839-3638 or go to www.VeinsVeinsVeins.com and request a free copy.

 

To be evaluated and treated for post thrombotic syndrome in the Buffalo Niagara region and Southern Ontario contact Hratch Karamanoukian, MD FACS at the Vein Treatment Center with offices in Williamsville, New York and Clarence, New York.

 

www.VeinsVeinsVeins.com and www.VeinGuide.com are partners with www.PeaceBridgeHealthCare.com.

 

 

 

DVT (deep vein thrombosis) is multifactorial - Dr. Karamanoukian - Treatment Varicose Veins Buffalo Niagara and Peace Bridge Healthcare
Saturday, August 10, 2013

 

 

 

It needs to be recognized that deep vein thrombosis formation is a multifactorial process, meaning that risk factors have to be present before deep vein thrombosis occurs in most patients.  This is reflected in a the scientific literature which clearly shows increased risk for developing deep vein thrombosis (DVT) for certain groups.  These include patients with Factor V Leiden mutations, those who use oral contraceptives and those who are obese.  As well there is an increase risk for tall and short people.

 

 

Patients with all risk factors who plan to travel, the benefits and risks of deep vein thrombosis prophylaxis need to be individually discussed.  Passengers who develop deep vein thrombosis have a risk factor and this is in order of frequency from the highest risk to the lower risk is

 

 

1. Thrombophilia. 

2. Use of oral contraceptive pill. 

3. Previous deep vein thrombosis. 

4. Recent injury to the lower extremity or surgery to the lower extremity.

5. Presence of varicose veins

6. Obesity.

 

 

Two or more combined risk factors markedly increase the risk of developing deep vein thrombosis. 

 

 

There is no evidence to support an increase risk of developing deep vein thrombosis when you consider the following risks:

 

 

1. Age or gender of travel passenger

2. Drinking alcohol during flight   

3. Use of sleeping pills

4. Seating arrangements 

5. Cabin environment

6. Physical activity or lack of physical activity during airplane travel

 

 

Of course even though there is no clear objective evidence to support the fact that physical activity or lack of physical activity does not significantly increase the risk of deep vein thrombosis, this should not be ignored.  Walking regularly every hour and exercising the lower extremities with foot pedal movements will activate the calf muscles and pump stagnant blood out of the legs. 

 

 

The use of class one support stockings have been shown to literally eliminate the risk of developing deep vein thrombosis in passengers known to be at higher risk of developing deep vein thrombosis.  

 

 

Low molecular weight heparin injections have also been shown to reduce the risk of developing deep vein thrombosis. 

 

 

Aspirin has been shown to be of no valve in preventing deep vein thrombosis as clotting in deep vein thrombosis formation is related to fibrin production and not to platelet activation.

 

 

To learn more about deep vein thrombosis contact Hratch Karamanoukian, MD FACS at the Vein Treatment Center or go to www.VeinsVeinsVeins.com and call 716-839-3638.

 

 

If you believe you have a deep vein thrombosis while on travel, go directly to an emergency room for evaluation with a duplex venous ultrasound or call your primary care physician for guidance.

 

 

www.VeinsVeinsVeins.com and www.VeinGuide.com are partners with www.PeaceBridgeHealthCare.com.

 

 

 

 

 

Ambulatory Venous Pressure Measurements for the Evaluation of Patients with Venous Ulcers
Monday, August 12, 2013

 

 

Ambulatory venous pressure measurements are used to investigate patients with venous stasis ulcers.  Ambulatory venous pressure measurements do not provide anatomical information but provide global hemodynamic information about the venous system in patients with venous stasis ulcers.  Ambulatory venous pressure measurements are invasive , unlike magnetic resonance venography, computed tomography, and plethysmography.

 

The normal venous pressure in foot veins are between 15 to 30 mmHg.  An elevated resting venous pressure indicates venous disease and  directly correlates with the severity of venous disease.

 

Generally, patients with venous stasis ulcers have venous pressure measurements between 45 to 60 mmHg.  The patients are asked to do 10 to 12 tip toe movements following which ambulatory venous pressure recovery time (RT) can be measured.  The recovery time of less than 18 seconds is considered pathological.

 

Ambulatory venous pressure measurements can be used to assess global venous function but is the most reliable physiologic tool for quantitating venous function.

 

Ambulatory venous pressure measurements are used for research purposes in vascular laboratories.

 

Foot veins are cannulated for this diagnostic study.

 

Venous Doppler ultrasonography is a noninvasive way to investigate patients with venous stasis ulcers.  Plethysmography is also a noninvasive technique to investigate patients with venous ulcers.

 

The most common type of plethysmography is strain gauge plethysmography. Other such as more graphic techniques are air plethysmography, foot volumetry, and light reflection rheography (also known as photo plethysmography).

 

For more information about diagnostic tools in evaluating patients with venous stasis ulcers contact Hratch Karamanoukian, MDFACS at the Vein Treatment Center with offices in Williamsville, New York and Clarence, New York.  Dr. Karamanoukian can also be contacted via www.VeinsVeinsVeins.com or by calling him for evaluation and consultation at 716-839-3638.

 

www.VeinsVeinsVeins.com and www.VeinGuide.com are partners with www.PeaceBridgeHealthCare.com.

 

 

Various Classifications of Venous Insufficiency at the Saphenofemoral Juction - www.VeinsVeinsVeins.com and www.PeaceBridgeHealthCare.com
Saturday, August 10, 2013

 

In a report published in the August 2013 volume of the journal Phlebology, Dr. M. Stucker and colleagues have published an analysis of the different types of venous insufficiency noted at the saphenofemoral junction by Duplex venous ultrasonography. 
 
 
The authors summarized that three different types of venous insufficiency could differentiate therapy of the great saphenous vein by the newer ablation technologies.  The authors have reported roles of the preterminal vein as well as the terminal vein at the saphenofemoral junction and have classified three subcategories.
 
 
Type I is an incompetent femoral and competent preterminal valve causing venous insufficiency. 
 
 
Type II is a competent terminal valve but incompetent preterminal valve. 
 
 
Type III saphenofemoral insufficiency is defined by an incompetent terminal and an preterminal valves which implies complete incompetence. 
 
 
The authors have concluded that the differentiation of the distinct types of saphenofemoral junction venous insufficiency and valve incompetence allows a more individual and perhaps more effective therapy to treat venous insufficiency.
 
 
For more information about venous insufficiency at the saphenofemoral junction and for different types of ablation therapies to treat saphenofemoral venous insufficiency contact Hratch Karamanoukian, MD FACS at the Vein Treatment Center at www.VeinsVeinsVeins.com or call 716-839-3638.
 
 
In the Los Angeles area contact Raffy Karamanoukian, MD FACS at the Santa Monica Vein Center or www.SantaMonicaVeinCenter.com or by call 310-998-5535.
 
 
 
Vein Wall Changes and Vein Valve Disesae in Chronic Venous Disease
Friday, February 8, 2013

 

 

Chronic venous disease is associated with significant morbidity and reduction in quality of life (QOL) indicators. The two major mechanisms of venous disease in chronic venous disease is :

 

1) Hypoxia (low oxygen concentration) in the venous bloodstream and vein wall and

 

2) Alteration in the wall tension of the vein wall which results from venous hypertension and venous valvular insufficiency

 

Venous hypertension results in superficial venous reflux, deep venous reflux (insufficiency) or superficial and deep venous insufficiency.

 

Researchers have shown that venous hypertension due to venous insufficiency results in the symptoms constellation which is common - leg pain, heaviness, fatigue, cramping, throbbing, restless legs and leg swelling.

 

If you want to read about compression stockings in detail, read our book(s) - they are free on request by email - we will send them to you in pdf form. Dr. Raffy Karamanoukian and I have written 6 books about venous isnufficiency and varicose veins.

 

 http://www.veinguide.com/about/26/dr.-karamanoukians-books.aspx - click to see our books

 

Comprehensive Information about the Venefit Procedure (VNUS Closure) at your fingertips by Buffalo Vein Expert Hratch Karamanoukian MD FACS, a Board Certified Phlebologist (Vein Specialist) - VeinGuide.com and VeinsVeinsVeins.com

 

Information about EVLT Never Touch at your fingertips from Santa Monica Vein Expert Dr. Raffy Karamanoukian, a Board Certified Vein Expert - www.SantaMonicaVeinCenter.com and www.Surgery90210.com

 

Dr. Hratch Karamanoukian is a member of the American College of Phlebology AND a Diplomate of the American Board of Phlebology. He can be contacted by calling 716-839-3638 orwww.VeinsVeinsVeins.com 

 

 

Dr. Raffy Karamanoukian is a member of the American College of Phlebology AND a Diplomate of the American Board of Phlebology. He can be contacted by calling 310-998-5535 orwww.SantaMonicaVeinCenter.com 

 

Drs. Raffy and Hratch Karamanoukian have authored 6 books about venous disease. The books are available on Amazon Kindle and Nook books for download.

 

Diagnostic Criteria for Post Thrombotic Syndrome - Vein Treatment Center in Buffalo Niagara welcomes Canadian patients with venous disorders and post thrombotic syndrome
Monday, August 12, 2013

 

 

Diagnosis of post thrombotic syndrome (PTS) has two components, namely clinical assessment with the Villalta score as well as duplex ultrasound study to document venous valvular incompetence.  The Villalta score is a clinical measurement of post thrombotic syndrome that grades the severity of the syndrome from 0 (absent) to severe (3) of five patient related symptoms which include pain, cramps, heaviness, pruritus, and paresthesias and six clinical signs which include edema, redness, induration of the skin, hyperpigmentation, venous ectasia or telangiectasia and pain on calf compression.

 

A Score of greater than or equal to five on the Villalta score indicates the presence of post thrombotic syndrome.  Mild post thrombotic syndrome has a score of five to nine, moderate post thrombotic syndrome has a score of 10 to 14 and severe post thrombotic syndrome has a score of greater than 14 or the presence of a venous stasis ulcer.

 

An evaluation by duplex ultrasonography of both lower extremities is necessary. Venous reflux should be sought and documented if it exists in the deep veins - the common femoral vein, femoral vein, popliteal vein, and posterior tibial veins – as well as in the superficial veins (great saphenous and small saphenous).

 

The presence of post thrombotic syndrome after total knee arthroplasty in a recent study was 28.9% by clinical assessment with the Villalta score.  Patients who have had total knee arthroplasty or total knee replacement therefore should have duplex ultrasonography if they continue to have symptoms that suggest post thrombotic syndrome.

 

To obtain a free copy of Dr. Karamanoukian’s book about postthrombotic syndrome contact him directly through www.VeinsVeinsVeins.com or call  716-839-3638.

 

 

Post Thrombotic Syndrome and Deep Vein Thrombosis

 

 

To be evaluated and treated for post thrombotic syndrome treatment center by Dr. Hratch Karamanoukian, MD FACS call 716-839-3638 or go to www.VeinsVeinsVeins.com or www.VeinGuide.com.

 

www.VeinsVeinsVeins.com and www.VeinGuide.com are partners with www.PeaceBridgeHealthCare.com

 

 

 

Clinical Features of Venous Insufficiency - Vein Expert at Buffalo Niagara
Tuesday, August 13, 2013

 

 

There are several key clinical features of venous insufficiency that are notable. There may be lower extremity swelling or edema and evidence of skin changes.  One of the early signs of skin changes in mild eczema of the skin, also known as gravitational eczema or venous stasis eczema.  The CEAP classification for venous stasis dermatitis is CEAP C4a.

 

Another early sign of injury to the skin in patients with venous insufficiency is hyperpigmentation or brown pigmentation of the skin due to the deposition of hemosiderin in the skin.  This occurs due to combination of reasons but mainly due to high venous pressures or venous hypertension which results directly from damage from the muscle pumping function in these patients.  This causes red blood cells to leak out of the capillaries and get deposited in the skin.  Breakdown of the red blood cells and hemoglobin forms hemosiderin deposition.  The clinical classification of hyperpigmentation resulting from chronic venous disease is CEAP C4.

 

Another serious manifestation of longstanding venous insufficiency is lipodermatosclerosis where there is induration or hardening of the skin as well as a leathery texture of the skin and subcutaneous tissue.  This affects the gaiter areas of the leg - the areas just above the ankle bone or malleolus.  Lipodermatosclerosis may be the precursor to more advanced venous stasis disease such as venous stasis ulceration.  In lipodermatosclerosis, there is contraction of the dermis and subcutaneous tissues and the area above the ankle is circumferentially narrower compared to the normal leg.  This pushes the calf muscle upward resulting in a ‘upside down champaigne bottle” appearance of the leg. The CEAP classification for lipodermatosclerosis in patients with advanced venous diseases is CEAP C4b.

 

Atrophe blance may also develop and in this condition the superficial blood vessels are obliterated or disappear from the skin and white patches of skin develop.  This indicates that the skin has been severely damaged by chronic venous valvular insufficiency.  These patients are at risk of developing venous stasis ulcers. 

 

The CEAP classification for venous stasis ulceration is CEAP C6.  A healed venous stasis ulcera is classified as CEAP C5.

 

For more information about lipodermatosclerosis and advanced clinical features of venous insufficiency contact Hratch Karamanoukian, MD FACS at the Vein Treatment Center with offices in Williamsville, New York and Clarence, New York or contact him directly through www.VeinsVeinsVeins.com or www.VeinGuide.com.  You can also schedule a consultation by calling 716-839-3638.

 

www.VeinsVeinsVeins.com and ww.VeinGuide.com are partners with www.PeaceBridgeHealthCare.com

 

 

Xarelto for Deep Vein Thrombosis - rivaroxaban for DVT - www.VeinsVeinsVeins.com and Buffalo Niagara Vein Treatment Center and Dr Karamanoukian
Friday, August 16, 2013

 

 

Acute venous thromboembolism is a common disorder with an annual incidence of 1 to 2 cases per 1000 persons in the general population.  Treatment with anticoagulants is effective in reducing the risk of recurrent disease, most notably increased in the first 6 to 12 months after the first episode of deep vein thrombosis.  The risk of recurrent DVT after treatment ends can reach up to 10% during the first year following deep vein thrombosis.

 

Standard treatment for venous thromboembolism is commonly with intravenous or subcutaneous heparin injections initially and overlapping with vitamin K antagonist such as warfarin or Coumadin.

 

Rivaroxaban is an oral agent which is a direct factor Xa inhibitor . Rivaroxaban is effective in the prevention of venous thromboembolism and it has shown to be effective after surgery.  A recent study was done to see if it is efficacious in treating venous thrombosis in general.  The study was published in the New England Journal of Medicine, volume 363, pages 2499 – 2510 by the EINSTEIN investigators.  The study showed that “rivaroxaban alone is as effective as standard therapy, with similar safety, for the treatment of acute DVT and that when treatment is continued, rivaroxaban is very effective  in preventing recurrences, as compared with placebo, and has an acceptable risk of bleeding”.

 

oral rivaroxaban, at a dose of 15 mg twice daily for the first 3 weeks, followed

by 20 mg once daily thereafter, without the need for laboratory monitoring, may provide an effective, safe, single-drug approach to the initial and continued treatment of venous thrombosis.

 

For treatment of DVT contact your hematologist or Dr. Karamanoukian at the Vein Treatment Center with offices in Buffalo Niagara.  You can contact him via www.VeinsVeinsVeins.com or www.VeinGuide.com or call 716-839-3638.

 

www.VeinsVeinsVeins.com and www.VeinGuide.com are partners with www.PeaceBridgeHealthCare.com.

 

 

How Does Pregnancy Affect Varicose Veins? Vein Treatment Center and Dr Hratch Karamanoukian
Sunday, August 18, 2013

 

 

There are physiologic changes such as increased blood volume during pregnancy and the mechanical effect of the ever enlarging uterus on the large veins in the retroperitoneum, that is, in the area behind the abdominal cavity where the uterus lies. This contributes to venous reflux of blood into the legs veins.

 

What is also recognized is the hormonal changes on the veins themselves. The three main hormones are estrogen, progesterone and relaxin:

 

1. High estrogen levels increase the capacitance of veins, that is their ability to hold more blood.

2. High progesterone levels weaken vein walls and make them more likely to become varicose.

3. High relaxin levels cause vasodilation and venodilation - increasing the vein wall diameter by realxing the smooth muscle cells in the vein wall.

 

So, wear compression stockings during pregnancy -- knee high during the first trimester and waist high in the second and third trimesters. Consult your obstetrician for more details and a prescription to get these stockings and do not self treat.

 

For more information about spider veins, reticular veins and varicose veins, contact Dr. Karamanoukian at the Vein Treatment Centers with offices in Williamsville, New York and Clarence, New York as well as the Advanced Aesthetic Medical Spa (AAMS) in East Amherst, New York or go to www.VeinsVeinsVeins.com, www.VeinGuide.com, www.AdavanceYourBeauty.com or call 716-839-3638 to schedule an appointment for consultation.

 

www.VeinGuide.com and www.VeinsVeinsVeins.com and www.AdavanceYourBeauty.com are partners with www.PeaceBridgeHealthCare.com

 

 

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